Yukio Mano, MD, PhD (1943–2004)Associate Editor, Journal of NeuroEngineering and Rehabilitation I was terribly shocked to hear of the tragic and sudden passing of Yukio Mano on November 7, 2004, at the age of 61. He had not been well this past year but had been working continuously until just ten days before his death.Yukio Mano Figure  was bornHis research interest was rehabilitation medicine, especially brain plasticity. He was the first Japanese developer of an apparatus that could deliver transcranial magnetic stimulation. Using this apparatus, he analyzed changes in the central nervous system resulting from various diseases, including brain plasticity after anastomosis of the musculocutaneous and intercostal nerves following cervical root avulsion, and cortical reorganization in training. The knowledge resulting from his research proved beneficial in the rehabilitation of disabled patients. He also emphasized a multidisciplinary approach to rehabilitation medicine and adopted new techniques from engineering. He received the Best Paper Award from ANNIE  in 2000 for his work entitled, "Adaptive FES Switching System for Hemiplegics".Yukio Mano served as a council member of the International Society of Electrophysiology and Kinesiology (ISEK) and, in 2000, he organized the XIII Congress of the ISEK in Sapporo, Japan. He was also a member of the editorial board of the Journal of Electromyography and Kinesiology. He served as a council member of many Japanese societies and organized nationwide congresses in Japan even in the year he died. He welcomed the launch of the new Journal of NeuroEngineering and Rehabilitation (JNER) and was honored to be asked to join the Editorial Board as an Associate Editor. He was indeed fully active to his last day.We cannot help praising him for all that he has accomplished in the fields of rehabilitation medicine, neurophysiology and kinesiology. We must also not forget that this remarkable scientist was also a caring family man. He always showed his love for his family as well as for his colleagues and friends. The loss of such an outstanding personality has been met with great sorrow by his family and the international scientific community. We will always remember him with great affection.


Birds, for example, know instinctively what type of nest to build for their offspring; salamanders don't need lessons to swim. But when it comes to primates—including humans—a good deal of behavior is learned. Primates exhibit a wide range of behaviors, not just among species but also among populations and even individuals. Yet the nature versus nurture debate still rages, particularly when it comes to understanding the roots of aggression. While bonobos are famous for using sex to resolve disputes, aggression is far more common in most primate species—again humans included. Our closest relative, the chimpanzee, has a reputation for being among the most belligerent, with rhesus monkeys and baboons not far behind. For many of these species, bouts of violence are often followed by gestures of reconciliation, such as grooming or, in the case of chimps, kissing. Since most primates live in social groups, it may be that such conciliatory measures serve to maintain some semblance of social structure, offsetting the disruptive effects of aggression.  but are also passed on to succeeding generations. Such cultural traditions have been documented in African chimp populations, which display over 39 behaviors related to “technology” (such as using stones to crack nuts), grooming, and courtship. While most of these cases involve either tools, foraging, or communication, Robert Sapolsky and Lisa Share report evidence of a higher order cultural tradition in wild baboons in Kenya. Rooted in field observations of a group of olive baboons  since 1978, Sapolsky and Share document the emergence of a unique culture affecting the “overall structure and social atmosphere” of the troop.A Primate's Memoir, Sapolsky studied the activities and lifestyle of the Forest Troop to explore the relationship between stress and disease. In typical baboon fashion, the males behaved badly, angling either to assume or maintain dominance with higher ranking males or engaging in bloody battles with lower ranking males, which often tried to overthrow the top baboon by striking tentative alliances with fellow underlings. Females were often harassed and attacked. Internecine feuds were routine. Through a heartbreaking twist of fate, the most aggressive males in the Forest Troop were wiped out. The males, which had taken to foraging in an open garbage pit adjacent to a tourist lodge, had contracted bovine tuberculosis, and most died between 1983 and 1986. Their deaths drastically changed the gender composition of the troop, more than doubling the ratio of females to males, and by 1986 troop behavior had changed considerably as well; males were significantly less aggressive.In his book After the deaths, Sapolsky stopped observing the Forest Troop until 1993. Surprisingly, even though no adult males from the 1983–1986 period remained in the Forest Troop in 1993 , the new males exhibited the less aggressive behavior of their predecessors. Around this time, Sapolsky and Share also began observing another troop, called the Talek Troop. The Talek Troop, along with the pre-TB Forest Troop, served as controls for comparing the behavior of the post-1993 Forest Troop. The authors found that while in some respects male to male dominance behaviors and patterns of aggression were similar in both the Forest and control troops, there were differences that significantly reduced stress for low ranking males, which were far better tolerated by dominant males than were their counterparts in the control troops. The males in the Forest Troop also displayed more grooming behavior, an activity that's decidedly less stressful than fighting. Analyzing blood samples from the different troops, Sapolsky and Share found that the Forest Troop males lacked the distinctive physiological markers of stress, such as elevated levels of stress-induced hormones, seen in the control troops.In light of these observations, the authors investigated various models that might explain how the Forest Troop preserved this (relatively) peaceful lifestyle, complete with underlying physiological changes. One model suggests that nonhuman primates acquire cultural traits through observation. Young chimps may learn how to crack nuts with stones by watching their elders, for example. In this case, the young baboon transplants might learn that it pays to be nice by watching the interactions of older males in their new troop. Or it could be that proximity to such behavior increases the likelihood that the new males will adopt the behavior. Yet another explanation could be that males in troops with such a high proportion of females become less aggressive because they don't need to fight as much for female attention and are perhaps rewarded for good behavior. But it could be that the females had a more direct impact: new male transfers in the Forest Troop were far better received by resident females than new males in the other troops.Sapolsky and Share conclude that the method of transmission is likely either one or a combination of these models, though teasing out the mechanisms for such complex behaviors will require future study. But if aggressive behavior in baboons does have a cultural rather than a biological foundation, perhaps there's hope for us as well.


