Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly.We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly. Hospitals and regional health authorities in Canada and elsewhere are facing significant resource allocation challenges. Priorities must be set among competing opportunities because demand for health care exceeds available resources. Board members and senior administrators are looking for practical ways to improve how they set priorities under resource constraints. The priority setting literature describes priority setting in various health care contexts -9. It idFairness is a key ethical goal of priority setting when health care resources are scarce. Experience shows that there is often disagreement on what principles should be used to make fair allocation decisions (i.e., distributive fairness) ,17. ThisTo assist decision-makers in developing fair priority setting processes, we conducted one-day workshops for Board members and senior administrators at three Canadian academic health science centres , who were seeking ethics advice on how to improve priority setting in their organisations. Each organization was faced with setting priorities among their clinical services to guide resource allocation under significant budget constraints. The goal of each workshop was to help decision-makers develop a strategy for fair priority setting based on the conditions of A4R. Using case-based plenary sessions to introduce the key concepts  and facilitating consensus through small and large group discussions, we assisted workshop participants in reaching agreement on: a) the criteria decision-makers would use to set clinical service priorities, b) the processes they would follow, and c) the parameters according to which they would evaluate the success of the priority setting exercise.We summarize key lessons learned from these workshops to help decision-makers in other health care organizations develop their own fair priority setting strategies and to improve understanding of researchers and policy makers about priority setting from the point of view of decision-makers.When decision-makers were asked what criteria they would use to set clinical service priorities, we found that responses clustered around eight (8) criteria Table . As a st'Strategic fit' described the extent to which clinical services contributed to advancing the strategic directions of the organisation, i.e., "fit" with the organization's vision, mission, values, and goals. This criterion was consistent with the idea that strategy should be a key driver of operational planning as a counterpoint to planning based on historical or short-term political considerations.'Alignment with external directives' identified existing government mandates and legislated obligations as relevant considerations for setting priorities. For example, each organisation had government directives to provide particular health services at prescribed volumes. This criterion recognised explicitly the limited degrees of freedom within which priorities could be set, but also highlighted the importance for decision-makers of participating with government in achieving regional and provincial health service objectives.'Academic commitments' consisted of two sub-criteria reflective of each organization's close affiliation with a local university and medical school. The 'education' sub-criterion emphasised the role of clinical programs in educating future health care professionals and in facilitating the integration of these activities with health service delivery. The 'research' sub-criterion emphasised the role of academic health science centres in establishing best practice standards, in generating new medical knowledge (including practice-based and bench research), and in developing technological innovation. Workshop participants felt that this criterion affirmed the unique role of academic health science centres in advancing society's health care knowledge and capacity.'Clinical impact' was defined primarily in terms of the service volumes necessary to ensure the clinical competence of medical staff to provide safe and effective care to patients. Other relevant factors included: evidence of effectiveness in health promotion and disease prevention, uniqueness of the health service in the local area, and quality of the service provided. Workshop participants expressed concern about their ability to measure clinical impact given the limitations of their institutional decision support capabilities (e.g., data, trained decision support staff). However, they felt that by identifying these factors, this could provide direction for the collection of appropriate data and information.'Community need' described the health service needs of patients in the organisation's local catchment area. This included current demand for health services, which could be measured on the basis of utilisation rates and waiting list data, as well as future demand based on population data and trends (e.g., aging population). Community need was further defined in terms of the availability of other health service providers. For example, community need was seen to be greater if the organisation were the sole provider of a health service to patients in the region than if there were other local providers whom patients might access for care.'Partnerships' highlighted existing formal agreements and commitments with other organisations in coordinating delivery of health care to defined populations . Partnerships were seen as effective ways to enhance service quality and to optimise resource utilisation within the region or local catchment area.'Interdependency' described the coordination and collaboration between clinical services within the organization to enhance service quality (e.g., through interdisciplinary models of care) or to use institutional resources more efficiently. In the two organisations that had achieving a "healthy" workplace as a strategic goal, workshop participants also related this criterion to quality of work life factors as key enablers of effective clinical coordination and collaboration.'Resource implications' included a cluster of factors related to the mobilisation and use of human and fiscal resources. Although recognising that strategic planning should not be over-determined by operational issues, workshop participants felt that the resource context was relevant for setting clinical service priorities. For example, the implications of prioritisation depended in part on the source of funding , the availability of staff (e.g., nurses) and capital resources (e.g., equipment, space), the flexibility of contractual agreements (e.g., union contracts), and the model of health service delivery, which could be more or less efficient in using available resources.When asked what key process elements would be needed in order for priority setting to be accountable and fair, workshop participants identified ten (10) elements Table . Some ofWorkshop participants identified a number of preparatory steps that should be taken before priority setting can begin:(1) The organisation should establish, refine, or confirm its strategic plan. This is to ensure that the clinical service priorities that emerge through the priority setting process align with and advance the organisation's mission and strategic goals. In effect, workshop participants felt that they needed to know first where the organisation was going so that they could set the right priorities for getting there.(2) The programmatic architecture of the organization  should be clarified in order to set clinical service priorities relative to current activities. This step was also felt to be important for defining precisely what order of clinical service activity was to be prioritised and for creating an accurate inventory of clinical services for prioritisation.(3) The specific responsibilities of the Board and senior management in relation to the priority setting process should be clarified explicitly and upfront. Decision-makers identified some confusion about these responsibilities given that clinical service priority setting involved an overlap of the strategic responsibility of the Board with the operational responsibility of Senior Management. During the workshop, Board members and Senior Managers drafted a memorandum of agreement delineating their respective roles and responsibilities in the priority setting process.Workshop participants also identified a number of elements that were critical to the design of the priority setting process itself:(4) The executive decision-making group should be multidisciplinary and its role should be clearly and explicitly defined in advance of priority setting. Workshop participants emphasised the importance of shared accountability for priority setting across the clinical and administrative leadership. Engaging the medical leadership in a decision-making role was identified as key to developing a successful priority setting process. The engagement of other non-medical clinical leaders (e.g., nursing leadership) was also thought to be important for ensuring the legitimacy of the priority setting process.(5) Stakeholders should be engaged in the priority setting process. Although the organisational executive would ultimately be accountable for making the priority setting decisions, workshop participants felt that stakeholders could be engaged particularly as key informants through expert and broader stakeholder consultation. This consultation should include both internal stakeholders (e.g., staff, patient advisory groups) and external stakeholders .(6) Priority setting criteria should be clearly defined and understood by decision-makers and stakeholders. Data/information should be collected to support their application in the priority setting process. Workshop participants felt that the criteria identified in the workshop could be further refined through stakeholder engagement and tested with decision-makers to ensure a common interpretation of each criterion and consistency in their implementation.(7) An effective communication strategy should be developed to ensure a transparent priority setting process. The purpose of the communication strategy should be to ensure that stakeholders know and understand the scope and necessity of priority setting decision-making, the degrees of freedom within which priority setting would take place (including explicit identification of any "sacred cows" that would be immune from priority setting), and the particularities of the priority setting process (who will do what, how the process will work, and why). In addition, the rationales for priority setting decisions should be communicated to stakeholders and should clearly demonstrate how these decisions are defensible in light of the priority setting criteria and available data/information.