Oryza sativa L.), barley (Hordeum vulgare L.) and wheat (Triticum aestivum L.) were linkage maps based on cDNA-RFLP markers. The low number of polymorphic RFLP markers has limited the development of dense genetic maps in wheat and the number of available anchor points in comparative maps. Higher density comparative maps using PCR-based anchor markers are necessary to better estimate the conservation of colinearity among cereal genomes. The purposes of this study were to characterize the proportion of transcribed DNA sequences containing simple sequence repeats (SSR or microsatellites) by length and motif for wheat, barley and rice and to determine in-silico rice genome locations for primer sets developed for wheat and barley Expressed Sequence Tags.Earlier comparative maps between the genomes of rice (The proportions of SSR types (di-, tri-, tetra-, and penta-nucleotide repeats) and motifs varied with the length of the SSRs within and among the three species, with trinucleotide SSRs being the most frequent. Distributions of genomic microsatellites (gSSRs), EST-derived microsatellites (EST-SSRs), and transcribed regions in the contiguous sequence of rice chromosome 1 were highly correlated. More than 13,000 primer pairs were developed for use by the cereal research community as potential markers in wheat, barley and rice.Trinucleotide SSRs were the most common type in each of the species; however, the relative proportions of SSR types and motifs differed among rice, wheat, and barley. Genomic microsatellites were found to be primarily located in gene-rich regions of the rice genome. Microsatellite markers derived from the use of non-redundant EST-SSRs are an economic and efficient alternative to RFLP for comparative mapping in cereals. The genetic maps of grass species have been constructed using a variety of marker types. Most of the older species-specific molecular maps were constructed with RFLP markers, but in recent times there has been increased utilization of PCR-based markers because of accessibility and higher throughput. Conservation of gene content and order has been detected among grass genomes through the use of comparative maps ,2. The aGenomic SSR (gSSR) markers are biased towards genome specificity ,5 and geRecently, several researchers -17 have When compared to gSSRs, EST derived SSRs (EST-SSRs) were less polymorphic in a study in hexaploid wheat  with onlin-silico to the rice genome. SSR-containing transcripts derived from different species, sharing a pre-determined threshold of similarity and matching the same location in rice were considered putative orthologs that may be used as anchors in comparative mapping studies.We used the rice genome sequence generated by the International Rice Genome Sequence Project (IRGSP)  to identThis paper describes a methodology for developing EST-SSR markers from wheat, barley and rice as markers for developing independent species maps as well as for homologous anchor markers for comparative maps. Over 13,000 untested PCR primer pairs for EST-SSRs were generated from the three gene indices and made available to the research community interested in grass genomes. Researchers are encouraged to evaluate a subset of primer pairs and send feedback regarding their utility to the GrainGenes  databaseBased on combinations of all four nucleotides, the canonical set of SSR motifs is represented by four different duplets (AC, AG, AT, CG), 10 different triplets, 33 different quadruplets and 102 different quintuplet motifs. In the source sequences, all these basic nucleotide motifs can be represented in variant forms of the same basic set or by their reverse complements but to keep a consistency in the database for estimating frequencies, they were transformed into the canonical motifs. Reverse complements and variants would include, for example, CT for AG and GAG for AGG. Sets of unigene sequences such as the TIGR gene indices have the advantage of built-in elimination of redundant SSR counts allowing for more precise estimates of EST-SSR frequency. The rice genomic SSR (gSSR) counts were processed a-posteriori to eliminate redundancy due to BAC/PAC clone overlaps (see methods). Mononucleotide repeats are common in genomic DNA and some are known to be polymorphic but these were deliberately avoided in the unigene database, because they are usually added by the RNA polymerase and are not present in the template DNA (e.g. poly A tails).Table The abundance of SSRs (perfect and imperfect) in the unigenes can range from one in every 100 to one in every two unigenes depending on the minimum length Table .Wheat unigenes contained a larger number of SSRs for all repeat length categories, followed by rice and barley unigenes. This is probably because wheat has more than twice the number of unigenes than rice or barley with 109,782 for wheat, 51,569 for rice and 48,159 for barley. The larger number of unigenes in hexaploid wheat may result from divergence of the genes in the three genomes, but also from a relatively larger EST dataset, i.e., more ESTs have been sequenced for wheat, with a sequence redundancy of 3.8×, versus 6× and 2.7× for barley and rice, respectively (see methods).The number of the ten most frequent motifs was tabulated for different minimal SSR lengths Table . The relp > 0.01).The longest SSRs were genomic microsatellites (as long as 726 bp). Unigenes had few SSRs longer than 40 bp, up to 333 bp in wheat ESTs. Often these were not useful for developing SSR markers because no flanking sequence was available to design primers. The overall mean length for rice gSSRs equal to or longer than 12 bp was 16.5 (s.d = 12.7), with no significant differences in mean gSSR lengths among the chromosomes in rice, while the mean length for EST-SSRs was 15.3 (s.d = 6) with no significant differences among the three species gene indices , and for anchoring rice, wheat and barley unigenes associated with microsatellites (by sequence similarity). Best similarity matches between the rice genome and 8,259 barley, 16,917 rice and 13,565 wheat EST-SSR unigenes were identified using BLASTN. From these, a total of 6,373 EST-SSRs mapped to R1 pseudomolecules including 1,104 from barley, 3,568 from rice and 1,701 from wheat with 88.8%, 98.4% and 89.1% average sequence similarity respectively.The contiguity of the pseudomolecule sequence of rice chromosome 1 (R1) , with only eight gaps for the whole chromosome, provided a convenient framework of coordinates for calculating density estimates of gSSRs features  the density of all rice unigenes mapped to R1, and b) the density of EST-SSRs (a subset from the unigenes) mapped to R1 provided an estimate of the relationship between gSSRs and gene regions in the rice genome. There was a striking resemblance in the patterns of the plots for the density of gSSRs and the density of unigene-derived EST-SSRs in R1 pseudomolecules Figure . The simA decomposition of the set of stringent gSSRs (see the methods section for criteria defining the "stringent gSSRs") by types in R1 Figure  showed tWe designed primer pairs for 5,425 wheat, 3,036 barley and 4,726 rice EST-SSRs conforming to the stringent restrictions described in the methods. The average product size expected from the set of designed primers was 217 bp for rice EST-SSRs, 213 for wheat and 218.9 for barley.in-silico to the rice genome. The Of those EST-SSRs, 42% of the wheat and 56% of the barley were mapped r2 = 0.94, p < 0.006) between genomic microsatellite frequency and the percentage of single copy DNA in several plant species with a wide range of genome sizes. Estimates of repetitive and non-repetitive single-copy DNA fractions were based on reviews of the literature describing renaturation kinetics experiments for each of the species. Plant species that have gone through genome expansion due to retrotransposon amplification, such as maize and wheat, had a lower genomic microsatellite frequency indicating that SSR frequency is not a function of overall genome size but rather the relative proportion of single-copy DNA.Morgante and colleagues  reportedr = 0.45, p < 1 × 10-5 and r = 0.62, p < 1 × 10-10, respectively) . The density pattern of transcribed regions (unigenes in R1) and of SSRs within transcribed regions (unigenes in R1 with SSRs or EST-SSRs) followed closely the density pattern of gSSRs in rice chromosome 1  of gSSRs along R1 was higher than both the density of transcribed regions and the density of EST-SSRs. A large number of gSSRs that are not already included in the set of EST-SSRs could still be associated with genes because, as Figure Other reports have documented a role for SSRs that are associated with genes in the control of gene expression. For example, several human diseases have been linked with events of triplet expansions in the past . ChromatIn rice, although the presence of a single-base mutation breaking an intron splice site is more directly responsible for the difference in phenotypes of the waxy gene, polymorphism due to SSR expansion has been associated with variation of expression levels in different japonica and indica varieties ,29. The One strategy to better exploit a database of EST-SSRs in order to find polymorphic markers is to first sample the longest SSRs ≥ 30 bp), favoring dinucleotide repeats, then follow with trinucleotide, tetranucleotide and pentanucleotide repeats . After e bp, favoOne percent of unigenes from the three species examined in this study have SSRs starting with a minimum of 30 bp Table . OverallAfter relaxing the microsatellite length constraint to a minimum of 20 bp, the overall number of SSRs in the unigenes increased to around 5%. An additional 3,195, 2,703 and 1,991 EST-SSRs in wheat, rice and barley become available for primer design. Acceptable primer pairs were designed for 2,622 wheat, 2,183 rice and 1,476 barley EST-SSRs in this category (which included the set mentioned previously).The set of EST-SSRs with acceptable primer pairs  were selThe relative proportions of di-, tri-, tetra-, and penta nucleotide repeats and motifs varied widely depending on length and were not consistent among the species examined. We have shown that ESTs are a good source of SSRs that can be exploited to develop microsatellite markers for wheat, barley and rice. The advantage to this approach is that the sequences are already available resulting in a lower cost than designing and testing microsatellites from anonymous genomic libraries, even if the polymorphism rate for EST-derived markers is lower.EST-SSRs are useful for enhancing individual species maps, but can be used as anchor probes for creating links between maps in comparative studies when designed from sets of orthologous genes, as demonstrated by Yu et al . The annUsing a different methodology, our results substantiated the report by Morgante et al  suggestiTIGR's non-redundant gene indices  from wheAll analyses of the rice genome used the version released in December 2002 by the International Rice Genome Sequencing Consortium  and consThe TIGR gene indices and the genome of rice were scanned with a modified version of Sputnik  availablIn order to eliminate the problem of counting the same microsatellites several times in the rice genome due to the redundancy created by overlapping regions between contiguous BAC/PACs in chromosomes 2 to 12, the gSSRs were annotated as redundant or not, according to their location in the tiling path. When located to a region in the BAC/PAC that overlapped with a neighbor clone :a) The SSRs are dinucleotides or trinucleotides of length equal or larger than 18 bp, tetranucleotides equal or larger than 16 bp or pentanucleotides equal or larger than 20 bp.b) The imperfect SSRs have less than 10% mismatches or gaps relative to a perfect SSR of the same length and motif.c) There is a minimum of 50 bp surrounding the SSR edges in the source sequence to allow for possible primer design.The parameters used for the Primer3 program specified an optimal Tm of 60°C with a minimum and maximum of 57°C and 65°C, respectively, and a 30% to 70% GC content with a low chance of dimer or hair-loop formation. The range for PCR product length was set to be between 100 and 300 bp.EST: Expressed Sequence Tag. SSR: Simple Sequence Repeat. gSSR: genomic SSR. EST-SSR: EST-derived SSR. UTR: Untranslated region flanking a coding region in DNA and messenger RNA. IRGSP: International Rice Genome Sequence Project. R1: rice chromosome 1. BAC/PAC: Bacterial artificial chromosomes or bacteriophage P1 artificial chromosomes (for cloning of large DNA fragments). MITE: Miniature Inverted-repeat Transposable Element.ML did all programming and design of computational experiments and databases. RVK contributed in the first database design. JY did wet-lab testing of a subset of primer pairs.ML and MES drafted the manuscript. All authors read and approved the final manuscript.EST-SSR designed primers Table listing the stringent subset of SSRs (≥ 16 bp tetranucleotides, ≥ 18 bp dinucleotides and trinucleotides, and ≥ 20 bp pentanucleotides) found in rice, barley and wheat gene indices for which primer sequences were designed, the source sequences, the primers, their in-silico mapping in the rice genome (to BAC/PAC clones or pseudo-molecule) and relevant metadata. File is a spreadsheet table, compressed with the zip program. The file (14 Mb uncompressed) is also available at the GrainGenes Triticeae EST-SSR Coordination page Click here for fileModified Sputnik source code and executable This is the source code with modifications, to the microsatellite searching program "Sputnik", originally written by Chris Abajian from the University of Washington at Seattle. The set of files are compressed using the zip program. File is also available at Click here for filePerl script to design primers in batch The script uses the Bioperl perl modules to control the Primer3 program in order to design primers from a microsatellite database stored in a MySQL database. The script can be modified to accommodate similar schemas on any database engine supported by the perl DBI module. File is also available at Click here for file


In view of the issues surrounding physical restraint use, it is important to have a method of measurement as valid and reliable as possible. We determined the sensitivity and specificity of physical restraint use a) reported by nursing staff and b) reviewed from medical and nursing records in nursing home settings, by comparing these methods with direct observation.We sampled eight care units in skilled nursing homes, seven care units in nursing homes and one long-term care unit in a hospital, from eight facilities which included 28 nurses and 377 residents. Physical restraint use was assessed the day following three periods of direct observation by two different means: interview with one or several members of the regular nursing staff, and review of medical and nursing records. Sensitivity and specificity values were calculated according to 2-by-2 contingency tables. Differences between the methods were assessed using the phi coefficient. Other information collected included: demographic characteristics, disruptive behaviors, body alignment problems, cognitive and functional skills.Compared to direct observation (gold standard), reported restraint use by nursing staff yielded a sensitivity of 87.4% at a specificity of 93.7% (phi = 0.84). When data was reviewed from subjects' medical and nursing records, sensitivity was reduced to 74.8%, and specificity to 86.3% (phi = 0.54). Justifications for restraint use including risk for falls, agitation, body alignment problems and aggressiveness were associated with the use of physical restraints.The interview of nursing staff and the review of medical and nursing records are both valid and reliable techniques for measuring physical restraint use among nursing home residents. Higher sensitivity and specificity values were achieved when nursing staff was interviewed as compared to reviewing medical records. This study suggests that the interview of nursing staff is a more reliable method of data collection. Nursing homes have the mandate to offer care settings to frail dependent older individuals. However, a renewed emphasis has emerged over the past decades to become more than just a home for older people . A growiAlthough predominantly intended as protective devices, physical restraints in nursing homes are being denunciated as measures that go conversely with the aforementioned principles . JustifiAccording to the literature, the overall prevalence of restraint use in nursing homes ranges between 4 and 68% ,20. ThisThe objective of this study was to determine the sensitivity and specificity of the measurement of physical restraint use reported by members of the nursing staff and reviewed from medical and nursing records among nursing home residents, compared to direct observation. Since underreporting is much more susceptible to be problematic than overreporting, another objective of this study was to compare the sensitivity of the information reported by one nurse with that reported by two nurses or more questioned together. Our research hypothesis was that sensitivity of the interview is highest when the information is collected from more than one nurse.The study was conducted in eight facilities representing a convenience sample of the long-term care facilities in the Quebec City area, Canada. These institutions were carefully selected in order to include a mix of characteristics in size , geographic location , university affiliation and vocation (units associated with psychiatric or rehabilitation team). Selection was made after discussion with nursing direction of each setting to gather units of different practice such as regular units and specialized units for residents with dementia or severe behavioral problems. Twenty-five subjects were randomly chosen from each unit; if an unit comprised less than 25 residents, all of its residents were included. This study was approved by