(8) Decision review processes should be developed to incorporate opportunities to revisit and review decisions. Workshop participants saw these as additional opportunities to engage stakeholders around difficult priority setting decisions, although they also expressed concern that this might invite conflict between stakeholders and decision-makers. However, it was generally felt that this could be mitigated if decision review processes were focused explicitly on providing a vehicle for new data/information to be brought forward, material errors in the original decision to be corrected based on available data/information, and procedural inconsistencies to be addressed.Workshop participants identified additional elements that were important to improve quality and strengthen capacity for fair priority setting in their organisations over time:(9) Process monitoring and formal evaluation strategies should be developed to ensure quality improvement and to realise a commitment to organizational learning. Workshop participants felt that the process should be monitored for adherence to the conditions of A4R, thus allowing for mid-course corrections to enhance fairness as the priority setting process unfolded. A formal evaluation process after priority setting would allow institutional good practices as well as opportunities for improvement to be captured so that this information could lead to improved priority setting in the future. For example, Martin & Singer have developed an ethics-based quality improvement model that focuses on evaluating and improving the fairness of priority setting processes .(10) The priority setting process should be supported by leadership development and change management strategies to strengthen institutional capacity for priority setting decision-making. Capacity strengthening should focus in particular on middle managers, who may not be among the decision-making group but who would play key roles in communicating with staff and in implementing the priority setting decisions.When asked how they would know that the priority setting process had been a success, workshop participants identified both outcome and process parameters Table . In eithOutcome parameters focused on the effects of priority setting on organizational priorities and budget, on staff, and on the community. Effects on organizational priorities and budget concerned the extent to which the priority setting process was successful in changing organizational priorities and shifting resources, in supporting and/or enhancing the mission of the organization, in contributing to conditions for growth, and in balancing the organizational budget. Effects on staff involved an evaluation of the impact of priority setting on staff satisfaction and morale, organizational recruitment and retention initiatives, and overall understanding of new priorities across the organization. Effects on the community focused on how external stakeholders, including members of the public, regional partners, health care peers , and affiliated academic institutions, responded to the priority setting initiative.Process parameters focused on the efficiency and fairness of the priority setting process. Efficiency of the priority setting process could be evaluated in terms of whether priority setting improved institutional capacity for allocating resources and making priority setting decisions, and whether stakeholders and decision-makers felt that the priority setting process provided a worthwhile return on the time invested to set priorities. Fairness of the priority setting process could be evaluated in terms of whether stakeholders understood and felt engaged in the priority setting process, whether priority setting decisions were justified and seen to be reasonable, and whether 'winners' and 'losers' both felt that they had been fairly treated.ex post facto.It was interesting to us that, although A4R was presented as an ethical framework for fair priority setting, workshop participants did not specifically identify conformity with its conditions as a parameter of success related to fairness. The importance of these conditions is clearly evident, however, among the fairness considerations they cited as well as the process elements they identified as key to setting priorities. Moreover, we had been invited to work with these executive teams precisely because they were seeking an ethical framework through which to improve how they set priorities in their organisations. This suggests to us that A4R was seen by workshop participants primarily as an ethical framework for process design rather than for the evaluation of priority setting processes Our findings from these three priority setting workshops illuminate the complex challenges faced by decision-makers in managing scarce health care resources. The range of criteria identified in the workshops provides insight into the competing goals  and multiple stakeholder relationships that decision-makers must consider in setting clinical service priorities. This is consistent with previous findings that efficiency considerations or simple technical solutions have only limited influence on decision-making and are not sufficient alone to guide priority setting decision-making ,17,24,25Although we report only on three health care organizations, the organisations were all academic health science centres facing similar resource challenges. Consensus around priority setting criteria and processes emerged independently among workshop participants in their large and small group discussions. However, this does not mean that these findings are exhaustive of the priority setting criteria that might be relevant for setting clinical service priorities  or the process elements that would be necessary to ensure a legitimate and fair priority setting process. Moreover, although our approach was based on the notion that fair priority setting requires a normative grounding in procedural justice – in this case, A4R – this does not mean that these findings are normatively 'right' for clinical service priority setting in all health care organisations. An evaluation of the normative 'rightness' depends to some extent on the specific institutional circumstances under which priority setting is taking place, the stakeholders who are affected, and the strategic goals that are being pursued. Experience shows, moreover, that the conditions of A4R are sufficiently general to guide fair priority setting in various institutional settings ,16,20,27Our experience shows that, from the perspective of Board members and senior leaders, our practical approach using A4R offers useful guidance for developing fair and publicly accountable priority setting processes under resource constraints. However, alternative priority setting approaches may also be beneficial. For example, program budgeting and marginal analysis, an economics-based approach, has been used with senior health care administrators in Canada and elsewhere to improve how priority setting optimises health and non-health benefits within available resources . A compaDespite these possible limitations, the lessons we report here fill an important gap in the literature about the criteria, processes, and parameters of success decision-makers would use to set priorities using an ethical framework. We expect that decision-makers in other health care organizations may find themselves in the workshop participants' experience of priority setting and may use these findings as a basis for discussing how they could enhance the fairness and public accountability of their own priority setting processes.• Hospitals and regional health authorities must set priorities in the face of resource constraints.• Decision-makers seek pragmatic ways to set priorities fairly in strategic planning, but find limited guidance from the literature.• We facilitated workshops for board members and senior leadership at three organizations to assist them in developing a strategy for fair priority setting.• Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations.• Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making.The authors were compensated by the health care organizations for facilitating the priority setting workshops and continue to consult with these and other health care organizations.JLG conducted the workshops on which this paper is based, collated and analysed the data, and drafted the manuscript.DKM participated in analysing the data and commented on earlier drafts of the manuscript.PAS conducted the workshops on which this paper is based, participated in analysing the data, commented on earlier drafts of the manuscript, and conceived of the paper.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


RSV is recognized as the most important cause of serious lower respiratory tract illness in infants and young children worldwide leading to hospitalisation in a great number of cases, especially in certain high-risk groups. The aims of the present study were to identify risk groups, outcome and incidences of hospitalisation for RSV bronchiolitis in Norwegian children under two years of age and to compare the results with other studies.We performed a population-based retrospective survey for the period 1993–2000 in children under two years of age hospitalised for RSV bronchiolitis.822 admissions from 764 patients were identified, 93% had one hospitalisation, while 7% had two or more hospitalisations. Mean annual hospitalisation incidences were 21.7 per 1.000 children under one year of age, 6.8 per 1.000 children at 1–2 years of age and 14.1 per 1.000 children under two years of age. 77 children (85 admissions) belonged to one or more high-risk groups such as preterm birth, trisomy 21 and congenital heart disease. For preterm children under one year of age, at 1–2 years of age and under two years of age hospitalisation incidences per 1.000 children were 23.5, 8.7 and 16.2 respectively. The incidence for children under two years of age with trisomy 21 was 153.8 per 1.000 children.While the overall hospitalisation incidences and outcome of RSV bronchiolitis were in agreement with other studies, hospitalisation incidences for preterm children were lower than in many other studies. Age on admission for preterm children, when corrected for prematurity, was comparable to low-risk children. Length of hospitalisation and morbidity was high in both preterm children, children with a congenital heart disease and in children with trisomy 21, the last group being at particular high risk for severe disease. Respiratory tract infections due to respiratory syncytial virus (RSV) are very common in young children worldwide. In temperate climates the infection occurs in yearly winter epidemics, and by two years of age most children have been infected . ReinfecLocal epidemiological studies are important when considering new strategies for the prevention of RSV bronchiolitis. An example of such a strategy is the monthly injection of the humanised murine monoclonal antibody palivizumab to certain high-risk groups, which in many studies has shown a significant reduction in the incidence of hospitalisation for RSV bronchiolitis .The aims of the present study are to identify risk groups, outcome and incidences of hospitalisation for RSV bronchiolitis in Norwegian children under two years of age, and to compare these results with other studies.. The number of children under two years of age born before completed 37 weeks of gestation in the service area during the study period and still alive after the neonatal period was identified from the Norwegian Medical Birth Registry . All children with trisomy 21 have a program for follow-up from birth in our hospital and the number of children under two years of age with trisomy 21 was therefore identified from in-patient and out-patient hospital records. The number of children in the general population with a CHD was not known in the present study and hospitalisation incidences could therefore not be estimated. Overall