the ethics committee at Laval University. Data collection took place between January and June 1992.A physical restraint was defined as a mechanical means applied on a resident in order to interfere with his/her mobility, including: vest, waist, wrist or ankle restraints, geriatric chair or wheelchair with fixed tray table, or any other type of locally designed devices . RestricPhysical restraint use was measured according to three methods: direct observation, interview with members of the nursing staff including licensed practical as well as registered nurses , and review of medical and nursing notes.Direct observation of restraints on care units were made independently by two trained research assistants using a pre-tested questionnaire. For practical reasons, observations were made before the chart reviews and the nurses' interviews on three occasions (7h00 AM, 11h00 AM and 3h30 PM) on one day. These specific times were selected as being representative of periods of different nurse staffing, and of overloaded periods during morning and afternoon.In order to reduce the occurrence of an information bias, the nursing staff was blinded to the main objective of the research project. Structured interviews were carried out the day following direct observation by one of the authors (PJD), who was unaware of the observations. Interviews with the nurse in charge of each unit were scheduled, although he/she had the liberty to be represented or assisted by other members of the nursing staff. Physical restraint use on each subject was identified for every hour during the last 24 hours, without knowledge of the times that direct observation was made, by means of a pre-tested questionnaire. The questionnaire covered questions about types of physical restraints (belt, vest, wrist, ankle, fixed tray table, siderails), reasons for use  and the duration including hours and minutes. Other information collected during the interview included: gross cognitive and functional information, risks for falls, history of falls during the last month, agitation, wandering, aggressive behavior and body alignment problems. Cognitive status was evaluated according to five items: recall, speech, and orientation to time, space and people. Three aspects of the functional status were assessed: urinary incontinence, fecal incontinence, and ability to transfer. Respondents could refer to subjects' clinical records at any time during the interview.Restraint use from subjects' medical charts and nursing orders for the last six months was reviewed with a pre-tested questionnaire by a research assistant who was blinded to the observations. Additional information taken into consideration comprised: demographic characteristics, prescriptions for restraints, methods of resident supervision, and psychotropic medications administered in the last 48 hours.Sociodemographic characteristics of the study sample as well as physical restraint use by methods of data collection were examined using descriptive analysis. Interrater reliability between the two research assistants was tested using the kappa statistic. Direct observation served as the gold standard . To be dData collection was carried out in 16 nursing units. Of these units, eight depicted skilled nursing home care units, seven nursing home care units, and one long-term care unit within a short-term care hospital. Information was collected for 377 residents with the help of 28 nurses. Residents' age ranged from 32 to 102 years, with a median of 80 years. The sample was 62% female, and median length of stay was 45 months (0 to 720 months). Benzodiazepines and neuroleptics were administered to 35% and 25% of the subjects, respectively.A total of 6,744 observations over a possibility of 6,786 were made (377 residents by three direct observations and six types of restraints). Prevalence results on physical restraint use according to direct observations : 0.73–0.97)), interviews with nursing staff and reviews of clinical records are summarized in Table The interview with nursing staff and the review of medical and nursing orders were both highly associated with the observation data Table . The intp = 0.03), agitated behavior (p = 0.04), body alignment problems (p < 0.001) and aggressive behavior (p = 0.01), and reported restraint use by nursing staff were observed. No association was observed for residents' age and sex, number of nurses interviewed, history of falls, wandering problem, disorientation to time, space or people, recall troubles, speech troubles, urinary and fecal incontinence, and ability to transfer.Sensitivity values according to specific residents' characteristics and other reported variables are given in Table The measurement of physical restraint use according to interview with members of the nursing staff and review of medical charts and nursing orders both reflect accurately the reality observed in long-term care setting residents. Our study has also shown that sensitivity and specificity values of the reported measurement are higher than those calculated from medical charts and nursing orders. This phenomenon is not surprising considering that the keeping of medical and nursing orders in nursing homes isn't usually done on a daily basis , as oppoThe current investigation was carried out in units of diverse facilities. The selection of these facilities was intended to allow the participation of subjects and care units of various characteristics as compared to other studies usually designed . The samLimitations of the current study must be taken into account when interpreting these findings. First, data were collected in 1992. Due to the implementation of the OBRA act, it is probable that the prevalence figures given in the current study are overestimations of those that would be observed in 2004. On the other hand, the province of Quebec just recently launched its first comprehensive policy on physical restraint use . FurtherIt is well known that the prevalence of residents with physical restraints is usually underreported since a social desirability bias tends to affect the validity of the information when the nursing staff has to declare the use of restraints . DespiteEven though other studies have observed an association between residents' characteristics and the risk of being restrained ,17,30,31Compared to review of clinical records, reported physical restraint use by interviewing nursing staff is a simple, efficient, and valid technique of collection of data regarding their use in nursing homes. No severe information bias was observed even though the use of physical restraints may be associated with poor quality of care. This method of measurement appears to be reliable and valid for research purposes. Moreover, our study provides support to the American initiative in regard to the monitoring of several outcomes in nursing homes through nursing staff reports -35. AccoThe authors declare that they have no competing interests.DL participated in the second line of statistical analyses, and drafted the manuscript. PV drafted parts of the document and contributed to the editing. RV contributed to the editing of the manuscript. PJD served as the Principal Investigator, designed the study, participated and oversaw field activity, revised and edited the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


As part of qualitative research for developing a culturally sensitive and developmentally appropriate videotape-based HIV prevention intervention for heterosexual African- American men, six focus groups were conducted with thirty African-American men to determine their perceptions of AIDS as a threat to the African-American community, characteristics of past situations that have placed African Americans at risk for HIV infection, their personal high risk behaviors, and suggestions on how HIV intervention videotapes could be produced to achieve maximum levels of interest among African-American men in HIV training programs.The groups took place at a low-income housing project in Houston, Texas, a major epicenter for HIV/AIDS. Each group was audiotaped, transcribed, and analyzed using theme and domain analysis.The results revealed that low-income African-American men perceive HIV/AIDS as a threat to their community and they have placed themselves at risk of HIV infection based on unsafe sex practices, substance abuse, and lack of knowledge. They also cite lack of income to purchase condoms as a barrier to safe sex practice. They believe that HIV training programs should address these risk factors and that videotapes developed for prevention should offer a sensationalized look at the effects of HIV/AIDS on affected persons. They further believe that programs should be held in African-American communities and should include condoms to facilitate reduction of risk behaviors.The results indicate that the respondents taking part in this study believe that HIV and AIDS are continued threats to the African-American community because of sexual risk taking behavior, that is, failure to use condoms. Further, African-American men are having sex without condoms when having sex with women often when they are under the influence of alcohol or other mind-altering substances and they are having sex with men while incarcerated and become infected and once released resume unprotected sexual relations with women. According to the men, substance abuse is an important part of the problem of HIV in the African-American community. This is in keeping with research that shows that drug use, especially crack cocaine, is linked to sexual risk taking among African Americans and to increased likelihood of becoming infected with other sexually transmitted diseases (STDs) including HIV. Thus, interventions for men should address condom use, condom availability, skills for using condoms, eroticizing condoms and substance abuse prevention. Men in the present study also strongly recommended that HIV/AIDS videotaped messages should include footage of the sensational effects of the disease. The HIV/AIDS epidemic continues to be a major public health challenge in the African-American community. Although African Americans constitute only 13% of the United States population, they have accounted for 39% of all the 886,000 estimated AIDS cases that have been diagnosed since the epidemic began in 1981 [While several successful intervention programs have been developed, evaluated, and implemented for African-American men who have sex with men, African-American women, and African-American adolescents , only a Several factors other than those reported by the CDC have placed African-American men at an increased risk of HIV infection. Essien et al.  exploredAn array of socioeconomic and cultural factors exacerbates high-risk behaviors that place African-American men at risk for HIV. First, nearly 25% of African Americans live in poverty , and sevA major challenge facing HIV prevention interventionists is the issue of developing HIV prevention programs that are firmly grounded in the cultural nuances of African Americans and the translation of these programs into effective HIV prevention practice. To date, several HIV intervention programs have been developed for African Americans -18, and This study used a qualitative exploratory research design to elicit information about the strategies for preventing HIV transmission among African-American men, ages 18–29. Thirty low-income African-American men participated in five focus groups that were conducted at a housing project targeted for convenience sampling and because of its location in close proximity to the research institution in Houston, Texas, a leading HIV/AIDS epicenter in the United States [The investigative team recruited focus group participants by displaying posters and flyers at strategic locations in the housing project identified by the manager. The flyer listed the study inclusion criteria: African-American heterosexual male, aged 18 – 29, self-reported unprotected vaginal sex in the last six months or having been diagnosed or treated for a sexually transmitted disease in the past year. The flyer also listed a university telephone number that prospective participants could call to obtain additional information and/or schedule their participation in a group. When calls were received, a trained research assistant confirmed eligibility. Those selected for participation were then encouraged to invite their friends to participate. Of the 97 prospective participants who contacted the university, 54 agreed to participate. Of that number, 30 appeared on the scheduled day and formed the study sample. The focus groups were conducted at the housing project's clubhouse by a facilitator with approximately 15 years experience conducting qualitative research studies with African-American men. Assistance was provided by a trained research assistant who took notes to ensure that pertinent information not captured by the audiotape was obtained and to record major points discussed.Participants were informed of the benefits of their involvement, that involvement was voluntary, that they could refuse to answer any question, and that they could cease participation at any time without penalty. Prior to the start of each group, written informed consent was obtained and agreement obtained to record the session. The participants were also told about the confidentiality of the information discussed at the meeting, especially important given that some of the men were acquaintances as a result of residency in or near the housing complex. They were advised that they would receive a $25 mall gift certificate and condoms as incentives for their participation. Respondents were also advised that the tapes, which were anonymous, would be destroyed following transcription and checking. All questions as well as the informed consent were provided in English.The investigative team utilized semi-structured and open-ended questions to elicit information from participants based on our research interest in determining perceptions of AIDS as a threat to African-American communities, characteristics of past situations which placed African Americans at risk for HIV infection, suggestions on ways to recruit African Americans into HIV/AIDS prevention programs and on how HIV intervention videotapes could be produced to achieve maximum levels of interest.A three-step staging process was used to generate the questions used in the focus groups: (1) generation of working hypotheses on facilitators and barriers to HIV prevention and program messages and methods by conducting interviews with six key informants experienced in HIV/AIDS prevention among African Americans; (2) reshaping of hypotheses until no new information was received by testing them in interviews with men similar to the target population; and (3) using the resulting hypotheses to generate questions and field testing them with members of the target population after which final changes were made.A guide consisting of a written list of questions and probes was used to conduct the interviews. According to McCracken , the advThe standard grounded theory approach of Glaser and Strauss was performed to conduct data analysis . GroundeThe study sample was comprised of 30 men between the ages of 18 and 29. Educational attainment ranged from tenth grade to college graduate with the greatest number of men stating that they had at least one year of post-secondary education. Most men identified themselves as day laborers attempting to earn income by doing various odd jobs as they become available. The remainder was unemployed. No men identified themselves as HIV positive, and none of the respondents had health insurance.The situational determinants of HIV risk taking and their impact on HIV/AIIDS prevention behaviors and education programs were examined. The discussion began by asking the men for their overall view regarding HIV and its impact on the African-American community. Specifically, they were asked if they believe that AIDS is a threat to the African-American community and to what they attribute its rapid spread. About one-half of men stated that it is due to lack of unsafe sex practices including having sex with multiple partners and failure to use condoms. A large number of men believed that African Americans have higher rates of HIV and AIDS due to their use of alcohol and drugs while a smaller number stated that AIDS is not a threat to the African-American community, but rather it is a universal problem or that African Americans have feelings of invincibility because they think that HIV happens to others and that God will protect them. A lesser number attribute the rapid spread of HIV and AIDS among African Americans to incarcerated men having sex with men while behind bars and returning to their female partners when they are released.Clarence, a 26-year old forklift operator, believes that AIDS is a threat to the African-American community due to failure to use protection from lack of understanding about the disease:A lot don't understand the disease or what the effect of it may be so they have unprotected sex because they don't understand the disease really well as they supposed to.""Ben, a 22 year old promotional worker, expressed his concerns about men having sex with men and also with women. He states:It is not a problem on the outside, but a lot of men have sex without condoms in the jails and they are bringing it right back home, and they are not telling anybody that they had sex in jail, and they are bringing it and sharing it among the girls.""Kenny, a 27 year old temporary worker, adds:I was recently locked up a couple of years ago. I met some guys you'd never think would be gay, undercover homosexuals, they pump weights with you, run track, and play basketball with you, but as soon as they are behind closed doors, their cellmate might be gay and they are banging in there. Even black gangs, sometimes when they initiate them, they do that, and they bring the disease back home.""Thus, incarceration