mortality after the neonatal period as well as the number of children moving out of the service area during the study period were low and have not been corrected for.Akershus is a large suburban and countryside region located around the capital of Oslo with approximately 10% of the total population in Norway. The Paediatric Department at Akershus University Hospital (Ahus) is the only hospital for children under 15 years of age living in the 20 northern, southern and eastern communities of the region and serves all kinds of hospital services, except for paediatric surgery. Deliveries have been rather stable at approximately 3.500 per year in the service area during the last decade. Due to a local agreement infants from approximately 500 unselected term deliveries from our service area are born at Rikshospitalet in Oslo each year, but these infants are admitted to our hospital in case of disease during childhood. The number of children under two years of age living in the service area at any time during the follow-up period were identified from official Norwegian Population Statistics th 1993 to January 31th 2000 and diagnosed as positive with RSV in nasopharyngeal aspirate (NPA). RSV was diagnosed by an enzyme-linked immunosorbent assay (ELISA) for RSV (Abbott TestPack RSV). The test is simple and easy to perform giving a result within 30 minutes. The sensitivity, specificity, positive and negative predictive value is stated to be 74–92%, 86–100%, 81% and 93% respectively [The present study is a population-based retrospective survey on children under two years of age admitted to the hospital with a diagnosis of bronchiolitis ICD 9 & 10) during the period February 5 & 10 dur764 children who fulfilled the diagnostic criteria were identified. A total of 77 children belonged to one or more well known high-risk groups. Of these, 58 children had been born before completed 37 weeks of gestation, some with additional diseases such as CLD (12 children) and CHD (four children). 12 children had a diagnosis of CHD as the only additional disease and seven children had trisomy 21, four of these also diagnosed with CHD. These 77 children were regarded as a high-risk group for subgroup analysis. No children with other well-known risk-factors  were identified. The remaining 687 children were born at term and healthy and regarded as a low-risk group for subgroup analysis.Data were analysed with the statistical programme SPSS, version 11. For analysis of gender we used the Chi square test and for comparisons between low-risk and high-risk groups we used the independent sample T-test. A p-value <0.05 was used as limit for statistical significance.During this seven years follow-up period 764 children (822 admissions) were hospitalised for RSV bronchiolitis. 93% (707 children) had only one hospitalisation and 7% (57 children) had two or more hospitalisations for RSV bronchiolitis during the first two years of life. The highest number of admissions was recorded during the winter months December-April, but cases were also found in late spring and early autumn. Both the number of admissions and peak-time varied between seasons but with no specific pattern of variability figure . A signiThe majority of children  were hospitalised within the first year of life with children less than six months old being responsible for 45% of all admissions. Median age at hospitalisation was 6 months (range 0–23 months) and a median length of stay of 4 days range 1–41 days) was observed (table –41 days During the study period nine children (1.2%) developed severe respiratory distress and needed mechanical ventilation and two of them (0.3%) died. Four of these children had no known risk-factors for severe disease. However, the two children who died were both considered as high-risk patients, one of them was diagnosed with CHD and the other with trisomy 21 as well as CHD.Of all RSV hospitalisations during the first two years of life 58 children (64 admissions) were born before completed 37 weeks of gestation with a median gestational age of 30 weeks (range 24–36 weeks). A significant male predominance of 68% was also observed in this group (P = 0.006). Median age on admission, after postnatal age, was 8 months (range 0–23 months). When corrected for prematurity (corrected age), median age on admission was 5.4 months (range -2.5–21.3 months). Also, a median length of hospitalisation of 8 days (range 2–27 days) was observed (table Seven children (eight admissions) diagnosed with trisomy 21 were hospitalised for RSV bronchiolitis during this follow-up study. Four of them also had a CHD. Two children needed mechanical ventilation during hospitalisation and one of them subsequently died.A median age on admission of 9.0 months (range 1–20 months) and a median stay of 7.5 days (range 2–34 days) were recorded for children in this particular risk group  and median stay of 6.0 days (range 2–14 days) was observed  were hospitalised for RSV bronchiolitis, giving a hospitalisation incidence under two years of 153.8 per 1.000 children.In this retrospective study, as in many other comparable epidemiological studies, we found that RSV bronchiolitis appears as an annual winter epidemic with relatively high hospitalisation incidences, predominance of boys, young age, short length of stay, few complications and low mortality . The ratSeveral international studies have shown an increased incidence of RSV-related hospitalisations over the last two decades. A Norwegian study for the period 1972–78 showed a mean hospitalisation incidence of 9.5 per 1.000 children for children under one year of age compared to our much higher incidence of 21.7 per 1.000 children for the period 1993–2000 in the same age group . Also, fOur study showed that only 1.2% of the children in the study population needed mechanical ventilation. This result is lower than in many other studies . On the Another observation in our study was that among the mechanically ventilated children 44% had no underlying risk-factors for severe disease. Further research into why some otherwise healthy children have a severe course of RSV bronchiolitis is therefore very important, not least when trying to define risk groups even better . ResearcFor the population at large our study showed, as in other studies, a low mortality. A total of two children (0.3%) died, one had trisomy 21 with an atrioventricular septum defect (AVSD) and the other had an underlying CHD.The number of high-risk children in our study is relatively small and the results should be interpreted with caution. The mean hospitalisation incidences for preterm children were lower than in many other studies, even though 20% of the preterm children suffered from CLD as well and had a low median weeks of gestational age (wGA) of 30. One possible explanation is that the population data for this particular risk group was not corrected for migration out of our service area and mortality after the neonatal period. However, it is unlikely that such corrections would significantly influence the results. Another explanation for the low incidence among preterm infants might be that most of them are hospitalised up to almost 40 wGA and are discharged only when the child has reached a weight of more than 2.000 g and have normal oral feedings. This means that they are more or less completely protected from RSV for a long period after birth. Our routines with focus on good parental information on how to protect the newborn infant from RSV after discharge from hospital might also be important. Median length of hospitalisation for preterm children was in our study significantly longer when compared to the low-risk children and is in accordance with results from many other larger studies.Children with CHD are a wellknown risk-group for severe RSV disease. Children with trisomy 21 with or without a concomitant CHD should also be considered a high-risk group. Our study showed a mean hospitalisation incidence per 1.000 children under two years of age with trisomy 21 more than 11 times the whole study population. Even more important, out of a total of seven children with trisomy 21, two needed mechanical ventilation and one child died. We would, however, recommend a larger study to meet these observations for children with trisomy 21.One of the findings in our study was the large proportion of otherwise healthy children needing mechanical ventilation. Our numbers are small, but when new policies to prevent severe RSV bronchiolitis are discussed this aspect should also be considered. The research for improved identification of risk-groups and development of an effective vaccine for immunization should therefore be given high priority.While the overall hospitalisation incidences and outcome of RSV bronchiolitis were in agreement with other studies, hospitalisation incidences for preterm children were lower than in many other studies. Age on admission for preterm children, when corrected for prematurity, was comparable to low-risk children. Length of hospitalisation and morbidity was high in both preterm children, children with a congenital heart disease and in children with trisomy 21, the last group being at particular high risk for severe disease.The author(s) declare that they have no competing interests.Our individual contributions to the study have been as following: HOF had primary responsibility for protocol development, outcome assessment, data acquisition and analysis and writing of the manuscript. TF participated in the development of the protocol and analytic framework of the study, and contributed to the writing of the manuscript. DB participated in the data analyses and the writing of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