and gang membership may facilitate HIV transmission and may be partially responsible for the high rates of bisexual activities in the African-American community.Jason, a 20 year old laborer explained that AIDS is a universal threat but that it is an epidemic among African Americans due to associated substance abuse and failure to use protection:It's a threat to everyone but we have a tendency in the black race, especially now with another epidemic that we have in our neighborhood called crack. People have a tendency now to be even careless with this drug. So they do things that they would not naturally do. Just having sex. The trust thing – we feel that we won't use condoms because we feel like they're uncomfortable, yeah, they kill the sensation and so then we're gonna jump in and do the do and so it has a stronger effect on us now than a lot of races.""Terry, a 28-year old home improver, asserts that African Americans do not believe that God will inflict added suffering (e.g., AIDS) upon them because they have already experienced hardship, God would not cause something else to make life difficult. He said:It's because of the color of our skin. People believe that, seems to believe that, oh, God is going to let them know or it's not going to happen to me or something like this. We done had enough bad happen to us.""Karl, a 29 year old college graduate did not believe that AIDS is a threat to the African-American community, but rather that statistics are inflated for this group due to the places where they obtain medical treatment. He believes the government keeps data that private physicians do not which results in inflated numbers for African Americans. Mistrust of healthcare system reporting about African Americans leads him to believe the situation is not as bleak as reports indicate. He stated:Most African Americans go to clinics which are state or federally funded and they keep that data. And most people with private health insurance go to their doctors and those private doctors don't submit that same data. So when you look at the quote-unquote per capita, it always looks like it is higher in the African-American community.""When asked to describe the means by which they had personally placed themselves at risk for HIV infection, almost half of participants cited unprotected sex or not taking the time to use protection "in the heat of the moment." These men did not have condoms in their possession, did not take the time to use a condom, or simply disregarded condom use because of dislike for them. Similarly, about one-third of men described specific situations with risks known to them at the time they engaged in unprotected intercourse. They included having sex with an HIV infected person, having sex with a stranger, sex with a drug user, and sex in exchange for money or drugs. The remainder of men stated that their drinking and drug use had created HIV risk situations.Austin, a 25 year old pipe fitter, explained that when he went to clubs and took women home, the result was being irresponsible and having unprotected sex:I've been drinking, just being in the room... the heat of the moment ... the heat of passion, just the heat of the moment taking away all the common sense.""Clarence is living with the consequences of having sex with strangers in a mood altered state. Although he did not contract HIV, he expressed that alcohol and unprotected sex resulted in him contracting hepatitis A.:Alcohol did that to me. I had sex with many women that I didn't know had the disease or nothing and I caught hepatitis A behind it once.""Like Austin and Clarence, Jason attributed his involvement in HIV risk situations as resulting from substance abuse. He stated:You don't mean to do it, but any mind-altering drug will lead you into a situation where you will have unprotected sex.""Joe, a 24 year old truck driver explained that he has unprotected sex in the heat of the moment and once he becomes involved in a sexual act, contact will occur without condom use.Once you get in a certain mood and you get stuck, I'm in that freak mode; there ain't no protection.""Harry, a 23 year old landscaper, described how he was told that his partner has AIDS but he continues to have sex with her but gets himself tested for HIV every 6 months. He, in effect, continues to take a chance and uses the test as a way to keep himself informed.In fact, I had two girls and they telling me that you know your partner tell you where they got AIDS from her, but yet and still you get yourself checked and you don't come up with AIDS. You know there's a doubt there somewhere. Every six months I have myself checked for almost a year because I supposed to get it from her. How did I miss it? I don't know.""Like their perceptions about the reasons for the rapid spread of HIV and the situations that have placed them at risk for infection, one-third of men stated that substance abuse is a barrier to safe sex practices. Other reasons stated as barriers were lack of money for condoms and judging a partner on appearance alone. About one-fifth of participants said they had no barriers to practicing safe sex.Karl believes that alcohol and drug use, specifically crack cocaine, creates a feeling of power over women which results in the women failing to negotiate safe sex practices. He said:I think alcohol and drugs, mood altering, mind altering, especially with that crack cocaine. When you get that crack cocaine, the fist thing you get, and you take you a hit, you automatically assume power. You know with that crack, you have power over women. You know you can make them do what you want them to do.""Freddy, a 28-year old laborer, explained that when a choice between drugs and condom has to be made, he will choose drugs. He stated that he did not have money to buy both condoms and drugs:I don't have enough money to go out and buy condoms that everybody wants. I need to spend money on condoms or I'm a spend it on getting the next hit.""Although infrequently stated, Jason said that he had, in the past, judged a woman's HIV/AIDS status based on her appearance:What prevented me from practicing safe sex in the past was, like I said, the way she looked. You feel that you know her, but now I see that you can't go on that.""Barry, a 26-year old construction worker, stated that he always uses protection. He said:Like I said earlier, if I can't find a plastic baggie or the plastic that you break on in, I wear a sandwich bag, hey, if I can't use that, I won't mess around. I won't do it!""Close to one-half of men were motivated to practice safe sex because they were personally acquainted with someone who had been affected by AIDS and had seen its effects firsthand. A quarter of men was adamant about remaining disease free or had previously acquired sexually transmitted infections. About 15% simply stated that life was their motivation.Barry has seen the effects of AIDS firsthand and the images have caused him to use condoms. He said:I was about to do it with no condom and that seriously woke me up, put a stop and then God stepped in and then about a year later, she passed. The loss of friends and hearing people over the news. Their body just shrivel up cause the body can't hold their bladder, their bowels I mean it's the ugliest sight to see. You know and that's enough to wake you up.""Austin, who in the past had taken strangers home and engaged in unprotected sex, explains that his concern for his future facilitates his use of safe sex practices:My motivation is AIDS, not contracting AIDS. The fact that I don't have any kids or I'm not married ... something that will affect my future. I mean I want kids. I wanna be married. I mean if I have AIDS or what have you, don't none of that happen.""Jason reiterates Austin's comments quite simply when he states:I want to live. That's the bottom line.""Motivation for safe sex practices was not always associated with action even in the face of prior sexually transmitted infection.Joe adds:One thing that motivates me is, I don't necessarily take heed to it though, but the only venereal disease that I have had in the past is them crabs or whatever you want to call it. One thing that motivates me is that I had got crabs and I felt dirty, I mean I felt real bad.""In light of their experiences, participants were asked to describe what they would recommend to curtail the spread of AIDS in the African-American community including what specific governmental, media and community interventions they would consider effective. A variety of recommendations were offered, but the majority believed that more education is needed. Other men suggested that condoms are distributed without charge and consistent condom use is urged. To recruit African Americans into HIV training programs, financial and social incentives were highly recommended as were the use of a community-based, community-friendly approach to program recruitment and implementation.Trevor, a 27-year old who is unemployed said:The way that AIDS can be prevented is just through education, you know, education and that's basically the only tool that we have is education. Uh, I think the parents play a good role in it [education] too."'Wally, a 20-year old bricklayer adds:There's only one way and it's through education and I mean education will sum it up. We have to educate on drugs, we have to educate on protective sex. I mean, education is it.""Freddy echoes the sentiments of Trevor and Wally regarding education but also discussed the need to provide condoms:We need to get more condoms out on the streets. All STDs have to be prevented so we have to get more education on the streets, not just about AIDS because they [AIDS and other STDs] work hand in hand.""Incentives such as gifts and social events were recommended as a means to get African-American participation in HIV prevention and risk reduction interventions. Wally stated the need to provide incentives to increase program participation:You can give and receive at the same time. What I'm saying is you may have to start having a little gift or something to get them to come in the first few times, or a meal.""Barry adds:You gotta give something to get something. Another thing, have you a little barbecue, have it sitting out or something and you can get a whole lot of people. And believe it or not, a crowd of people will open up to a conversation, too.""Karl stressed incentives and programs for adolescents:Sometimes especially with the younger generation, you have to give them something that they want. Give them caps, give them T-shirts, but at the same time, push the condoms.""Outreach workers were advised to eliminate formality and go into the community to provide their programs. They should make an effort to ensure the target community members are comfortable with their presence. Jason said:And go into the neighborhoods and walk around and talk to folks. People have a tendency to stay away from people in a suit and tie in a neighborhood.""Gene, a 20-year old laborer added:Instead of making it formal, just come in off the streets. Go to the people and give them that incentive and sit down and talk to them.""It is believed among two-thirds of men participating in these discussion groups that the government can assist AIDS prevention by firstly, providing funding for community-based education programs, secondly, providing convenient and free testing, and thirdly, free condom distribution. Other suggestions included quarantining or having a salient means of identifying those affected by HIV and AIDS, providing more medication and treatment for those affected, and having stiffer penalties for those who knowingly transmit the virus.Jason believes in the efficacy of outreach programs that provide free testing and incentives:Just have three of four vans, just go to different neighborhood, have free testing, give T-shirts.""Terry believes in the community approach to governmental intervention:I think the greatest weapon we have against AIDS is knowledge and we must bring some type of community-based program.""Roger asserted his belief that the entire US population should be tested and those with HIV and AIDS identified and placed in isolation:Either quarantine, mandatory testing for HIV for the whole US population. You go to get tested. You're going to a quarantine island for the rest of your life.""Terry believes that the government should impose stringent punishment against persons who knowingly infect others with HIV:I think we can make stiffer penalties for people with AIDS that are willingly passing the disease on. Probably the government can open some more clinics or help the doctors find a cure.""To create a video that addresses HIV prevention, close to one-half of participants recommended using a sensational approach that includes those morbidly affected by HIV and AIDS. They believe that the video should include footage of people in pain, being shunned by friends and family, and suffering tremendous physical pain. They also recommended testimonials from infected persons. A quarter of respondents believed that the video should be educational providing information about transmission and prevention. The remainder suggested the use of rappers to promote the message of prevention and acknowledgement that HIV happens to African Americans.Karl who has a college degree stated that a video developed for AIDS prevention should include the disease's effects on the person:They need to see those people suffering to let them know that this is how you're going to end up if you don't begin to practice safe sex. But also how people are being discriminatory to you, treating you like crap like you're this or that or you're contagious or something.""Roger has similar views but adds that education about high risk behaviors should be included:Stay away from the dope and don't go tricking and also go to the hospitals. A lot of African Americans are not educated on the full blown AIDS and how it destroys the major organs in your body. And let them see first hand on what you're dealing with here.""Jason would like a video that includes the various modes of transmission as well as prevention information:Just about everything that you can get on it from drug use to safe sex to having sex with the same partner. You know it's different ways you can catch it and a lot of people don't know that.""When asked what can be done to recruit African Americans to HIV training programs, most men suggested the use of participation incentives, especially those that are financial and preventive (condoms). The men also recommended recruiting participants from and having the programs take place within the communities in which the target population resides.Wally said:You may have to start with a few passes; they can be little small things. Then everyone would gradually grab a hold and then their minds would be off on what you're giving personally and they could see what they can receive. You can give and receive at the same time. What I'm saying is you may have to start having a little gift or something to get them to come in the first few times, or a meal.""Jason suggests community-based recruitment:Stand at every corner. AIDS is gonna get too bad in a couple of years. We don't want it to be too late before we say, "Hey, let's put education groups here and people just stop here and get rubbers.""The results indicate that the respondents taking part in this study believe that HIV and AIDS are continued threats to the African-American community because of sexual risk taking behavior, that is, failure to use condoms. Further, African-American men are having sex without condoms when having sex with women often when they are under the influence of alcohol or other mind-altering substances and they are having sex with men while incarcerated and become infected and once released resume unprotected sexual relations with women. According to the men, substance abuse is an important part of the problem of HIV in the African-American community. This is in keeping with research that shows that drug use, especially crack cocaine, is linked to sexual risk taking among African Americans and to increased likelihood of becoming infected with other sexually transmitted diseases (STDs) including HIV ,28. AfriAlthough most respondents indicated they have knowledge of behaviors that place one at risk for HIV and they are motivated by reasons such as life and not wanting to contract an STD, they still fail to consistently use condoms and may even have sex with someone they know is HIV positive and they continue to suggest that more educational programs are needed. This shows that knowledge and motivation are not enough for behavior change to occur. These men need education but education that is provided in a way that has been different from what has been offered in the past because it seems not to change their behaviors. Interventions for men should address condom use, condom availability, skills for using condoms, and eroticizing condoms. Substance use programs should incorporate sexual risks. Men in the present study strongly recommended that HIV/AIDS videotaped messages should include footage of the sensational effects of the disease. There is a trend toward reality broadcasting in the US and development and field testing of such a videotape for AIDS prevention might prove worthwhile . Low-incPrior research has identified the leading causes of HIV infection among African-American men that includes sexual contact between African-American men who have sex with men, injection drug use and heterosexual contact. These high-risk behaviors are exacerbated by the high rate of poverty among African Americans that may be due to high rates of unemployment and associated drug related economic activities, injection drug, and substance abusers' engagement in unprotected sex when they are under the influence of drugs and alcohol ,13. The Although most of the men had completed high school or beyond, they were mainly homeless or living in substandard