One of every 6 United Status birth certificates contains no information on fathers. There might be important differences in the pregnancy outcomes between mothers with versus those without partner information. The object of this study was to assess whether and to what extent outcomes in pregnant women who did not have partner information differ from those who had.We carried out a population-based retrospective cohort study based on the registry data in the United States for the period of 1995–1997, which was a matched multiple birth file . We divided the study subjects into three groups according to the availability of partner information: available, partly missing, and totally missing. We compared the distribution of maternal characteristics, maternal morbidity, labor and delivery complications, obstetric interventions, preterm birth, fetal growth restriction, low birth weight, congenital anomalies, fetal death, neonatal death, post-neonatal death, and neonatal morbidity among three study groups.There were 304466 twins included in our study. Mothers whose partner's information was partly missing and  totally missing tended to be younger, of black race, unmarried, with less education, smoking cigarette during pregnancy, and with inadequate prenatal care. The rates of preterm birth, fetal growth restriction, low birth weight, Apgar score <7, fetal mortality, neonatal mortality, and post-neonatal mortality were significantly increased in mothers whose partner's information was partly or  totally missing.Mothers whose partner's information was partly and  totally missing are at higher risk of adverse pregnant outcomes, and clinicians and public health workers should be alerted to this important social factor. Pregnancy outcomes are not only important measures of health status of the mothers and infants, but are important measures of socioeconomic development in a society. For example, infant mortality has been considered the single most comprehensive measure of the health and wealth in a society ,2. Both Epidemiologic studies based on a data with missing information on exposure, outcomes, and potential confounders can bias the study results, unless the missing occurred randomly . PreviouWe used a large twin registry data in the United States to examine this issue. This data has been used in several peer-reviewed studies -14. The We used the matched multiple birth file created by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention . The mulThere were two variables for the partners in the data: partner's age and race. The eligible study subjects were divided into three groups according to the availability of the two variables of the partners: both available (group 1), one missing (group 2), and both missing (group 3).nd stage <3 hours), prolonged labor (2nd stage >20 hours), dysfunctional labor, breech, malpresentation, cephalopelvic disproportion, cord prolapse, anesthetic complications, and fetal distress), and obstetric interventions (cesarean section, vacuum / forceps, and labor inductions) among the three study groups. Finally we compared the rates of fetal and neonatal mortality and morbidity among the three study groups. We used the Chi-square test to test the difference of all rates among the three study groups, used the normal approximate method to calculate the 95% confidence interval of the rates of maternal medical complications, labor and delivery complications, obstetric interventions, and the fetal and neonatal mortality and morbidity. We calculated the relative risk in group 2 and group 3 compared with group 1 for all the outcomes mentioned above. Fetal death was defined as stillbirth weighing 500 grams or more, or if weight was unknown, 20 completed gestation weeks or more. Neonatal death was defined as live-born infant died at 0–27 days of age, and post-neonatal death was defined as those died at 28–364 days of age. Preterm birth (PTB) was defined as gestational age < 37 weeks. Fetal growth restriction (FGR) was defined as less than 10th percentile of birth weight-for-gestational-age z score. The birth weight-for-gestational-age z score was calculated using the following formula:We first described the distribution of the maternal characteristics  of the three study groups. The prenatal care service was defined as adequate, intermediate, and inadequate according to the time of prenatal care visit initiation and the number of prenatal visit using the method described by Kessner et al . If the Z = (observed birth weight - mean of birth weight)/SDWhere mean and SD was based on all infants in the database, stratified by gender and gestational week. Low birth weight (LBW) was defined as birth weight <2500 grams. Low Apgar score was defined as five minute Apgar score < 7. Anemia was defined as hemoglobin <13. Other fetal and infant outcomes examined included birth injury, hyaline membrance disease, meconium aspiration syndrome, assisted ventilation (<30 minutes and > = 30 minutes), seizures, central nervous system anomalies, circulatory / respiratory anomalies, digestive system anomalies, urogenital system anomalies, musculoskeletal / integumental anomalies, and chromosomal anomalies.There were 304466 twins (152233 twin pairs) in the database. Of which, father's age and race were recorded in 259302 twins (129651 twin pairs, 85.17%, group 1), father's age or race was missing in 6036 twins (3018 twin pairs, 1.98%, group 2), and both father's age and race were missing in 39128 twins (19564 twin pairs, 12.85%, group 3).Table Table Table Our large population based study found that the risks of fetal and infant mortality, low birth weight, preterm birth, fetal growth restriction, Apgar score <7, and the need for mechanical ventilation were increased in infants born to mothers with missing information on partner's age or race, especially when both variables of the partner were missing. The women reported no information (or reported only part of the information) on partners appear to have higher prevalence / incidence of most of the maternal morbidity and obstetric complications than in mothers with available information on partners. The poorer pregnancy outcomes observed in women with partner's information been partly and  totally missing than in women with available information on partners were due largely to known important socioeconomic factors for adverse pregnancy outcomes. Many of these women were teenagers, black race, unmarried, with low education, high frequency of cigarette smoking, and inadequate prenatal care services. Teenagers , black rOur findings that the rates of FGR, LBW, Apgar score <7, hyaline membrane disease, and assisted ventilation were significantly higher in the group with paternal information totally missing than the group of only partly missing suggest that the totally missing group is a particularly high risk group, whereas in the partly missing group, the missing may have occurred in randomly.Exceptions did occur, however. For example, the occurrences of several maternal medical conditions, such as cardiac disorders, diabetes, and RH sensitization, were actually lower in women with no available information on partners (group 2 and 3) than women with available information on partners (group 1). This may, in part, be due to the younger maternal age in groups 2 and 3 than in group 1. The risk of cardiac disorders and diabetes increases rapidly with advancing age ,22. YounOur study examined the difference of adverse pregnancy outcomes among three study groups in twins only. It is biologically plausible to apply the study findings to singletons and higher order of multiple pregnancies as well, although the magnitude of the differences may be smaller in singletons and larger in higher order of multiple pregnancies than in twins.Since in the database, there was no indication why a particular variable was not recorded, we can only speculate the reason of missing partner's information. Corresponding variables (i.e., age and race) for the mothers, including those mothers with missing information on partners, were completely recorded. These women may have no relationship or only remote relationship with their partners, as suggested by the extraordinarily high unmarried rates (61% for women missing one variable on their partners and 96% for women missing both variables on their partners). As a result, they may have difficulty or for unknown reasons they may be reluctant to provides partner's information. The paternal information missing may be a comprehensive measure and may be related with age, education, socioeconomic status, race, religion background, or even the reporting quality in different place. Our study only described the association between the paternal information missing and the adverse pregnancy outcomes. Exploration of the reasons of missing partner information and its relationship with adverse pregnancy outcomes require in-depth analysis of data with relevant information.Women with no available information (or partly) on partners appear to have higher risks of developing adverse pregnancy outcomes. For this reason, extra attention for these women and their offspring by health care providers and public health workers is needed.The authors declare that they have no competing interests.Hongzhuan Tan carried out the data analysis and drafted the manuscript. Shi Wu Wen designed the study and helped in results interpretation. Mark Walker participated in the sequence alignment and participated in the results interpretation. Kitaw Demissie participated in the study design and results interpretation.The pre-publication history for this paper can be accessed here:


Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) commonly require hospitalization and admission to intensive care unit (ICU). It is useful to identify patients at the time of admission who are likely to have poor outcome. This study was carried out to define the predictors of mortality in patients with acute exacerbation of COPD and to device a scoring system using the baseline physiological variables for prognosticating these patients.Eighty-two patients with acute respiratory failure secondary to COPD admitted to medical ICU over a one-year period were included. Clinical and demographic profile at the time of admission to ICU including APACHE II score and Glasgow coma scale were recorded at the time of admission to ICU. In addition, acid base disorders, renal functions, liver functions and serum albumin, were recorded at the time of presentation. Primary outcome measure was hospital mortality.Invasive ventilation was required in 69 patients (84.1%). Fifty-two patients survived to hospital discharge (63.4%). APACHE II score at the time of admission to ICU {odds ratio (95 % CI): 1.32 (1.138–1.532); p < 0.001} and serum albumin (done within 24 hours of admission) {odds ratio (95 % CI): 0.114 (0.03-0.432); p = 0.001}. An equation, constructed using the adjusted odds ratio for the two parameters, had an area under the ROC curve of 91.3%. For the choice of cut-off, sensitivity, specificity, positive and negative predictive value for predicting outcome was 90%, 86.5%, 79.4% and 93.7%.APACHE II score at admission and SA levels with in 24 hrs after admission are independent predictors of mortality for patients with COPD admitted to ICU. The equation derived from these two parameters is useful for predicting outcome of these patients. Chronic obstructive pulmonary disease (COPD) is characterized by irreversible airway obstruction that leads to chronic disability. Patients with COPD have a longstanding downhill course that is interspersed with episodes of exacerbations requiring hospitalization. COPD is known to be a common disease. There is lack of recent data regarding the burden of this disease from India, with only study on prevalence of COPD published in 1981 . During It is important to identify patients at the time of admission who are likely to have poor outcome, so that such patients can be managed aggressively. Many prognostic scoring systems have been devised for the same purpose. These scoring systems help to segregate patients who are the sickest and are likely to die from those who are expected to have better outcome and survive. Most of these scoring systems have been devised for a broad range of critically ill patients. The present study was planned to determine the predictors of mortality in patients with exacerbation of COPD admitted to ICU over a one-year period. An attempt was made to develop a scoring system using the predictors of mortality that would help to identify patients at high risk of dying.Prospectively collected data of patients with acute respiratory failure secondary to COPD admitted to medical ICU of All India Institute of Medical sciences, New Delhi, India (a tertiary care center in north India) over a one-year period (January 2002 to December 2002) was reviewed. Diagnosis of COPD was based upon the characteristic findings on history and examination with typical radiographic abnormalities . Patient2 despite maximal pharmacological treatment and deteriorating acidemia. Initiation of weaning from mechanical ventilation was considered as soon as the patients were considered capable of breathing spontaneously. Method of weaning trials included t-piece trials, gradual reduction of synchronized intermittent mandatory ventilation (SIMV) breaths and pressure support ventilation (PSV).Management of the patients was the primary responsibility of the ICU team. A treatment strategy was individualized for each patient and was the sole prerogative of the treating physician. All patients received regular nebulized bronchodilators including salbutamol (as frequently as 5 mg every 15 minutes to every 8 hours), ipratropium bromide (as frequently as 0.5 mg every 15 minutes to 0.25 mg every 8 hours), and intravenous corticosteroids. Most patients also received antibiotics (n = 75, 91.5%). Oxygen therapy (2-3 lt/min) was administered to spontaneously breathing patients. The decision to institute ventilatory support was taken by the treating physician. Wherever feasible non-invasive ventilation (NIV) was used as the initial strategy. Endotracheal intubation was done for usual indications such as respiratory arrest, deteriorating level of consciousness, rising PaCO2 / FiO2 ratio less than 200 without any evidence of left atrial hypertension (American-European Consensus Conference) [eg, pneumonia) and two or more of the following: temperature > 38°C or < 36°C; heart rate > 90 beats/min; respiratory rate > 20 breaths/min or PaCO2 < 32 mm Hg; and WBC count > 12 × 109/L, < 4.0 × 109/L, or > 0.10 immature forms (ie, bands)  [Clinical and demographic profile at the time of admission to ICU including age, sex, smoking status, history of previous hospital admissions, history of previous intubation and/or ventilatory support, prior evidence of cor pulmonale with or without congestive heart failure were recorded. Findings on clinical examination including heart rate, respiratory rate and mean blood pressure were recorded. Acute physiology and chronic health evaluation II (APACHE II) score and Glasgow coma scale (GCS) were recorded at the time of admission to the ICU. Acid-base abnormalities at the time of presentation were analyzed by recording the arterial blood gas analysis and serum electrolytes (estimations done on AVL 995S). Renal functions, liver functions and serum albumin (SA) done at the time of admission were also recorded. Development of complications during mechanical ventilator such as pneumothorax and ventilator associated pneumonia (VAP) were recorded. Development of acute respiratory distress syndrome (ARDS), sepsis and multi-organ failure was also documented. ARDS was defined as presence of bilateral pulmonary infiltrates on chest radiograph in presence of hypoxemia with PaOSPSS version 10.0' (SPPS Corp, Chicago, IL, USA). Descriptive analysis consisted of mean with standard deviation and range for various parameters. Study group was split on the basis of final outcome. Various parameters were compared between the two groups to identify the predictors of mortality. Continuous variables were analyzed using student's t-test whereas Fisher's exact test was used to compare the ordinal variables. Baseline parameters significant on univariate analysis at p < 0.1 were identified as potential predictor variables. These parameters were evaluated using multivariate logistic regression analysis (backward stepwise method) to determine independent predictors of mortality. An equation was constructed using the independent predictors based on the adjusted odds ratios and a diagnostic rule was defined. To evaluate the predictive capability of the variables and the equation, receiver-operator characteristic (ROC) curves were constructed with sensitivity (on X-axis) and 1-specificity (on Y-axis) for various cut-offs. Significance was considered at p < 0.05 (only two tailed) for the present study.Data were double entered to minimize errors and managed on an 'Excel' master sheet. Analysis was done using the statistical software 'Demographic and baseline clinical and laboratory profile of the study group are presented in Table Non Invasive Ventilation (NIV) was used as initial strategy in 17 patients (20.7%). This strategy had a success rate of 59% (n = 10). Sixty-nine patients (84.1%) received invasive ventilation (including seven patients who failed NIV and had to be intubated). Sepsis developed in 11 patients (13.4%) and all these patients eventually died. Parameters associated with development of sepsis were high APACHE II score (18 vs. 12, p = 0.005) and low SA (2.6 gm/dL% vs. 3.3 gm/dL, p < 0.001). VAP developed in 6 patients (8.7%) and was associated with an increased stay in the ICU (18 days vs. 10 days, p = 0.021) as well as increased stay in the hospital (30 days vs. 15 days, p = 0.005). Outcome was not significantly affected by development of VAP (50% versus 42.8%).Hospital mortality was 36.6% (n = 30). Various parameters were compared for survivors and non-survivors table . In addiPrimary outcome measure of the present study was hospital mortality. Overall mortality rate was 36.6%. There was a high incidence of need of MV (84.1%). In studies that have taken into account all the patients with COPD requiring hospitalization, mortality rate has been to the tune of 6-42% -10. Weis2 [2 and HCO3 were not independent predictors of mortality they tended to be lower in patients who died and the difference was statistically significant on bivariate analysis. Also, mean pH was similar for the two groups. This has not been reported in the earlier studies and investigators in the past have mostly found high PaCO2 levels to be associated with worse outcome. A possible reason for this finding is that patients with hypercapnia with concordantly high HCO3 are usually taken care of by mechanical ventilation. On the other hand, low mean PaCO2 and HCO3 levels in non-survivors probably reflected underlying metabolic acidosis. It has been reported earlier also that, for similar level of acidosis, patients with respiratory failure resulting in respiratory acidosis have better outcome as compared to patients with metabolic acidosis, that is commonly secondary to associated non-pulmonary organ failure [2 as well as HCO3) whereas non-survivors consisted of patients with metabolic acidosis (lower PaCO2 and HCO3 but similar pH). Another finding that corroborates the same fact is that all patients, who had associated renal failure and/or sepsis, died. The incidence of these two complications was significantly higher in non-survivors . Patients with both these complications commonly have associated metabolic acidosis.Various physiological parameters estimated at the time of presentation were analyzed to find predictors of mortality. Only two parameters, namely APACHE II score at admission to ICU and SA in the first 24 hours of admission, were found to be independent predictors of hospital mortality. The same two parameters also predicted development of sepsis on bivariate analysis. Some of the earlier studies have found blood gas parameters like pH  and PaCO2  to be us2 -16 did n failure . Mean pHPrognostic utility of APACHE II score has been extensively investigated. It has been found useful for prognosticating critically ill patients across a wide array of diagnostic categories. Earlier studies have also found APACHE II score to be useful in predicting mortality in COPD patients with acute exacerbation -21 althoAn important purpose of the present study was to define predictors, which could help to identify patients that are likely to have worse outcome. This would help us to segregate patients who need to be managed aggressively from the very beginning. We looked at individual predictive utility of the parameters (SA and APACHE II score) that were found to be independent predictors of mortality. Both these parameters had good predictive value as evidenced by high AUC values. To improve the predictive utility, an equation was constructed using the adjusted odds ratio of the two parameters. ROC curve for this equation had a superior AUC value of 0.912. A good prognostic marker needs to be highly specific so that false positives remain low. On the other hand, good sensitivity is also desirable so that false negatives are not too high. A cutoff value of -2.97 has been suggested, which is associated with good specificity (86.5%) as well as sensitivity (90%) for predicting mortality of these patients. Cut-off that were associated with 100% specificity and sensitivity were also determined as different ICU's across the globe may have different priorities at different times.Although prospective studies are required to validate the findings of present study, an equation devised by combination of APACHE II score and SA appears to make sense. Estimation of APACHE II score makes use of various physiological variables but does not include SA levels. Also, the chronic physiology score in APACHE II fails to stratify patients according to varying severity of chronic illnesses. This tends to happen in patients with COPD as well. Use of SA, which predominantly reflects the severity of chronic illness, in the equation seems to complement the predictive capability of APACHE II score. The results of the present study reflect the complex interplay of factors that occurs in patients with exacerbation of COPD. In these patients, an acute insult in the form of exacerbating illness develops on top of a chronic smoldering illness. Severity of both acute insult as well as the underlying disease in the background of the level of nutritional status tends to determine the outcome of these patients.Although the equation is useful in to identifying patients with exacerbation of COPD who are likely to have poor outcome, it cannot be looked at in isolation. Other particulars of these patients such as associated illnesses and co-morbidities must be kept in mind before taking a final decision. It cannot be overemphasized that given the sensitivity and specificity of the equation, certain patients with a score below the suggested cut-off may also be sick. Also, the state of patients with exacerbation of COPD tends to remain in a constant flux and need constant monitoring. In spite of having a low score at presentation many of these patients may deteriorate during hospital stay.It is concluded that APACHE II score at admission and SA levels with in first 24 hrs after admission are independent predictors of mortality for patients with exacerbation of COPD. The equation derived by combining these two parameters is useful for identifying patients that are likely to have poor outcome.The author(s) declare that they have no competing interests.GCK: concept and design of study, management of patients, preparation of the manuscript. AB: concept of the study, management of patients, statistical analysis, preparation of the manuscript. SKS: management of patients and critical review of the manuscript.The pre-publication history for this paper can be accessed here:


Long-range communication requires special technology. Although we usually think of nerve cells communicating over distances measured in millimeters, they must also stretch over centimeters and even meters to enable movement and sensation throughout our bodies. In a disorder known as spastic paraplegia, people experience stiffness and loss of function in their legs because the far ends of the longest nerves in the spinal cord degenerate. One form of this disease, autosomal dominant hereditary spastic paraplegia (AD-HSP), is most frequently caused by mutations in a gene that codes for the enzyme Spastin.Until recently, the function of Spastin has only been inferred by its similarity to another protein, Katanin, which chops up microtubules. The microtubules in neurons, as in all types of cells, provide a network to transport materials from one place in the cell to another. For neurons to communicate with each other and with muscles, neurotransmitters packaged at one end of the cell make the journey through the cell's long, narrow axon on the backs of microtubules. At the other end of the cell, the neurotransmitters reach small cellular projections (boutons) where they are released as a signal to the receiving cell. Since long spinal cord axons are most often affected by AD-HSP, researchers have suggested that transport through axons might be culpable.Drosophila by identifying the spastin gene in this species and manipulating its expression.Is there a link between Spastin, microtubule severing, and AD-HSP? To address this question, Nina Tang Sherwood and colleagues studied the function of Spastin in the fruitfly Drosophila Spastin in neurons regulates microtubule networks. Overexpressing spastin caused collapse of the embryonic central nervous system and also eliminated the microtubule network, as expected based on the related Katanin protein's microtubule-severing activity. But—surprisingly—knocking out spastin did not yield the opposite result. spastin-null flies had fewer microtubule bundles, particularly at the far ends of the neurons. They also exhibited smaller and more numerous boutons that were unusually clustered together.They found that indeed On the basis of their results, the authors speculate that Spastin cuts microtubules to a manageable size. Too much Spastin chops the microtubules into useless fragments, but too little Spastin may leave microtubule polymers too large to be efficiently moved into newly forming boutons. With an intermediate amount, microtubule pieces are the right size for transport throughout the neuron.spastin-null flies, neurotransmitter release is impaired and flying is impossible. Flies even tend to drag their hind legs. This weakness in the legs is just one compelling parallel to human AD-HSP. The severity of symptoms in people is highly variable, similar to the variability in phenotypes exhibited by Drosophila with intermediate spastin gene mutations. The authors caution, however, that they do not prove that the fly phenotypes observed arise through the same mechanisms that cause human AD-HSP. The utility of Drosophila as a model for human AD-HSP has yet to be demonstrated, but the importance of Spastin in regulating neuronal microtubule networks in vivo is no longer in doubt.Without Spastin, normal motor function ceases. In


Mental chronometry, which has origins dating back over a century, seeks to measure the time course of mental operations in the human nervous system How do we relate human thought processes to measurable events in the brain? Mental chronometry, which has origins that date back more than a century, seeks to measure the time course of mental operations in the human nervous system . From thIn the 1950s, studies of reaction time were combined with the then-developing mathematical theory of information  to addreRecording the average event-related electrical potentials from scalp electrodes became a research tool in the 1960s, with the advent of analog and then digital computers to accomplish the recording and averaging. It became clear that components of the event-related potential could be systematically related to sensory and motor stages of information processing. For instance, a visual stimulus was found to evoke a short-latency scalp response from the primary visual cortex at about 60 milliseconds, followed by positive and negative voltage changes in neighboring visual areas. Similarly, scalp recorded potentials from the frontal cortex could be recorded in relation to motor activity. It was now possible to observe some of the sensory and motor stages that were inferred from Donders's subtractive method   and lateWhen the fMRI method for localization is brought together with methods that can accurately measure timing of the same activity  they can provide considerable insight into the nature of thought. Consider the simple task of deciding whether a presented digit is above or below five . DehaeneMoreover, scalp-recorded, event-related potentials showed a separate scalp distribution and latency for each variable . SubsequOf course, not all human activities involve a set of exhaustive and independent serial stages that can be shown to add up to the overall reaction time. While tasks like the number comparison discussed above can be usefully divided into stages, some components may deal with simultaneous operations and may be limited only by a total capacity of central mechanisms. We know that many situations involve parallel processing and feedback loops at many levels. Sternberg has attempted to apply a modified version of additive factor theory to brain systems using neuroimaging that allows for some of these possibilities ,16.PLoS Biology, Sigman and Dehaene [Laboratory studies often use the simultaneous execution of two different tasks  to simulate the more realistic situations where humans time-share activities. In this issue of  Dehaene  provide Many cognitive and emotional tasks studied with neuroimaging have implicated a small number of brain areas that are consistently active. Mental chronometry plays a role in suggesting the cognitive operations that each of these areas performs and how they are organized in real time. The toolkit of new techniques provides the basis for further tests to evaluate whether a chronometric model reveals a crucial set of connected computations (circuit) for carrying out the task. For example, using a magnetic pulse delivered outside the skull, it is now possible to induce a reversible lesion at the time of a particular computation to determine whether the specific computation assigned to a given area is truly needed to carry out the task. Studies using diffusion tensor imaging can examine whether there are large-scale connections between neural areas posited by a particular model. In describing the links between brain and behavior, mental chronometry is still a cornerstone that binds psychology to the techniques of neuroscience.


Nobody should do a new research study, says Clarke, without first systematically reviewing the literature. And journal editors should insist that all research papers are accompanied by an up-to-date systematic review Nobody should do a trial without reviewing what is known On May 2, 1898, George Gould used his address to the founding meeting of the Association of Medical Librarians in Philadelphia to present a vision of the future of health information. ‘I look forward,’ he said, ‘to such an organisation of the literary records of medicine that a puzzled worker in any part of the civilised world shall in an hour be able to gain a knowledge pertaining to a subject of the experience of every other man in the world’ [In these early years of the 21st century, with tens of thousands, if not hundreds of thousands, of new research articles being published every year, people who need to make decisions about health care are much more overwhelmed with information than they were in 1898. Some of this information is of good quality, but some of it is not. Thus, anyone wishing to use the health literature to make well-informed decisions must both identify the relevant research from amidst this vast amount of information and then appraise it. This is an impossible task for many. Even though making access to the literature easier and cheaper will increase the ability of people to find research, it will also reveal just how much information there is out there and how daunting is the task of making sense of it.www.ncbi.nlm.nih.gov/PubMed). What about if you searched the whole of the Internet with one or more search engines? Almost certainly, as the speed of the search increased through these four approaches, so would the number of articles retrieved—and also the time that it would take to read through them, appraise them, and decide if they were relevant to whatever decision you were trying to make.You can get a good idea of the size of the task—and of how electronic publishing and the Internet have transformed the situation—by imagining the following four steps. How long would it take to find articles in your area of interest by paging through back copies of a relevant journal? What about by using its index? Now imagine finding articles of interest to you by going to the Internet and searching PubMed  in 1997 and 2001 found that this was not the case, at least for these journals. Only two of more than 50 reports of randomised trials in these journals in May of those two years included an updated systematic review [If today's health researchers discussed their findings in the context of relevant, already-existing research, many of the problems of information overload would be eased. You would only need to find the most recent report of a relevant study; its discussion section would place that study within the context of an updated systematic review. This was suggested by the original CONSORT statement on the reporting of randomised trials in 1996 . HoweverIncluding an updated systematic review along with a report of a randomised trial (or any other piece of research) might seem too much to expect of researchers, who might not feel able or willing to do the additional work required. However, the absence of a review should raise the question: on what did the researchers base the design of their new study? To embark on a new study without first systematically reviewing what has been done before is to risk doing research for which the answer is already known. It would also mean that the researchers had denied themselves the opportunity to learn from the successes and failures of others when designing their own study. In addition, researchers have a responsibility to the participants in their research to make sure that the study is of the most appropriate design possible. To help make sure that this is the case, when designing a new study researchers should ensure that they have been adequately informed about what research has been done previously. Conduct a systematic review of your research question before embarking on a new study, or identify a relevant review done by someone else.Design your study to take account of the relevant successes and failures of the prior studies, and of the evidence within them.Discuss the findings of your study in the context of an updated systematic review of relevant research.Publish the systematic review within, alongside, or shortly after the report of your study.Provide information from your study to others doing systematic reviews of similar topics.www.cochrane.org) [www.york.ac.uk/inst/crd/darefaq.htm). And with the ability to publish longer versions of articles on the Internet than are practical in print, concerns about article length should no longer be a barrier to the inclusion of a systematic review.It might even be the case that the researchers are able to draw on the work of others, who already have done a systematic review of the relevant topic. Over the last decade, The Cochrane Collaboration  has prodane.org) . There awww.cochrane.org) is an international, nonprofit, and independent organisation dedicated to helping people make well-informed decisions about health care by preparing, maintaining, and promoting the accessibility of systematic reviews. These reviews are published electronically in The Cochrane Library, which is available on the Internet and CD-ROM. The Cochrane Collaboration was established in 1993 and is named after the British epidemiologist, Archie Cochrane.The Cochrane Collaboration  within the new study, alongside it, or shortly thereafter.Returning to George Gould's vision, but bringing it into the modern era, I hope for a system in which everyone making a decision about health care in any part of the world would be able, in 15 minutes, to obtain up-to-date, reliable evidence of the effects of interventions they might choose, based on all the relevant research. Journals, especially new ones such as


The mean age at first ICD implantation was 42 ± 14 years. Brugada syndrome, as well as other primary electrical diseases (e.g. long QT), were systematically excluded in all patients by the absence of the typical electrocardiogram  at rest and/or after pharmacological tests . Recurrence of cardiac events was prospectively assessed.During a mean follow-up period of 41 ± 27 months, VF recurrence with appropriate shock occurred in 7 patients (39%) covering a total of 27 shocks. The median time to first appropriate shock was 12 ± 9 months. There were no deaths. In the electrophysiological study, 39% of patients were inducible, but inducibility failed to predict subsequent arrhythmic events. Forty-four percent of patients suffered 21 inappropriate shocks, which were caused by sinus tachycardia, atrial arrhythmias or lead malfunction.excluding patients with the Brugada syndrome or other known causes. ICD prevents sudden cardiac death but inappropriate shocks remained a major issue in this young and active population.Idiopathic ventricular fibrillation patients have a high recurrence rate of potentially fatal ventricular arrhythmias,  Idiopathic ventricular fibrillation (VF) is defined as spontaneous ventricular fibrillation in the absence of any structural heart disease, including coronary artery disease, valvular heart disease, myocarditis, cardiomyopathy or electrophysiological diseases, with a well-defined cause, such as the long QT syndrome, the Brugada syndrome, ventricular pre-excitation (WPW), and drug intoxication . The conBrugada syndrome is characterized by a unique electrocardiographic (ECG) pattern of right bundle branch block with ST elevation in the right precordial leads. Transient forms of the disease in which the ECG normalizes for a period of time have been described. Administration of sodium channel blockers will unmask the abnormal ECG in patients with transient normalized ECGs ,3. The AThe total population under investigation included 455 consecutive patients who received a third generation ICD, with stored electrograms capabilities for hemodynamically poorly tolerated ventricular tachyarrhythmias, from 1992 to 2000. Of these, 29 were initially diagnosed as idiopathic VF associated with a structurally normal heart, normal left and right ventricular ejection fraction and normal coronary arteries. During the follow-up, 11 patients developed a new diagnosis potentially explaining VF, and were excluded from the final analysis. Four had right ventricular dysplasia, 5 had Brugada syndrome with the typical ECG manifestations after a drug challenge, and 2 patients had long QT syndrome. A final diagnosis of idiopathic VF was made in the remaining 18 patients. All patients had survived either an episode of cardiac arrest due to VF (12 patients) or a syncopal episode associated with documented self-terminating polymorphic ventricular tachycardia or fibrillation (6 patients). In 15 patients, the documented VF was seen during daily activity (one episode during sustained effort) and in 3 patients, during night-time. Out of the 18 patients, 10 had a previous history of unexplained syncope.torsade de pointes, catecholamine-induced polymorphic VT, and Brugada syndrome. No patient had a past history of ischemic heart disease, congestive heart failure or family history of unexpected sudden cardiac death. All patients had a normal physical examination, blood testing and exercise test. Structural heart disease was excluded in all by echocardiography, cardiac catheterization including right and left ventricular angiography and coronary angiography. Patients on anti-arhythmic therapy before their cardiac arrest were excluded from the study, as well as those with electrolyte disturbances, history of significant alcohol or drug abuse or prolonged QTc. Of the 18 patients, 10 patients had normal right ventricular endomyocardial biopsy and 8 patients had a normal cardiac magnetic resonance imaging. Moreover, in 5 patients, an ergonovine provocation test was performed to exclude coronary artery spasm. Brugada syndrome was systematically excluded in all patients by negative serial ECG recordings with the typical coved or saddle shaped-type ST-segment elevation in the right precordial leads. All patients received iv administration of a sodium channel blocker to unmask a concealed form of the disease and all tests were negative. Flecainide (2 mg/kg body weight) was used in 9 patients, procainamide (10 mg/kg body weight) in 4 patients, and ajmaline (0.7 mg/kg body weight) in 7 patients.Idiopathic VF was defined as VF in the absence of demonstrable cardiac abnormalities as previously reported . Thus, wProgrammed electrical stimulation was performed in all patients using up to 3 extra-stimuli at 3 different drive cycle lengths (600, 500, and 430 ms) delivered to the right ventricular apex. The coupling interval of the first 2 extra-stimuli was not shorter than 180 ms and not shorter than 200 ms for the third extra-stimuli. In case of non-inducibility, programmed stimulation was also performed from the right ventricular outflow tract. Sustained VF was defined as VF at a cycle length ≤ 200 ms and lasting ≥ 30 seconds or requiring immediate defibrillation. Sustained ventricular tachycardia (VT) was defined as VT lasting ≥ 30 seconds or requiring termination secondary to hemodynamic instability. Non-sustained VT was defined as >6 consecutive ventricular complexes or VT lasting <30 seconds.All patients received a transvenous ICD with stored electrograms. Recorded episodes were reviewed and adjudicated as appropriate or inappropriate therapies. VF was defined at follow-up as consecutive ventricular beats recorded from the device at a cycle length of 240 msec or less. In all patients, the ICD was programmed with only 1 ventricular fibrillation detection zone at 180 bpm (333 msec). Only shock therapy was programmed. All patients were seen at follow-up in our centre.All data are expressed as mean ± standard deviation. Kaplan-Meier analysis was used to analyze time intervals until the first appropriate shock.c for the entire population was 410 ± 20 msec. All patients had a normal left ventricular ejection fraction (≥ 50%) without regional wall motion abnormalities. Mean left ventricular ejection fraction (EF) was 69 ± 8% (range 52 to 81%). No patient had significant coronary artery disease (defined as ≥ 50% stenosis). Microscopic examination of right ventricular biopsy specimens in 10 patients showed no evidence of a viral, infiltrative or dysplasic process in the myocardium. Baseline electrophysiological studies were performed in all patients and showed normal sinus node, atrioventricular node and His-Purkinje function in all. Inducible sustained ventricular arrhythmias occurred in 7 patients (39%). From these, 4 patients had sustained VF and 3 patients had sustained inducible monomorphic VT or ventricular flutter (cycle length 230 ± 20 ms). Two extra-stimuli were required in 5 patients and 3 extra-stimuli in 2 patients. Non-sustained VT-VF was induced in 3 patients. No arrhythmia could be induced in 8 patients.The study cohort consisted of 13 men and 5 women (Table After a mean follow-up of 41 ± 27 months (ranging from 5 to 92 months), 7 of the 18 patients (39%) with idiopathic VF had VF or sustained polymorphic VT recurrence and received appropriate shocks  received an inappropriate shock for a total of 21 discharges. Atrial fibrillation was responsible for 57% of them (12 episodes in 4 patients). These were older patients with a mean age of 53 ± 14 years. Six inappropriate shocks (4 patients) were triggered by sinus tachycardia. These patients were younger with a mean age of 31 ± 13 years. Lead malfunction caused 3 inappropriate shocks in 2 patients. Six shocks in 2 patients were classified as of unknown cause, even after careful examination of the intracardiac electrograms. These shocks were probably inappropriate since no clinical symptoms occurred during these episodes and these 2 patients already experienced inappropriate shocks for atrial fibrillation.During the follow-up period, first-time generator replacement was performed in 9 patients after a mean of 43 ± 11 months after initial implantation (range 21 to 58). End of life battery was the indication for replacement in 8 patients, and 1 had an ICD component failure. A second replacement was done in 2 patients. Lead replacement was also indicated in 2 patients for lead insulation fracture. Adjunctive anti-arrhythmic drugs were required in 11 patients after ICD implantation in order to control for the occurrence of appropriate or inappropriate shocks  at the shortest coupling intervals that resulted in ventricular capture. Three patients had a fast monomorphic VT inducible even if the clinical presentation was aborted sudden cardiac death. This may suggest an underlying structural heart disease undetected by the current investigation. Although general cardiac function can be normal, patients might have discrete abnormalities, which are currently unidentifiable. Better risk stratification is required to identify patients who will experience recurrent VF over time. Therefore, defibrillator implantation could be seen as the primary therapy in patients with idiopathic VF, since no stratification has yet identified patients at risk of arrhythmia recurrence.The inducibility rate (39%) of sustained VT/VF observed in our study is also in accordance with the results of the UCARE registry . Of impoThe impact of multiple battery replacements over time in this young population with idiopathic VF needs to be emphasized. It is noteworthy that half the population (9/18 patients) had an ICD replacement and 2 other patients had their transvenous lead replaced during follow-up. We also observed a high incidence of inappropriate shocks (44%), mainly caused by atrial fibrillation and sinus tachycardia. This is well in accordance with other studies where up to 40% inappropriate discharge rates were observed even with fourth generation ICDs . The addIdiopathic VF patients have a high recurrence rate of ventricular arrhythmias, even after the systematic exclusion of patients with the Brugada syndrome or other known electrical diseases from the analysis. ICD prevents sudden cardiac death in this population, but treat only the final manifestation of an unknown disease. Inappropriate shocks remain a major concern in this young population.The author(s) declare that they have no competing interests.JC participated in the hypothesis generation and drafted the manuscript. PG and PB were project managers. FP participated in the final writing of the manuscript. All authors have read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:


Intracardiac echocardiography (ICE) is a useful tool for guiding transseptal puncture during electrophysiological mapping and ablation procedures. Left-sided accessory pathways (LSAP) can be ablated by using two different modalities: retrograde approach through the aortic valve and transseptal approach with puncture of the fossa ovalis. We shall report two cases of LSAP where transcatheter radiofrequency ablation (TCRFA) was firstly attempted via transaortic approach with ineffective results. Subsequently, a transseptal approach under ICE guidance has been performed. During atrial septal puncture ICE was able to locate the needle tip position precisely and provided a clear visualization of the "tenting effect" on the fossa ovalis. ICE allowed a better mapping of the mitral ring and a more effective catheter ablation manipulation and tip contact which resulted in a persistent and complete ablation of the accessory pathway with a shorter time of fluoroscopic exposure. ICE-guided transseptal approach might be a promising modality for TCRFA of LSAP. Trans-catheter radiofrequency ablation (TCRFA) has become the treatment of choice for patients suffering from refractory to medical treatment supraventricular tachycardias ,2. DurinLeft-sided accessory pathway (LSAP) may be ablated using two different modalities: conventional approach through the aortic valve, or transseptal puncture of the fossa ovalis. By using the traditional approach, the left atrium is reached by a retrograde way through the left ventricle and crossing the mitral valve ,4 whereaWith the technological and miniaturization advances of low frequency transducers capable of enhanced tissue penetration, intracardiac echocardiography (ICE) has become feasible and potentially useful for guiding transseptal puncture and ablation procedures, especially when location of specific anatomic landmarks appears to be more crucial ,11.In this manuscript, two cases of ICE-guided catheter ablation of LSAP via transseptal approach have been described.A 24 year-old woman with Wolf-Parkinson-White (WPW) syndrome and recurrent episodes of sustained supraventricular tachycardia, refractory to medical therapy, was referred to our Department in order to attempt TCRFA procedure. The electrophysiological study was performed off therapy using three diagnostic catheters (one decapolar and two quadripolars) which have been positioned in the coronary sinus , His bundle region, and high right atrium/right ventricular apex. The clinical arrhythmia was diagnosed as an orthodromic atrio-ventricular re-entrant tachycardia (AVRT) due to a LSAP that was repetitively induced by both right atrial and ventricular programmed electrical stimulation. The length of the tachycardia cycle ranged from 310 to 300 msec. A well-localized accessory pathway insertion was detected in the lateral left free wall with atrial-ventricular (AV) and ventricular-atrial (VA) intervals of fusion noticeable only in CS2  of all accessory pathway locations . They caThe use of ICE during ablation procedures in order to treat LSAP has been previously reported . The obsIn conclusion, ICE-guided transseptal approach might be a promising modality for TCRFA of LSAP. However, this report needs to be confirmed by further studies.AV= atrial-ventricular;AVRNT= atrio-ventricular re-entrant tachycardia;CS= coronary sinus;ICE = intracardiac echocardiography;LSAP= left sided accessory pathway;TCRFA= transcatheter radiofrequency ablation;VA= ventricular-atrial;WPW= Wolf-Parkinson-White.The authors declare that they have no competing interests.RC carried out intracardiac echocardiography and drafted the manuscript, VD carried out electrophysiological study, AS drafted the manuscript, MS carried out electrophysiological study, MS drafted the revision of the manuscript, GG drafted the manuscript.All authors have read and approved the final manuscript.Brockenbrough needle immediately after the puncture of the fossa ovalis can be clearly visualized.Click here for file


We have previously shown that irregular lifestyle of young Japanese female students are significantly related to their desire to be thinner. In the present study, we examined the nutritional knowledge and food habits of Chinese university students and compared them with those of other Asian populations.t-test. Chi-square analyses were conducted for non-parametric variablesA self-reported questionnaire was administered to 540 students, ranging in age from 19-24 years. Medical students from Beijing University (135 men and 150 women) in Northern China and Kunming Medical College in southern China (95 men and 160 women) participated in this study. The parametric variables were analyzed using the Student's Our results showed that 80.5% of students had a normal BMI and 16.6 % of students were underweight with the prevalence of BMI>30 obesity being very low in this study sample. Young Chinese female students had a greater desire to be thinner (62.0%) than males (47.4%). Habits involving regular eating patterns and vegetable intake were reported and represent practices that ought to be encouraged.The university and college arenas represent the final opportunity for the health and nutritional education of a large number of students from the educator's perspective. Our findings suggest the need for strategies designed to improve competence in the area of nutrition. The increasing problem of obesity has been observed in many lower-income countries during the last decades. China has adopted an open-market policy and experienced explosive economic growth, which has led to less food scarcity at the national level and to a remarkable transition in the structure of the diet of Chinese . The comIn previous reports, we examined eating habits and dietary knowledge of female students in Japan. Our results showed that irregular lifestyle was significantly related to indefinite complaint, with the majority of students having a desire to be thinner although the prevalence of students who were overweight was very low in this study sample . Univers2). The questionnaire was designed by the authors and based on a national dietary survey held by the Health and Labor Ministry of Japan. Some of the authors also traveled to China to investigate the dietary life of Chinese to facilitate questionnaire design. The questionnaire was first written in Japanese and then translated to Chinese utilizing fluent bilingual linguistic services. The translated Chinese version was back-translated to insure the original meaning was not lost. Informed consent was obtained from all participants of this study according to the Declaration of Helsinki. The statistical software package SPSS 10.0 was used for the analysis of data [t-test. Chi-square analyses were conducted for non-parametric variables. All analyses were two-tailed, and a 'p' value less than 0.05 was considered statistically significant.This study was carried out between February 2001 and April 2002. Medical students from Beijing University (135 men and 150 women) in Northern China and Kunming Medical College in southern China (95 men and 160 women) participated in this study. A sample of 540 students aged 19 – 24 years were administered a self-reported questionnaire. The questionnaire consisted of 21 questions regarding eating, drinking and smoking habits (19 questions), with 2 questions related to dieting (trying to lose weight). Self-reported height and weight were used to calculate BMI (kg/mThe response rate was 96% 512 / 540). The characteristics of the subjects are shown in Table 2 / 540. The life style practices were compared by gender see . The majWhen subjects were asked about their history of dieting, 22.7% of respondents reported that they had dieted see . The proThis study aimed to determine the health, nutritional knowledge and dietary behavior of university students in China. As a result, we recorded the distribution of BMI among Chinese students and found a low prevalence of obesity, a finding that is consistent with a study of Japanese female students (BMI≥25 overweight was 5.8%, BMI>30 of obesity was 0%) . In the The results of our study show that the majority of students regularly eat three times per day, and almost 80% of students eat vegetables and fruit twice per day. These eating habits ought to be encouraged. The traditional Chinese diet contains plenty of vegetables and is rice-based. The present study reported a high proportion of Chinese students eat breakfast daily. In contrast, a dietary survey of young Japanese subjects revealed a low rate of individuals engaged in regular eating patterns . The skiOur results showed that body figure perception was significantly different between female and male students. A number of researchers have investigated the relationship of body image and gender role. Women tend to desire a thinner figure, express more anxiety about becoming fat, and are more likely to diet than men ,16. In cIn conclusion, our findings reveal that the majority of students were classified into the normal BMI group, with the prevalence of BMI >30 obesity being very low in this study sample. Young female students had a greater desire to be thinner than male students. Habits involving regular eating patterns and vegetable intake were found and represent practices that ought to be encouraged. The meal and snack patterns in Chinese students were very similar to the traditional eating pattern model, although diets are changing rapidly in China and other low-income countries. The university and college arenas represent the final opportunity for nutritional education of a large number of students from the educator's perspective. Our findings suggest the need for strategies designed to improve competence in the area of nutrition, especially with respect to information relating to sources of nutrition and healthy weight management. Furthermore, public demand for health and nutritional information should be taken into consideration when implementing strategies aimed at improving the nutritional well-being of individuals.R.S carried out questionnaire design, manuscript drafting and total coordination of the study. K.T has been involved in drafting and revision of the article. R.A contributed to the data entry and its analysis. L.CJ contributed to the questionnaire design, data collection and language translations. N.S contributed to final approval of the manuscript.Table 2 containing the results of questions related to lifestyle practices with special reference to food habit. The meal patterns, consumption of fruits and vegetables, consumption of fried foods, consumption of alcohol were assessed in male and female students. The Chi-square analyses were employed to compare the behavioral differences by gender. The evaluations of statistical significance were made at the p < 0.05.Click here for fileTable 3 contains the results of body shape perception and health consciousness of male and female students. Male and female respondents were categorized in to 4 groups respectively, according to mean BMI of ± 1 standard deviation (SD). Analyses were made between BMI groups using Chi-square analysis. The evaluations of statistical significance were made at the p < 0.05.Click here for file