housing. Their conditions of poverty may exacerbate their risk for infection because they may engage in illegal or high-risk behaviors. The barriers these men face related to poverty should also be addressed when developing training programs. This may call for the involvement of social service workers. Like programs developed for African-American women, they must be presented in settings that are familiar, comfortable and easily accessible to the target audience and incorporate culturally relevant contextual information .Before developing programs, health educators should become familiar with the facilitators and barriers to HIV risk reduction behaviors among this population. They should also recognize that African Americans are a heterogeneous group and that not all messages will work with all audiences. The messages must be tailored and celebrate the diversity that exists within this population. Interventions such as videotapes should have mass appeal yet contain contextual, cultural, and gender specific messages.There are several limitations to this study. Qualitative data collection methodology was employed and it is therefore not possible to make assumptions or draw inferences. Next, the data cannot be generalized to other African American men. The participants were homeless and low-income and selected using a convenience sampling approach. The goal of this study, however, was to recruit low-income African-American men because by virtue of their income status they may be at increased risk for HIV infection. Although the findings from this research are limited, they may provide a foundation for conducting future research among and developing a videotape-based HIV intervention for low-income African-American men.The author(s) declare that they have no competing interests.EJE, AFM and GOO conceived and designed the study. EJE, AFM, RJP jointly planned and executed the data analyses. EJE and AFM wrote the paper with assistance from RJP, GOO and NIO.The pre-publication history for this paper can be accessed here:


We set out to describe the risk of hospitalization from heart disease, stroke, and diabetes among persons born in India, all foreign-born persons, and U.S.-born persons residing in New York City.We examined billing records of 1,083,817 persons hospitalized in New York City during the year 2000. The zip code of each patient's residence was linked to corresponding data from the 2000 U.S. Census to obtain covariates not present in the billing records. Using logistic models, we evaluated the risk of hospitalization for heart disease, stroke and diabetes by country of origin.After controlling for covariates, Indian-born persons are at similar risk of hospitalization for heart disease , stroke , and diabetes mellitus  as native-born persons. However, Indian-born persons are more likely to be hospitalized for these diseases than other foreign-born persons. For instance, the risk of hospitalization for heart disease among foreign-born persons is 0.70  and the risk of hospitalization for diabetes is 0.39  relative to native-born persons.South Asians have considerably lower rates of hospitalization in New York than reported in countries with national health systems. Access may play a role. Clinicians working in immigrant settings should nonetheless maintain a higher vigilance for these conditions among Indian-born persons than among other foreign-born populations. Immigrant populations in industrialized nations are on average healthier than their native-born counterparts . HoweverStudies conducted in countries with national health-care systems have noted approximately twice the risk of hospitalization for ischemic heart disease or myocardial infarction among South Asian immigrant men relative to native-born men aged 45–64 . This amWe set out to describe relative differences in the rates of hospitalization for heart disease, stroke, and diabetes among Indian-born persons relative to native-born persons or other foreign-born persons living in New York City. Unfortunately, there are no national datasets that provide individual level data for the risk of hospitalisation among specific immigrant sub-groups. It is, however, possible to compare the risk of hospitalization among immigrant sub-groups on an area-level using established small area analytic techniques via local datasets with a large sample size . Herein,We obtained all hospital admission records for residents of New York City from the Statewide Planning and Research Cooperative System (SPARCS) and population data for New York City from Census 2000 . The SPAth Revision codes 410, 413, and 428 respectively), stroke (430–438), and diabetes (250) as the dependent variables in each regression model. The following categorical variables were entered as independent predictors: age (0–6, 7–17, 18–44 [reference], 45–64, 65+), sex , education level (completed high school versus no high school [reference]), and country of birth (born in India, other foreign-born persons, and native-born [reference]).We used this model to calculate hospitalizations for manifestations of atherosclerotic heart disease . Indian-born persons, however, are more likely than other foreign-born persons to be hospitalized for stroke; the average foreign-born person has a risk ratio of 0.75 .While the risk of hospitalization for diabetes similar among Indian-born persons and native-born persons , the likelihood of hospitalization for this condition is considerably higher on average than that of other foreign-born persons regardless of sex. Foreign-born persons overall are at 39% the risk of hospitalization for diabetes mellitus .While Indian immigrants to industrialized nations are at similar risk of hospitalization for heart disease, diabetes, and stroke as their native-born counterparts, they are at much greater risk of hospitalization for heart disease, stroke, and diabetes than are immigrants from other countries. Although earlier studies have found differences in the risk of heart disease among Indian-born persons to England and Canada by sex, we found that risks were similar among males and females,11.In an earlier paper, a higher age-adjusted mortality rate due to ischemic heart disease and stroke was noted among foreign-born women relative to native-born women . In thatOur study was subject to a number of important limitations. While the hospitalization data contained insurance status, the census data did not. We were therefore unable to control for insurance status in our study.Given that foreign-born persons in the U.S. approach three times the rate of lacking health insurance as native-born persons (33.4% versus 12.2% respectively), it is pA second limitation was our use of zip-code-only data for the proportion of foreign-born in a neighbourhood, which may be confounded by ecological factors. This was minimized somewhat by examining individual-level hospitalizations for all variables but education and country of birth. It is notable that our data on the foreign-born overall are constant with a growing body of literature showing lower morbidity and mortality among immigrants to the United States than native-born persons.The risk differences we found between native-born persons and persons born in India were not large – for every 100 hospitalizations for heart disease among native-born persons, we would expect 2–3 additional hospitalizations among persons from India. However, the risk of heart disease, cancer and diabetes is significantly higher than those of other immigrant groups with a similarly low prevalence of smoking,10,11. TIndian-born New Yorkers are at substantially higher risk of heart disease, stroke, and diabetes than other foreign-born persons. However, these risks are comparable to that of heart disease, stroke, and diabetes among native-born persons. It is also conceivable that access to health services plays a role in the risk of hospitalisation for heart disease or related conditions given that higher hospitalization rates have been observed in countries with universal health coverage. Prospective data are needed to refine our understanding of the risk factors associated with heart disease in persons from India. As with interpreting data with any epidemiological study, results should not be generalized to clinical practice without first considering the individual patient's socio-demographic risk profile. Nevertheless, clinicians working in facilities serving foreign-born populations may wish to maintain a higher degree of vigilance for heart disease and its risk factors among persons from India.The author(s) declare that they have no competing interests.PM planned the analysis, outlined the study, reviewed the data and regression analyses, and contributed to the development of the manuscript.HJ compiled the data, designed the small area analyses, and conducted the regression analyses.KK contributed to the planning of the analysis and the preparation of the manuscript.The pre-publication history for this paper can be accessed here: