As such, Balb/C mice were injected intravenously, with an anti-mouse c-kit (CD117) monoclonal antibody chemically coupled to a human IL-3 gene-containing plasmid DNA. Mice were sacrificed for tissue analyses at various days after injection of the conjugates.in vivo transfection of a reporter gene eGFP demonstrated transfection of CD117+/Sca1+ hematopoietic immature cells. By PCR analysis of genomic DNA and RNA using primer specific pIL3 sequences, presence and expression of the human IL-3-transgene were detected in the bone marrow up to 10 days in transfected mice but not in control animals.By ELISA, the production of human IL-3 was evidenced in the sera of animals 5 days after treatment. Cytofluorometric analysis after in vivo. While availability of marketed recombinant growth factors is restricted, this targeting strategy should permit delivery of therapeutic genes to tissues of interest through systemic delivery. In particular, the ability to specifically target growth factor expression into repopulating hematopoietic stem cells may create new opportunities for the treatment of primary or radiation-induced marrow failures.These data clearly indicate that antibody-mediated endocytosis gene transfer allows the expression of the IL-3 transgene into hematopoietic immature cells,  In vivo gene targeting of highly specific cell subsets remains the main challenge for gene therapy of a broad range of conditions associated with acquired diseases, including infectious disorders, cancer and failure of the hematopoietic system [In vivo gene transfection is more appealing than in vitro transfection of an aliquot of cells or tissue that would be then reinfused to the patients, because it potentially concerns the total population of targeted cells disseminated in the whole body; this is particularly relevant to patients with primary or secondary failures of the hematopoietic system, since, in most instances, residual foci of hematopoiesis exist that cannot be easily located and cannot be collected by a marrow harvest procedure. In vivo targeted transfection of specific subsets of hematopoietic stem cells (HSC) might help to sustain hematopoietic recovery from bone marrow aplasia by providing local production of growth factors.c system ,2. In viin vivo targeted gene transfer cannot use current viral vectors. Although cationic liposomes have been promising systems in transfecting cells in tissue culture, it has been recognised that their in vitro efficiency does not correlate with their ability to deliver DNA after in vivo administration [Systemic gene delivery systems are needed for therapeutic applications in which the target cells are not directly accessible . Howeverstration -10.Tissue-specific targeting can be achieved through ligand receptor interactions ,12. We hin vitro by the transfer of G418 resistance (neor) into human T-cell lines [in vivo by the transfer of β-galactosidase activity into mouse splenocytes [in vivo, we have shown a specific tumor targeting after a single intravenous injection in mice bearing tumour expressing the renal carcinoma – related G250 tumor associated antigen [In previous studies, antibodies directed against internalised cell surface antigens such as the T lymphocyte-related CD3 molecule or the B lymphocyte-related surface IgD were chemically coupled to purified plasmid DNA encoding various reporter genes. This approach was validated both ll lines  or humanll lines  and in venocytes . We haveenocytes . More re antigen .in vitro biological effect on hematopoiesis [in vitro, this study was focused on specific in vivo targeting of hematopoietic tissues.We have previously reported that the method is suitable for the production of a functional growth factor in specifically CD117+ targeted cells, mediating an opoiesis . As our IL-3-encoding plasmid DNA. CD117 antigen is expressed on a CD34+ hematopoietic subpopulation and is readily internalised upon binding to its ligand [in vivo targeting of hematopoietic immature cells via a systemic route, mediating an efficient in vivo transgene expression.In the present study, we used anti-CD117 (c-kit) mAb covalently coupled to human The human IL-3 coding sequence  was ligated to synthetic fragments containing the natural leader sequence of human IL-3 and was subcloned into pCEP4 vector (Invitrogen Corporation). Transgene expression was controlled by the cytomegalovirus (CMV) enhancer-promoter sequence. The Epstein-Barr Virus replication (oriP) and nuclear antigen (encoded by the EBNA-1 gene) were carried by this plasmid to permit extrachromosomal replication in human, primate and canine cells . pCEP4 aIgG mAbs were chemically coupled to plasmid DNA as previously described . Brieflyin vitro transfection of HSC may be observed in a dose-dependent effect for up to 100 μg of conjugate [We have previously shown that onjugate .BalbC mice (6 weeks) were intravenously injected with a dose of up to 400μg of monoclonal 2B8 (BD Biosciences Pharmingen) covalently coupled to the pIL3 plasmid (named conjugate) and as negative control the monoclonal 2B8 and plasmid DNA uncoupled (named unconjugate) or irrelevant human monoclonal antibody (G250) covalently coupled to the pIL3 plasmid (named control conjugate) or physiological serum (named control serum).enhanced green fluorescent protein encoding plasmid pEGFP-1 provided from Clontech and was named eGFP conjugate.In a set of experiments, two intraperitoneal injections of chloroquine (32.5 mg/kg) were performed 2 hours and just a few minutes before intravenous injection of conjugates. The tolerance of chloroquine  was in the range reported in mice for the study of malaria treatment . MonocloMice were intravenously injected twice (day 0 and day 2) and euthanasied 5, 7 or 10 days after the first injection of the conjugate, after proper anaesthesia.Human IL-3 production in serum was assayed by High Sensitivity ELISA (R & D Systems). Controls were sera or cell culture supernatants of control mice .After euthanasia, the presence of the transgene was investigated in blood, brain, lungs, liver, spleen, kidneys, adrenal glands and bone marrow. In order, to observe toxicity the weight of mice and their organs were measured .In mice injected with eGFP conjugate, a MACS magnetic cell separation systems  was used to enrich cells expressing CD117 and Sca1 from mononuclear bone marrow cells. Negative and positive cells were collected for experimental use. To achieve a purity greater than 50%, it was necessary to perform two sequential passes through magnetic columns. The overall recovery of CD117 was about 30% and enrichment 40 fold, as assessed by the fraction of CD117/Sca1 positive population before and after separation. Cells were analysed by flow cytometry to determine the purity of cell fractions. Then the presence of eGFP positive cells was investigated by flow cytometry into negative fraction (CD117/Sca1 negative populations) and positive cell fractions (CD117/Sca1 positive populations). All experiments were conducted according to French regulation for animal experimentation .Long-term cultures of bone marrow cells were performed, as previously described . At one 5 cells from bone marrow were assayed for clonogenic hematopoietic immature cells [5 cells/ml in complete methylcellulose M3434 from Stem Cell Technologies . Cultures were incubated at 37°C in 5% CO2 and removed at 14 days. Colonies were defined as containing more than 40 cells using an inverted microscope. Cells were then harvested and studied for IL-3 gene expression. Two weeks post-transfection, semi-solid colonies were removed from methylcellulose culture for PCR analysis of the presence of the pIL3 plasmid.5 × 10re cells . Briefly33P-5'-end labeled oligo-probe specific of human IL3 coding sequence (ACGGCCGCACCCACGCGACA), in Southern blot analysis as previously described [The simultaneous isolation of total cellular RNA and DNA from tissues or cells was performed using TriPure Isolation Reagent Kit (Roche Diagnostics) . Total cescribed . To deteescribed .Balb/C mice were intravenously injected twice (day 0 and day 3), with the anti-mouse CD117 (c-kit) 2B8 mAb conjugated to pIL3 expression vector. Control animals received unconjugated pIL3 expression vector and 2B8 mAb (named control unconjugate) or irrelevant G250 mouse mAb covalently coupled to the pIL3 plasmid (named control conjugate) or physiological serum (named control serum). To increase the transgene processing into cells, mice were injected with the conjugate up to a dose of 400μg in the presence or not of chloroquine known to diminish endosomal DNA degradation . Mice weGene targeting was then evaluated by injecting mice with eGFP conjugated or unconjugated to either 2B8 mAb or to G250 control mAb. At day 5, the presence of transfected cells into bone marrow mononucleated cells was analysed into the purified CD117- and CD117+ subpopulations, by flow cytometry using anti-CD117 and anti-Sca1 Abs. As shown in Table IL3 transgene DNA in the spleen of transfected animals up to day 7 (not shown). In control animals , pIL3 DNA but no RNA was detected in peripheral blood but not in serum until day 5 after the first injection and then disappeared .To assess the tissue specificity of the targeting, presence of pIL3 plasmid was investigated in bone marrow, blood cells, liver, spleen, lungs, kidneys, adrenal glands, and brain. PCR analysis of genomic DNA and RNA isolated from bone marrow and blood (or serum) was performed using primer specific pIL3 sequences. Specificity of the PCR and RT-PCR products was assessed by a Southern blot hybridised with a specific radiolabelled human IL3 probe. The expected 542 bp band of the PCR product corresponding to the IL3-transgene presence (both DNA and RNA) were was specifically detected in the bone marrow of transfected mice up to 7 days for RNA and 10 days for DNA, post transfection , did not reveal any change, suggesting the lack of toxicity detected in mice receiving the conjugate (data not shown). Furthermore, since no IL3 transgene was evidenced in these organs, further investigation of potential toxicity of conjugate might not be relevant.Finally, clonogenic assay hematopoietic immature cells were performed on cells removed from sacrificed animals. As shown in Table Long-term cultures of bone marrow cells from mice receiving the conjugate or the controls were performed. After 1 week of selection in hygromycin-containing medium (plasmid conferred hygromycin resistance), cells were cultured for another 2 weeks and then viable cells were quantified using trypan blue exclusion assay. As illustrated on Figure vitro can be especially useful for studying the biological effects of various growth factors [in vitro biological effect on hematopoiesis [in vitro, the present study focus on specific targeting of hematopoietic tissues, in vivo.Although much progress has been accomplished in the field of gene therapy over the last years, there is still a need to develop more effective vectors and new strategies . Using a factors . Our conopoiesis . Since oWe first demonstrated the efficacy of our approach since the transgene and its product (RNA and circulating human IL3) were found in mice injected with anti-CD117/pIL3 conjugate. It is of note that although human IL3 was only detected in plasma of chloroquine-treated mice injected with high quantity of conjugate (400μg); human IL3 encoding RNA were evidenced in treated mice injected with lower quantity of conjugate (100μg). These results were in accordance with the design of these experiments aiming at observing even a transitory and local effect (within the bone marrow).PCR analyses of tissues evidenced the specific targeting of the hematopoietic system since brain, liver and lungs were negative. Only the spleen of mice transfected with the conjugate and kidneys of control animals (transfected with unconjugate mixture of Ab and DNA or with the control conjugate) displayed a positive PCR signal. Observed shortly after the last plasmid injection in blood, the presence of plasmid might be due to the intravenous administration route used and in kidney, to a progressive elimination of the plasmid in this organ of refinement. These results correspond to kinetic of plasmid availability when not using the specific vector (conjugate) to carry plasmid into progenitor cells. In the latter case, CD117+ cells were specifically transfected, and among them, Sca1+ cells were positive, suggesting a targeting of hematopietic progenitor cells via the systemic route.Several parameters contribute to the efficiency and specificity of our system such as the internalisation of the antigen targeted, the choice of the transgene used, the tissues targeted, the conformation of the conjugate. Bone marrow was a good candidate for gene targeting as it is a highly proliferative tissue, as opposed to tissues which possess terminally differentiated cells such as hepatocytes or adipocytes, which are more resistant to transfection .in vivo performance. These include avid interaction with serum components, resulting in colloidal instability, including both aggregation and dissociation of the conjugates and rapid elimination from blood circulation [in vivo administration. Protamine has been shown to cause condensation of DNA, which promotes cellular entry [Factors affecting the bioavailabilty of the administered conjugates strongly determine their culation ,32. Therar entry ,34. Our gene delivery system is specific and leads to transient gene delivery and expression. It may prove useful and safe for numerous clinical applications of gene transfer in hemato-oncology and radiopathology, whereby a stable genetic modification is not required, in contrast to the gene therapy approaches for genetic diseases. For example, it may be of interest to facilitate the long-term reconstitution of hematopoiesis through transient gene delivery into progenitor cells of patients after therapeutic and /or accidental exposure to chemo/radiotherapy. Whether our approach could be used to potentate hematopoietic reconstitution following irradiation remains to be studied.Our HSC Hematopoietic Stem CellsThe author(s) declare that they have no competing interests.AC, OD, AD, MB, SF, MM, PP carried out the studies. FH, DT participated to the designed of the study and its coordination. All authors read and approved the final manuscript.


In silico experiments reveal how evolution can work--without missing links. What can biologists learn from them? Rich Lenski decided he was onto a good thing from his very first encounter with digital evolution. It all began when he used the technology in which artificial organisms in the form of computer code evolve independently by self-replicating, mutating, and competing to re-examine an earlier study with bacteria. The original study had contradicted ‘some influential theory’ suggesting that random mutations show a systematic tendency towards synergistic interactions. His digital results, he discovered, matched his organic ones.‘It's great when these two powerful experimental systems agree, because it suggests some generality about the evolution of genetic architectures', recalls Lenski, professor of microbial ecology at Michigan State University (MSU). ‘But even if the digital and biological realms sometimes come into scientific conflict, it would only lead one to ask why and then probe the relevant factors more deeply’.He can hardly contain himself. ‘It's a win–win situation, leading towards increased generality, on the one hand, and further experiments to better understand specific outcomes, on the other’. For his part, Lenski has since gone much further with the technology  and alsoRichard Lenski is using digital organisms to do ‘impossible’ evolutionary experiments. In one, he says, ‘we test every incipient mutation before it occurs in a population and then allow it or disallow it, depending on its fitness effect, to see how important neutral and deleterious mutations are for long-term adaptation’.Lenski, professor of microbial ecology at Michigan State University, says his mind boggles at how digital evolution opens up so many avenues for research. ‘I sometimes feel like a kid in a candy store who might starve because he can't make up his mind what he wants’.exactly is the hypothesis I want to test, and what exactly must I measure to test that hypothesis?’These opportunities and, at the other end, the prospect of having too much data to analyse, which Lenski admits is a strange thing for an evolutionary biologist to complain about, enforce a discipline to prioritise and define objectives: ‘What Such enthusiasm for the technology makes it difficult for him to understand why some biologists might dismiss digital evolution as ‘very interesting but with no value’ or turn their backs on it altogether. ‘My own view’, says Lenski, ‘is that something that is very interesting is also worth thinking about and exploring more fully, especially when it offers the opportunity to examine complex problems in greater depth and with more precision than is otherwise possible’.But he cautions against mistaking his enthusiasm for studying digital organisms as a call to abandon other lines of research. ‘There's obviously much of value for understanding evolution that comes from many different empirical and theoretical perspectives’, he says. ‘That's one reason that evolutionary biology is such a vibrant field right now’.Lenski still spends as much research time on bacteria as he does on digital organisms. ‘Although it's sometimes frustrating not to be able to devote 100% to each system, each one is so interesting to me that I couldn't bear to drop either of them’. The two systems have different strengths and limitations, which Lenski tries to exploit in his research, he says.E. coli populations, he and his colleagues showed earlier this year how they used gene-expression arrays to work backwards to a set of key mutations in a global regulatory gene. More recent work, currently being written up, ‘has led us to some adaptive mutations in several other key loci’, he notes.From his laboratory's studies on long-term As for his digital research using the Avida software system, Lenski acknowledges that speed is an obvious advantage, but not the most significant one. ‘An even more important advantage is the ability to observe the dynamics and dissect the outcomes of evolution with absolute precision. For example, there are no missing links in the digital world’.Nevertheless, he wryly highlights one shortcoming of Avida: ‘We'll know that we have been successful once the Avidians have evolved the ability to design their own experiments and write the papers without us’.This is a world where time-scales contract and, above all, where other constraints of ‘wet’ biology have no place.Earlier this year, he and Chris Adami, who heads the Digital Life Laboratory at the California Institute of Technology , published some breathtaking findings from the field. Their collaboration brings together biologists and computer scientists, physicists and philosophers in an artificial world on a quest to understand how evolution works. Though they may still be some way from reaching that objective, their latest advance suggests that they are on the right track.The research confronts evolutionary theory's long-standing challenge to explain how an organism can develop complex features simply as a result of random mutation and natural selection. The challenge remains a controversial one, too. Supporters of intelligent design, a branch of the creationist movement, promote the notion of ‘irreducible complexity’ as evidence that Darwinian evolution is a flawed theory. The notion purports that a complex feature cannot evolve sequentially from its elements, and must have been designed in one step by some higher intelligence.Traditional investigations, based on molecular biology and palaeontology, have yielded much evidence about the incremental evolution of the eye or the brain, for instance. But continuing ignorance about many developmental processes and the absence of key fossil records mean that accounts without missing links, to endorse the theory, may never be realised.Which is what tempted Lenski and Adami to examine the challenge in their virtual world. This is a world where timescales contract and, above all, where other constraints of ‘wet’ biology have no place. ‘It's not just the speed, by any means’, says Lenski. ‘It's also the power to manipulate almost any variable one can imagine, to measure variables with absolute precision, to store information that then allows one to trace back a complex chain of events, and to take evolved organisms and subject them to new sorts of analyses that one might not even have anticipated when first collecting the data’.It is a place where virtue is made of simplicity. ‘The worlds we're dealing with here are extraordinarily simple compared with the real world’, says Adami. ‘Any of the biochemistry associated with transcription and translation, for example, anything more complex than relatively short viral types of genomes, that's out of our league’, he notes. ‘We can't see transcription and translation because we don't have transcription and translation–-we go right from sequence to function’.But the principles of evolutionary theory make such restrictions unimportant, he says. ‘Many of the [theory's] predictions don't depend on these little details of molecular biology’, notes Adami. ‘The principles are very, very general, and very simple, and in the end they are mostly responsible for the overall dynamics that you see in these simple systems’. Lenski goes further. These virtual realities, he says, ‘offer us a window into an alternative world, and perhaps even a part of the future of our own, where the fundamental evolutionary mechanisms of mutation and natural selection play out in a novel physical realm’.Escherichia coli. ‘We're making great strides elucidating the precise genetic bases of the adaptation that has occurred during tens of thousands of generations in our long-term E. coli populations’, he reports. ‘Even after more than 30,000 generations in a constant environment, we're still seeing some major phenotypic evolutionary changes’, he adds.Lenski is interested in watching evolution as it happens and has a track record in the study of evolving organic systems, primarily using http://dllab.caltech.edu/avida/) earlier this year, a decade after work began.Adami, who also works in theoretical physics at the Jet Propulsion Laboratory at Caltech, has developed a software platform, known as Avida, for research on evolving computer programs, the digital organisms that he terms ‘Avidians’. The second version, Avida 2.0, became available for free public use  transitional forms, even when the transitional forms are favoured for performing different functions from those that evolve later’.For many other biologists, however, digital evolution seems to have very little relevance. One eminent British evolutionary biologist dismissed the research in just eight words, according to the field's godfather, Tom Ray. ‘His comment: “It's just not biology. Period. End of discussion”. That's the whole story right there’, recalls Ray.Less strident reservations concern the limits on complexity that the virtual world imposes and suspicions about the ability of digital processing to mirror evolutionary principles accurately. For Francisco Ayala, professor of biological sciences at the University of California, Irvine, it appears to be simply a question of trust in the natural world. ‘Computers can give you only what you put in’, he says. ‘With natural models, you're not putting anything in—you're segregating a small region as an aspect of reality’.There are also more mundane worries over the technical skills needed for the computational operations, a fear acknowledged by Lenski. ‘Computational skills are certainly opening up some exciting new directions [in evolutionary biology]’, he says, ‘but there are of course many other useful skills and fascinating directions’. At Caltech, meanwhile, Adami's team is trying to make Avida easier to use, backed by the National Institutes of Health's first-ever funding for digital-life work.Misunderstandings about the technology arise over whether the research is an ‘instance’ or a ‘model’ of evolution, suggests Ray, who now divides his time between the Advanced Telecommunications Research Laboratories in Kyoto and the University of Oklahoma, where he holds chairs in zoology and computer science. ‘I never intended [Tierra] as a model, but that's the way a lot of people saw it because they weren't really prepared for this new idea, this different perspective of another instance of life’, he says. ‘They had a more traditional view of what you do with a computer, which is that you send e-mail, you process things, and you make models’.Levels of veracity determine limits of extrapolation, says Ray. ‘Digital evolution is an abstraction, and it's not going to be able to tell us what humans will evolve into or why dinosaurs went extinct or what will be the next emerging disease…. You need the whole planet to do that kind of modelling’. But once you appreciate the constraints, ‘it's a phenomenally good tool, because it's evolution in a bottle. You can instrument it 100%’, he notes. ‘I think Lenski and Adami have done a very good job of developing it that way’. Ray himself is now more interested in genomics and pharmacology and their application in a biologically inspired engineering project to design software agents, or ‘virtual creatures’, as he terms them.For Lenski, experiments with Avida provide ‘both an “instance” and a “model” of evolution’. He says that ‘populations of the digital organisms really do evolve and adapt, albeit in an unfamiliar physical realm. At the same time, they provide a sort of experimental model for testing and understanding the general principles of evolution’.And he agrees with Ray that digital evolution is not intended to explain how we got where we are today, ‘in the sense of unravelling which species are more related to which other species, or what organismal features are adaptive for what purposes, and so forth’. The goal, says Lenski, is to examine evolutionary processes and dynamics in greater depth and detail than are otherwise possible. ‘Watching a process as it occurs and being able to probe genetic details and manipulate environmental variables can provide new insights and evidence that one cannot get by comparative studies that typically require one to infer historical processes from present-day patterns’.Pseudomonas fluorescens, which grow from single genotypes in pristine tubes, to test long-standing hypotheses about the causes of ecological diversification. ‘The bottom line is that we're reducing the complexity we see in the real world to a much more manageable level’, he says. ‘The nice thing about bacterial populations is that ecological and evolutionary timescales coincide, so that you can actually see the ecological context of evolutionary change’.Such developments fascinate and enthral Paul Rainey, an evolutionary ecologist, even though he rarely needs any computing power for his research and recognises that digital evolution still lacks an ecological dimension. Rainey, who earlier this year moved from Oxford to become professor of ecology and evolution at the University of Auckland, uses bacterial populations of ‘It's a phenomenally good tool, because it's evolution in a bottle.’Rainey, a friend and colleague of Lenski's, would welcome the chance to take advantage of the speed, robustness, and flexibility of digital evolution to further his research, but doubts whether the technology will ever be able to match the performance of his ‘wet’ laboratory. Though his natural model is simple, it remains far too complex to program, he suspects. ‘We try to understand how selection is working in this very complex ecological context, which includes interactions between genotypes and within genotypes and interactions with an environment that is constantly changing’, he says. ‘This sets the scene for selection, and the selective forces are constantly changing…. None of that complexity is really captured in Avida’.But Rainey is in for a surprise, according to Adami. ‘The pace of development of Avida has accelerated’, he says. ‘More people are working on it because we have bigger grants. And Charles Ofria [who helped to design the software as a postgraduate at Caltech] is doing much of the development at Michigan State  with his students’. The result is that Avidians have made their first steps towards sexual freedom within ecologically diverse environments or, more accurately, code recombinations in a multi-niche virtual world.For almost a decade, says Adami, Avida has been a single-niche world in which every organism in the population sees exactly the same world and only a single species inhabits that world. But Avida has now been expanded, he continues, ‘in such a manner that populations can see different types of worlds and they can adapt independently to different resources’. A research paper is being finalised on how the software is making its first steps towards incorporating the notion of evolutionary ecology. ‘We show what pressures are necessary to make a population that is homogenous branch out and speciate into a stable system’, notes Adami. ‘Now we want to explore recombination, which we've always shied away from.’ With asexual reproduction virtually understood, the researchers are ready to tackle sexual reproduction in the digital world, says Adami. ‘Some people are furiously working at implementing that.’‘Our goal is not to mimic natural systems in detail, but rather to expand Avida to give digital organisms access to more of the basic processes of life’, says Lenski. ‘Our goal is not so much to endow the ancestral organisms with additional capabilities, but rather we want to see how digital organisms will evolve if they are placed in an altered world where such things as sex and communication are physically possible. I see many years of interesting research along these lines’.Reflecting on future applications for the research, Lenski suggests it highlights how the traffic in computational biology is now becoming a significant and little recognised twoway exchange. Computer scientists are not only helping biologists to organise and analyse their vast datasets, says Lenski, but ‘biological principles, from evolution and genetics to neurobiology and ecology, are informing computer scientists and engineers in designing software and hardware … and that holds tremendous promise for the future’.


Nearly 10% of the population of Turkey lives in the Southeast Anatolian Project (SEAP) region. The population growth rate and the rate of unintended pregnancies are high and family planning services are insufficient in this region. Lifetime induced abortion rate is also high in this region.Public health problems of the SEAP region were investigated in the "SEAP Public Health Project" in 2001 and 2002. As it is one of the most important health problems of the women living in this region; induced abortion was also investigated in this project.An optimumsample size representing the rural and urban area of the region (n = 1150) was chosen by the State Institute of Statistics by a sampling method proportional to size. 1126 of the area's 1150 houses have been visited and data about induced abortions have been obtained by applying a questionnaire to 1491 ever married women who live in the region.It has been found that 9.0% of these women who had at least one pregnancy in their life had at least one induced abortion. The lifetime induced abortion per 100 pregnancies was found to be 2.45. The primary reason given for induced abortions was "wanting no more children" (64.6%). Lifetime induced abortions were 5.3 times greater with women using a family planning method than women not using family planning methods. Lifetime induced abortions were 4.1 times greater with unemployed women than working women. Most of the women have used private doctors in order to have an induced abortion.Although 32.29% have not yet begun to use a contraceptive method after their last induced abortion, 43.75% of the women have since started to use an effective contraceptive method. 23.96% of them have begun to use an ineffective contraceptive method.Induced abortion is still an important problem at the SEAP region. The results of the study remind us that unemployed women and women who have more than four children is our target group in the campaign against induced abortions. Most of the women use private doctors in order to have an induced abortion. Thus, priority must be given to educate private gynecologists with respect to induced abortion. After induced abortions, a qualified family planning consultant can be given to women and they can be secured to use a suitable contraceptive method. Abortions are divided into two groups as 1) induced abortion and 2) spontaneous abortion. The spontaneous abortion rate increases when the maternal and natal care is insufficient. Induced abortions occur at the desire of the couple and an increase in induced abortion rate is a good indicator of insufficient family planning services. The aim of the family planning services is the prevention of unwanted pregnancies. Inadequate access to contraceptive methods, method failure caused by misuse of the methods and non-use of effective methods are the reasons of unwanted pregnancies, which lead women to induced abortion [Abortion is defined by World Health Organization (WHO) as a pregnancy that ends before 28Induced abortions have been used as a family planning method for many years and become an important problem in women's health especially in developing countries. It is one of the main causes of death of women of reproductive age . InducedIn Turkey, the Population Planning Law legalized the provision of safe abortion services within ten weeks in May 1983. As a result, the facility to terminate unwanted pregnancies in safe conditions has been provided . But indNearly 10% of the population of Turkey lives in the Southeast Anatolian Project (SEAP) region. The population growth rate and the rate of unintended pregnancies are high and family planning services are insufficient in this region.Public health problems of the SEAP region were investigated in the "SEAP Public Health Project" in 2001 and 2002. Induced abortion was one of the health problems investigated in this project.The Southeast Anatolian Project (SEAP) region has a population of approximately 6 million people and nearly 10% of the population of Turkey lives in this region. The population growth rate and the rate of unintended pregnancies are high and family planning services are insufficient in this region.Public health problems of the SEAP region was investigated in the "SEAP Public Health Project" and this project was supported by the SEAP Regional Development Management of Prime Ministry Republic of Turkey and conducted by a consortium constituted by the Turkish Parasitology Association, Gaziantep University, Dicle University (in Diyarbakır province) and Harran University (in Şanlıurfa province). Induced abortion – an important problem for women – was investigated in this project in 2001 and 2002.The population of the nine provinces in the region is 6,128,973. In order to investigate the public health problems of the region such as abortion, an optimumsample size which represents the rural and urban area of the region was determined as 6900 . This number (6900) was divided to the average number of households (approximately 6 people live in each house in the SEAP region) and the number of houses in the sample was found to be 1150. An optimum sample size representing the rural and urban area of the region was chosen by the State Institute of Statistics by a sampling method proportional to size.Questionnaires were prepared by the academic staff of public health departments of medical faculties of the two universities (Gaziantep and Dicle Universities). Three of the questionnaires were for individuals  and one of the questionnaires was about the house conditions. Before the study, the questionnaires were applied to houses that were not in the study sample as a pilot study and then checked.A team for questionnaire application was constituted in every province and the teams were educated about the questionnaires. These teams visited all of the houses in the sample with a public health specialist (the head) and applied the questionnaires by face-to-face interview. Data about the people living in the house were obtained by the house questionnaire. Data about the demographic features of women, fertility, and features about abortion were obtained by the questionnaire from 5 year and older girls and women. Educated nurses  applied the questionnaire to women by face-to-face interview in a separate room.1126 households of the area's 1150 houses participated to the survey. Households of the 24 houses were not found at home during the study. There were 1491 ever married  women in the 1126 houses that participated in the survey.The data were evaluated using the SPSS 5.0 and Excel programs. Chi-square, Student's t test and logistic regression analysis were used for the statistical analysis.There were 1491 ever married  women in the 1126 houses that participated in the survey. 1266 (84.9%) of these women had at least one pregnancy in their life.9.0% of the women who were ever married and who had at least one pregnancy in their life have had at least one induced abortion in the past. The rate of the women who have had two or more induced abortions was found to be 3.63%. The lifetime induced abortion rates of the women who were ever married and who had at least one pregnancy in their life according to some basic factors are shown in Table The percentage of women who have made at least one lifetime induced abortion was higher in women living in urban areas 10.39%) than women living in rural areas . The percentage of lifetime induced abortion was higher in 35–49 age group  than the other age groups (p < 0.01). Lifetime induced abortion rate was 7.15% in illiterate women and 10.53% in literate women and was higher among women who graduated from a primary school or higher . The percentage of women who have had at least one induced abortion was found to be higher in unemployed women and Turkish women than the other groups   (Table "Wanting no more children" is the primary reason given for lifetime induced abortion 64.58%). In 63.54% of the lifetime induced abortions both of the couples have decided to the induced abortion together. Most of the lifetime induced abortions take place at the private doctors' consultant room (46.88%)  (52.38%) took the first and condom (26.19%) took the second place among the effective family planning methods. Withdrawal, with a rate of 87%, took the first sequence among the ineffective family planning methods . Lifting heavy things (35.4%) took the second place. Women who live in rural areas preferred to lift heavy things (64.3%) while women in urban areas preferred to take drugs (50.0%).The percentage of having at least one induced abortion among ever married women who had at least one pregnancy in their life in the SEAP region was 9.0% (lifetime induced abortion rate). Approximately one out of ten ever married women has made at least one induced abortion in their life. Also, 2.45 induced abortion per 100 lifetime pregnancies occurred at the region. When we evaluated the results of the Turkish Demographic and Health Survey 1998; (TDHS 1998)  the percentage of lifetime induced abortion among ever married women was reported as 18.2% and induced abortion per 100 pregnancies during the five-year period before the survey was 7.6 for the East Anatolian region . The SEAP rates were lower than the TDHS 1998 [There is a decrease in the lifetime induced abortion rate in the course of time compared with the TDHS 1998. Also, there is a decrease in the lifetime induced abortion rate in the same region (in the East Anatolian provinces) when the data of the TDHS 1993 is compared with the data of the TDHS 1998. Induced abortion rate per 100 pregnancies during the five-year period before the survey has decreased to 7.6 from 8.7 in the course of time . A similHowever, this low lifetime induced abortion rates do not show a success because unintended pregnancies end with births in the region. As a matter of fact, 30.1% of the latest births of the women during the last five year period were not desired by both of the couples in the Southeast Anatolian region . Also, tThe rate of induced abortion was higher in urban areas than rural areas. This was similar with the TDHS 1998 .Lifetime induced abortion rate was 7.15% among illiterate women, 10.53% among literate women and was higher among women graduated from primary school or higher . In a study conducted by Akın et al. similar results have been found [In the logistic regression analysis the total number of pregnancies of the women, the family planning method usage status of the women and the employment of the women have been evaluated as the independent factors affecting lifetime induced abortion. As the total number of pregnancies increases, lifetime induced abortion risk increases (odds ratio is 1.7). Women who have more than four children may be the target group of the studies planned on this subject. In a study conducted by Akın et al. a similar odds ratio (1.1) have been found .Lifetime induced abortions were 4.1 times greater with unemployed women than working women. This was due to the fact that these women have lower family planning usage rates but their pregnancy rate was high.These results remind us that unemployed women and women who have more than four children must be our target group in the campaign against induced abortions as a family planning method.Lifetime induced abortions were 5.3 times greater with women using a family planning method than women not using family planning methods. I.e. the usage of family planning methods are 5.3 times higher among the women who have had an induced abortion in the past. In a study conducted by Akın et al. similar results were reported during the five-year period before the survey (odds ratio is 2.9) [Lifetime induced abortions have usually taken place at a health facility and with the assistance of health personnel. After these lifetime induced abortions, a qualified family planning consultant can be appointed to these women and they can be encouraged to use a suitable contraceptive method. The rate of effective family planning method usage after induced abortion was 43.7% in our study. The same rate was 34.2% in the TDHS 1998 during the five-year period before the survey . There iAfter lifetime induced abortion, 32.3% of the women were not using a family planning method in the study and this was nearly the same with the percentage evaluated in the TDHS 1998 during the five-year period before the survey (32.1%) . There wAfter lifetime induced abortion, 67.71% of the women have begun to use a family planning method in our study.The primary reason given for the last induced abortion was "wanting no more children" 64.5%) and this is similar with the data of the TDHS 1998 % and thi.Although the rate of lifetime induced abortions are decreasing in the course of time it is still an important health problem in the SEAP region. Unintended pregnancy and total fertility rates of the region is still higher than the other regions of Turkey. Thus, family planning services, the educational level of women and the status of women need improvement.Although 9.0% of the ever married women who had at least one pregnancy in their life have made at least one induced abortion and 2.45 induced abortion per 100 lifetime pregnancies occurred at the SEAP region, these rates are lower than the whole rate of Turkey. But, the high fertility rate shows us that family planning services are insufficient in the region. Also 32.29% have not begun to use a contraceptive method after their last induced abortion and 23.96% of them have begun to use an ineffective contraceptive method. This shows an important lack on this subject. After these lifetime induced abortions a qualified family planning consultant can be appointed to these women and they can be encouraged to use a suitable contraceptive method. Also to decrease lifetime induced abortions; women who have more than four children and unemployed women may be the target group of studies planned on this subject.The author(s) declare that they have no competing interests.AİB participated in the conception and design, provision of study materials, analysis of the data, statistical expertise, drafting the article and revision of the article. BÖ participated in the conception and design, collection and assembly of data, provision of study materials, analysis of the data, statistical expertise, drafting the article, revision of the article and final approval of the article. SÖ participated in the conception and design, collection and assembly of data, provision of study materials, analysis of the data, statistical expertise, drafting the article, revision of the article and final approval of the article. SŞ participated in the conception and design, collection and assembly of data, provision of study materials, analysis of the data, statistical expertise, drafting the article, revision of the article and final approval of the article. TŞ participated in the collection and assembly of data, provision of study materials, analysis of the data and statistical expertise. GS participated in the conception and design, collection and assembly of data, provision of study materials, analysis of the data and statistical expertise. AC participated in the conception and design, collection and assembly of data, provision of study materials, analysis of the data and statistical expertise. Eİ participated in the conception and design, collection and assembly of data, provision of study materials, analysis of the data, statistical expertise, drafting the article, revision of the article and final approval of the article. HA participated in the collection and assembly of data, provision of study materials, analysis of the data and statistical expertise. YP participated in the collection and assembly of data, provision of study materials, analysis of the data and statistical expertise. FA participated in the conception and design, collection and assembly of data, provision of study materials. MA participated in the conception and design, collection and assembly of data, provision of study materials.The pre-publication history for this paper can be accessed here:


An organism's ability to sense and respond to potentially harmful pathogens is key to its survival. To fight off disease and infection, organisms must detect pathogens, activate immune cell signaling pathways, and produce molecules able to thwart a pathogenic attack. So fundamental is this need that molecules and protein domains related to innate immunity are evident in organisms as diverse as plants, flies, and humans, highlighting the ancient origins of defense mechanisms. Once detected, the pathogen's presence triggers a cascade of signaling events that generate a rapid response tailored to specific classes of pathogens.Drosophila fruitfly, they elicit a range of defensive reactions in the fly, including the production of antimicrobial proteins, phagocytes (which engulf the pathogen), and toxic metabolites. A microbe sets off one of these responses by interacting with a receptor, triggering a pathway that activates a special class of transcription factors, which in turn activate genes needed to make antimicrobial peptides, say, or toxins. Drosophila attacked by fungi and a certain class of bacteria activate these transcription factors through a pathway (the Toll pathway) that also operates in mammals.When pathogens attack the A second pathway is activated when a different class of bacteria attack. While the general steps of this pathway, called the Immune deficiency (Imd) pathway, are known—Dredd-mediated activation of the Relish transcription factor, for example, is central to this antibacterial response—the details and mechanisms remain unclear. Signaling pathways are notoriously complex and the Imd pathway is no different. In the current model, bacterial pathogens stimulate a transmembrane receptor, which activates the Imd protein, which then transmits the signal through intermediary proteins, which ultimately activate Dredd, sending Relish into the nucleus to activate genes required for an immune response.PLoS Biology, Edan Foley and Patrick O'Farrell use a genome-wide approach to characterize the Imd pathway, with an eye toward understanding what regulates the Dredd-Relish interaction. To identify pertinent genes and their roles, Foley and O'Farrell took advantage of a technique, called RNA interference (RNAi), that can selectively target and “silence,” or inhibit, nearly any gene. After silencing a gene, researchers can then track how a cell responds and infer the gene's function. The technique uses double-stranded RNA (dsRNA) molecules with nucleic acid sequences that match a gene of interest (RNA can bind to DNA through complementary base pairing). The dsRNAs precipitate a series of steps that ultimately degrade the messenger RNA associated with the gene, preventing messenger RNA translation, thereby silencing the gene.In this issue of Drosophila genes with counterparts in mammals or the worm C. elegans , then developed a cell culture model to analyze the components of the Imd pathway. Since the cells in these cultures respond to the presence of bacterial proteins by generating antimicrobial peptides, they provide a good testbed for identifying genes involved in the pathway. Foley and O'Farrell's RNAi screen identified many molecules involved in signaling, including both signal inhibitors and activators. Among these signaling components, they discovered two new genes: one, which they named sickie, is required to activate Relish; the second, called defense repressor 1 (dnr1), appears to inhibit Dredd activity and thus inhibit the pathway. Based on molecular analysis of these genes—which involved exposing cells to bacterial proteins—the authors propose a model of Imd signaling in which Dredd and the protein produced by dnr1, called Dnr1, operate through a negative feedback loop: Dredd activity appears to promote the accumulation of its own inhibitor, Dnr1. Since suppression of Dnr1 through RNAi can trigger an immune response, the authors explain, it appears that interruption of this feedback loop activates the signaling pathway. Without the inhibitory action of Dnr1, Dredd can activate Relish, which dissociates from Dredd, enters the nucleus, and activates the transcription of antimicrobial genes.The authors produced over 7,000 dsRNAs corresponding to most of the It's likely that the two genes described here play a key role in activating Relish, the authors conclude, and that others identified in this screen will also prove significant. Since many of these components are conserved in mammals, the pathway may likewise operate in humans. Future experiments will be the test of these assumptions, but until then, Foley and O'Farrell have demonstrated the soundness of using RNAi screens on a large scale to dissect the elements of a complex signaling pathway.


Services to meet adequate rehabilitation needs of elderly stroke survivors are not always provided. Indeed, since 1995, in the wake of the Quebec shift to ambulatory care, home care services, mainly those related to rehabilitation of the elderly, are either unavailable or incomplete. The aim of this study was to examine the rehabilitation needs of this clientele from their hospitalization to their reintegration into the community.The "Handicap Production Process" conceptual approach was chosen to help identify the rehabilitation needs of persons affected by physical or cognitive disabilities due to the interactions between personal and environmental factors, and . This qualitative exploratory study was performed in 2003. Data were collected among four groups of experts: patients, caregivers, health care providers and administrators. Data triangulation was used to ensure a rigorous analysis and validity of the results.Unfulfilled needs could be found in the categories of pertaining to residence, community living, psychological and emotional needs. Indeed, it appears that a psychological follow-up to discuss acceptance and consequences of non-acceptance would facilitate mid-to long-term rehabilitation.Improving accessibility to healthcare services, respecting priority parking spaces for the disabled as well as promoting public awareness would enable a better social reintegration and recovery of social roles, thus limiting the onset of handicap situations. After a stroke, a good proportion of the elderly rapidly re-enter the community without having benefited from rehabilitation services to help reduce their impairments and disabilities. Indeed, in Canada, only about 10% of stroke sufferers have access to intensive rehabilitation services  and be aThe World Health Organization  defines The HPP (handicap production process) ensues from the works of the International Network of the Handicap Production Process Figure  – formerPersonal factors relate to the person's basic characteristics like age, sex, socio-cultural identity, body systems (integrity vs. impairment) and the aptitudes (capacities vs. disabilities). Body systems identify components of the whole body. Integrity of these systems is based on the human biological norms while an impairment relates to a degree of anatomical, or physiological damage. Aptitudes are associated with a person's capacity for physical or mental activity such as walking or understanding. The value of an aptitude is measured on a scale ranging from optimal capacity to total disability. In the HPP, ensure the survival and thriving of an individual within society, during his/her entire life. They are arranged in twelve categories, the first six referring to activities of daily living and the last six relating to social roles valued by the person or his/her socio-cultural context. These categories are: nutrition, body condition, personal care, speech, habitation, mobility, responsibilities, interpersonal relationships, community living, leisure activities as well as education and work. The environmental factors are the constituents of a person's surroundings than can affect the realization of a living habit. Interactions between personal and environmental factors create needs that impact a person in the execution of his/her activities of daily living, thus limiting his/her social participation. A positive interaction between personal and environmental factors supports social participation while a negative interaction produces the development of handicap situations.Les besoins de santé des individus. Unpublished manuscript). It could be a need for a resource to provide adequate and ample services. Bradshaw's taxonomy [Needs are subjective, since they are felt by the person , the aim of this research was to investigate the expressed and normative rehabilitation needs of post-stroke elderly living in the community.As proposed by Morgan and Krueger , an induIn order to achieve experimental diversification, participants were identified by purposive selection. The patients (n = 4) and the caregivers (n = 5) were recruited through social workers from the local community service centers, daycare centers and also chosen from a data bank of participants to previous studies. Health care providers (n = 9) were solicited through directors of professional services and coordinators of rehabilitation or home-based services. They worked in different fields of healthcare and services, in rural and urban areas. Administrators (n = 7) were recruited through hospital managers who would identify which one was more familiar with the study clientele and worked in various rural and urban areas. All participants were recruited because of their critical abilities and their experience with needs related to the stroke process from onset to reintegration into the community. The area were the research took place is known as rural and semi-rural with a population of 150,000.Each of the four meetings lasted approximately two hours and was recorded on audiotape. A interview guide (Appendix 1 ) was buiIn order to ensure the validity of results, data was triangulated as described hereafter. During the last minutes of the meetings, the assistant-moderator would ask the participants to clarify some statements she had jotted down during the encounter. She would then sum up the meeting to validate its content with the participants, at which time they could complement, rectify or add to the information already given. This information along with the notes of the observer would help summarize the focus after each of the meetings. Later, a member of the team listened to the audiotape, allowing further analysis of the data. In the following weeks, each participant was sent a brief report of his/her focus group meeting. One week later, each participant was contacted to corroborate the content of the report. During these interviews, the comments of the participants testified to their understanding and approval of each report and allowed to add some details. Verbal and written summarized reports on the four groups were presented to the research team.Normative and expressed needs were grouped according to the twelve categories of the HPP model. After analysis of the focus groups, two categories were added in order to include psychological-emotional needs as well as psychological-cognitive needs and the education and work categories were abandoned. The participants from the four groups identified their needs as: a) needs already fulfilled or not mentioned, b) needs partially fulfilled c) unfilled needs.Characteristics of the participants of the four focus groups are presented in Table Eight out of nine health care providers had a fairly good knowledge of stroke and seven of them had more than nine years of experience with a stroke clientele. They were from different professional fields: special education (1), occupational therapy (1), social work (2), neuropsychology (1), speech therapy (1), physiotherapy or physical rehabilitation therapy (3). These professionals practiced in an active care hospital (2), a CLSC (4), a daycare center (2), a day hospital (1) and a community organization (1). The administrators came from the same kinds of facilities with the addition of an intensive functional rehabilitation unit and a rehabilitation center. Four of the administrators had a restricted knowledge of stroke and had other customers aside from stroke patients. Two out of seven took care only of persons over 65 years old or with neurological problems. Education fields of the administrators were either management or health related disciplines.patients were acceptance of their health problem (stroke) and accessibility to physiotherapy and occupational therapy services on an outpatient basis. Then subsequently followed the needs relating to adapted means of transportation, medical follow-up, home visit from healthcare personnel, and stimulus and motivation provided by a caregiver. Domestic help and encouragement from the healthcare personnel were also important needs that have been expressed. Patients were more communicative about their needs relating to community, their psychological and emotional needs, and house alteration requirements. Unfulfilled needs mainly included the occasional home visit from a health professional, domestic help, coaching by the CLSC and medical follow-up.The most important expressed needs of the caregivers was that the patient be loved, surrounded, and that he felt secure. These were followed by the necessity to make home adaptations, the need to inform the stroke patient and to provide him with physical and mental stimuli. Finally, the needs relating to tactile sensation problems, supportive care and attention, and acceptance of the situation were also important. It is worth noting that participating caregivers looked after individuals much more severely impaired than our group of patients. These caregivers mentioned the same categories of needs but in a different order of priority. For them, the psychological needs were the top priority; then came the need to adapt the home followed by community living needs. Notice that the beneficiaries had not resumed many of their social roles in the community. According to the caregivers, the less fulfilled needs were mainly related to psychological needs and associated with community living. Specifically, they concerned medication and its side effects, adaptation to this new situation for the caregiver and acceptance by the beneficiary. Respite, emergency help, supportive care and attention, training of family members were also needs partially fulfilled in these categories.The foremost rehabilitation need identified by the health care providers, the needs that were less fulfilled mainly concerned related to community living, psychological needs and speech impairment. More precisely, they included: leisure activities, awareness, long-term family support, bond between spouses, respect of the person's pace, delivery of timely and simplified medical information to the patient and his/her spouse, adaptation of the home and respite, because in rural areas, for instance, there is no specialized transportation.For the Re-education for basic activities like eating or getting dressed and psychological assistance for acceptance, self-esteem and dignity were the most important. Followed the capacity to communicate and the family's need to be supported in understanding the health problem. Finally, long-term follow-up, simplification of the information given and home alterations also constituted essential needs, again according to the health care providers. For the most part, the health care providers worked with severely disabled persons. In their view, the interventions having to do with personal care held a priority over those concerning psychological needs and communication needs. As also identified by the caregivers, needs related to community living and the home followed.administrators' view, a psychological support intervention made by the case manager, for instance, was more necessary in rural areas. They mentioned more "partially fulfilled" needs in the areas of speech, mobility and community living. They underlined the necessity to become sensitive to this clientele with cognitive problems and their needs for spirituality, means of transportation, financial support, the need to maintain and improve speech re-education.In the Administrators emphasized their wish to ensure the complete management of the patient. They were interested in the list of needs identified by the patients, since the needs of the affected individuals cannot be dissociated from those of their family. Needs identified as a priority by the administrators were a stabilized health condition, recovery of biological, psychological and social abilities, compensation mechanisms, integration into the community and support in finding a new sense to one's life. The chronology of those needs was unanimous because it set a continuum in the rehabilitation process. Priority needs identified by the administrators seemed closer to those listed by the patients. Administrators seemed to believe the patients had made a fairly good functional recovery and insisted on needs related to community living, personal care and psychological well-being. Finally, they were the only ones to clearly talk about spiritual needs.On the whole, unfulfilled needs were identified in the four groups as from categories relating to housing, community living, psychological and emotional needs. Table Although some of the categories were partially fulfilled for the health care providers and administrators, the gradient of the providers' opinion on each of the needs specifically mentioned, stood between "partially fulfilled" and "unfulfilled". Conversely, the gradient of the administrators' answers stood between "fulfilled" and "partially fulfilled". Interestingly, only the patients' group acknowledged nutrition needs.In Lewinter et al. , resultsThe perceived needs of the caregivers really stood out during focus groups and would be inseparable from those of the patients. Caregivers considered rehabilitation in terms of recovery and excluded compensation mechanisms. For instance, they were unable to imagine any possible means to compensate for poor vision, a need expressed by the patients. While patients referred to the psychological need of accepting the situation, caregivers mentioned the psychological need to face one's own limitations and the probability of complete rehabilitation. These results agreed with the study of Gauthier  who collFrom our results, it seems that supporting the caregiver at the time of the hospitalization would allow him to offer a better support to the stroke victim. That support would perhaps allow acceptance of the situation and an active implication in the rehabilitation. Long-term follow-up and respect of the person's pace were mentioned as being important. Caregivers felt useful and appreciated this phase of the rehabilitation where attendance, supportive care and attention as well as information were provided at the day hospital. All groups pointed out the need for a more aggressive early re-education and a continuing rehabilitation. None of the groups mentioned needs pertaining to responsibilities. Finally, needs associated with sexuality were acknowledged by all groups, but none offered any solution.Health care providers felt powerless, even frustrated, with so many needs to be fulfilled and so little human resources available. Health care providers proposed many possible avenues worth exploring in relation with community and some ways of addressing psychological problems.The health care providers identified most of the partially fulfilled needs, ranging the whole continuum of the rehabilitation process. They pointed out the necessity for health system administrators to acknowledge expressed and normative needs of stroke patients. Adding human resources would begin solving the problem. Patients who benefit from intensive rehabilitation (about 10% of the stroke clientele) are treated according to their impairments in order to diminish their disabilities and improve their functionality. Services to help the family and to modify to the physical environment are usually available. The only help rarely provided is that of fulfilling psychological or cognitive needs and supporting social integration. However for 90% of the stroke clientele who only benefits from rehabilitation services at the acute care hospital, little of their needs are fulfilled.This data concurs with that of Lewinter et al.  on the iIn general, the answers of the administrators were based on what the resources should offer instead of on the accessibility to services, which they were less aware of. It seems that most of the participating administrators were preoccupied by the needs of the patients throughout the whole process and not only when they were using their services. They proposed solutions focused on the needs of the patient and on the most adequate resource to fulfill those needs at this stage of the rehabilitation process. In fact, the need for specially trained personnel to help prevent contractures and dehydration, as well as spiritual needs, were reported by administrators from chronic care facilities. Spiritual needs had also been reported by McLean et al.  in theirRegarding prevention and treatment of secondary impairments, which is the second stage of the rehabilitation process described by Duncan, et al. , adminisMany strengths and limitations have to be mentioned. Methodologically speaking, holding the first meeting with the patients' focus group ensured a valid identification of their needs, as they were perceived. As for the other participants, recruitment was done in a rigorous manner in order to obtain a fairly equal number of representatives from rural and urban areas, from various professions, and from different types of rehabilitation resources, including representatives of community organizations. It should be mentioned that recruitment of the patients and caregivers was difficult; participants from these two groups were probably not typical of persons being dismissed to their home after a stroke. However, the fact that the severity of the stroke ranged from severe to mild in those two groups increases the external validity of the results.Recall bias is significant in this study as patients and caregivers had to recall events that took place few years ago.The implication of the four groups of participants ensures a better validity of the data as was suggested by Liu and Mackenzie . The rigAfter a stay in an active care hospital (ACH), before the patient is discharged, a meeting between family members and a stroke specialist  could allow discussions about a possible mental depression of the stroke patient and about upcoming difficulties. It would also be necessary at this time to give the caregivers information on their loved one's health status and to inform them of their future needs.After hospital discharge, a specially trained healthcare worker could remain available by telephone to counsel the caregivers. Finally, a psychological follow-up of the caregiver would allow him to better support his/her relative in his/her rehabilitation process. After discharge from the hospital or from the rehabilitation center, a better communication between healthcare facilities and increased availability of services at the CLSC – like twice a year home visits by a health care provider – are suggested by the patients. As concluded by Lewinter et al , it seemImproving accessibility to services, respecting priority parking spaces for the disabled and promoting public cooperation would allow for a better social integration and recovery of social roles. On the whole, a better distribution of financial resources between institutions having to deal with this clientele, would allow long-term support of the person and his/her family. Health care providers first suggest that full rehabilitation teams  be created (for example stroke team). They also propose the appointment of a case administrator or pivotal health care provider, based on the total system concept in healthcare, which would simplify communication between partners . Services would be more suited to the needs of the individual and available for the families. Intervention priorities would be centered on needs expressed by the person. Education programs on how to deal with different types of clienteles would be made available to the health care providers to help them adjust to the difficulties associated with all kinds of issues. For mid- to long-term needs, improving means of transportation, adding support groups in rural areas, improving long-term follow-up in urban areas, humanizing of care, making information accessible, educating the neighbours and demystifying stroke by informing the public, would help integration and recovery of social roles to counter handicap situations. Finally, it is imperative to consider the perceived and expressed needs of the patients and caregivers and to integrate those needs with the normative needs identified in planning rehabilitation programs.Appendix 1: Course of the group discussions for the patients, caregivers, health providers and administratorsClick here for file


Individuals with coronary artery disease are at high risk for adverse health outcomes. This risk can be diminished by aggressive lipid management, but adherence to lipid management guidelines is far from ideal and substantial racial disparities in care have been reported. Lipid treatment and goal attainment information is not readily available for large patient populations seen in the fee-for-service setting. As a result, national programs to improve lipid management in this setting may focus on lipid testing as an indicator of lipid management. We describe the detection, treatment, and control of dyslipdemia for African Americans and Caucasians with coronary artery disease to evaluate whether public health programs focusing on lipid testing can eliminate racial disparities in lipid management.Physicians and medical practices with high numbers of prescriptions for coronary artery disease medications were invited to participate in the Quality Assurance Program. Medical records were reviewed from a random sample of patients with coronary artery disease seen from 1995 through 1998. Data related to the detection, treatment, and control of dyslipidemia were abstracted from the medical record and evaluated in cross-sectional stratified and logistic regression analyses using generalized estimation equations.Data from the medical records of 1,046 African Americans and 22,077 Caucasians seen in outpatient medical practices in 23 states were analyzed. African-American patients were younger, more likely to be women and to have diabetes, heart failure, and hypertension. The low density lipoprotein cholesterol (LDL-C) testing rate for Caucasian men was over 1.4 times higher than that for African-American women and about 1.3 times higher than that for African-American men. Almost 60% of tested Caucasian men and less than half of tested African Americans were prescribed lipid-lowering drugs. Tested and treated Caucasian men had the highest LDL-C goal attainment (35%) and African-American men the lowest (21%).Although increased lipid testing is clearly needed for African Americans, improvements in treatment and control are also necessary to eliminate racial disparities in lipid management. Disparities in treatment and goal attainment must be better understood and reflected in policy to improve the health of underserved populations. Individuals with coronary disease (CAD) are at high risk for subsequent cardiovascular disease events and mortality. ClinicaImproved lipid management through the diagnosis of dyslipidemia has been a focus of quality improvement programs in the outpatient fee-for-service setting such as Medicare's Health Care Quality Improvement Program. Lipid tThis study describes outpatient lipid management for African Americans and Caucasians with CAD seen in medical practices throughout the United States. Data from medical records were examined for indicators of lipid management including lipid testing, lipid-lowering drug prescription, and goal attainment. Our objectives were to characterize lipid management across race-sex groups and evaluate the extent of disparities for the three components of lipid management: detection, treatment, and control. We then discuss the implications of our findings with respect to possible underlying causes and health policies for closing the gap in race-sex lipid management disparities.The Quality Assurance Program (QAP) is a national program sponsored by Merck & Company conducted during the late 1990's to identify physician practice patterns and to promote evidence-based best practices for the medical management of patients with cardiovascular disease seen in the outpatient setting . The QAPMedical records were reviewed by Access Medical Ltd  using a standardized electronic abstraction tool developed specifically for QAP-II. The QAP database contains data obtained from the medical record including race, sex, date of birth, medical history, and medical procedures. The most recent serum lipid testing results and the most recently recorded prescriptions for lipid-lowering drugs were also determined from the medical record. The medical record of each patient was reviewed only once. Patients were not followed over time. Patient and physician identifying information were not included in the QAP-II database to ensure confidentiality.Physicians and medical practices throughout the United States with high numbers of prescriptions for medications used in the treatment of cardiovascular disease were invited to participate in the QAP. The specialties of participating physicians included cardiology, internal medicine, family medicine, and endocrinology. Patients with cardiovascular disease were randomly selected within each participating medical practice.Patients included in the QAP study were at least 21 years of age with CAD and/or heart failure and were seen at least twice in two years by the participating physician. Patients were excluded if the medical record indicated a terminal illness, history of a transplant or awaiting transplant, or deceased.International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes (410–414), and cardiac procedures consistent with CAD .Patients without medical record documentation of CAD were excluded from analysis. The presence of CAD was ascertained during analysis from abstracted medical record data based on medical history, Only patients with medical record documentation of African-American or Caucasian race were included. To reduce the influence of between-state variation in lipid management from states that contribute little information about African American populations, medical practices were excluded if they were located in states with fewer than 10 African-American patients in QAP-IIMeasures of detection (lipid testing), treatment (lipid-lowering drug prescription), and control  were the indicators of lipid management considered in this study. Low density lipoprotein cholesterol (LDL-C) testing was measured as the percentage of patients with at least one serum LDL-C value documented in the medical record. The use of lipid-lowering drugs  was measured as the percentage of patients with medical record documentation of at least one prescription for a statin (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor) or non-statin lipid drug . Goal attainment among those with documented LDL-C values was based on recommended guidelines for patients with coronary artery disease (LDL-C < 100 mg/dL).We conducted a cross-sectional analysis of abstracted medical record data obtained from QAP-II. Indicators of lipid management  and potential confounding or explanatory variables were examined within strata of race and sex. Co-morbid conditions including diabetes mellitus, myocardial infarction, heart failure, and hypertension were identified from medical history and diagnosis codes.Logistic regression analyses were performed to evaluate the associations of race and sex with each of three dichotomous lipid management indicators while controlling for multiple confounding and explanatory variables. We accounted for correlations within medical practices using the generalized estimation equation (GEE) method. This meThe independent variables included in the regression models in addition to race and sex were age, medical history , and geographic region of medical practice. Logistic models predicting lipid-lowering drug prescriptions included a term for serum LDL-C concentration in addition to the above variables. LDL-C concentration was included to control for the severity of hyperlipidemia as a factor in the physician's decision to treat with lipid-lowering drugs.A total of 23,123 CAD patients with documented race and sex seen by 1,171 physicians at 238 medical practices in 23 states were included in the study. Of these patients, 1,046 were African American and 22,077 were Caucasian. African-American compared to Caucasian patients were more likely to be women (53% versus 36%). The average age for the study population was 69 years and ranged from 22 to 97 years.Within each race group, women were older than men on average and within each sex group Caucasians were older than African Americans Table . The preWithin sex strata, the percent of patients with LDL-C tests was lower for African-Americans compared to Caucasians Figure . Within Almost 60% of Caucasian men with LDL-C testing were prescribed lipid-lowering drugs Figure . The proIncluding those prescribed and not prescribed lipid-lowering drugs Table , a quartAmong patients tested and treated with lipid-lowering drugs about two-thirds or more failed to achieve goal Figure . Tested Results from GEE logistic regression analyses controlling for age, co-morbid conditions, and geographic region Table  were conConsistent with previous reports, our findings demonstrate that outpatient lipid management for CAD patients in the late 1990's had much room for improvement and that substantial race-sex disparities existed,16,21-26Much of the information needed to assess lipid management can be found only in the medical record. This information is generally not available to national and local public health programs attempting to implement policies promoting quality improvement in the many and diverse medical practices treating large patient populations. The most readily available data for patients seen in the fee-for-service setting is derived from administrative insurance claims for the reimbursement of costs associated with drugs and services. Insurance coverage for lipid-lowering drugs varies across plans. In contrast, lipid testing for CAD patients is a widely covered service that can be identified using electronic billing data without the need to review patient records in medical practices. For this reason, lipid testing is a focus of national efforts in the Medicare population to improve outpatient lipid management in the fee-for-service setting. Our finUnderlying causes of inadequate lipid management among CAD patients are multiple and likely vary by race and process of care . Factors that limit patient-physician encounters and continuity of care may partially account for racial disparities in lipid management. For example, African-American Medicare consumers with diabetes were more likely to receive outpatient care from emergency departments and had fewer physician visits per year than their Caucasian counterparts,27. The A report regarding racial disparities in the use of prescription drugs from the Center for Studying Health System Change provides evidence of other factors explaining racial disparities in lipid management. In thisBarriers to lipid management due to affordability may result in racial disparities if affordability differs by race. Patients who can not afford treatment may be less likely to aggressively pursue it with their physicians and may be less likely to comply with physician recommendations for testing and treatment. Secondary prevention of cardiovascular diseases among CAD patients with pharmacologic agents such as statins has been shown to be cost effective. But druThe fact that African Americans are more likely to be of low income has greater implications than simply the inability to afford medications. Income is one of several indicators of socioeconomic status correlated with factors related to health including education. Low eduAchieving LDL-C goal is challenging for all races, but African Americans may require especially aggressive lipid management accompanied by an enhanced understanding of reasons for failure to achieve goal. A recent report concerning patients with CAD and/or diabetes seen at a Veterans Affairs Medical Center found that African Americans were less likely to achieve lipid goal than Caucasians when prescribed identical doses of the same lipid-lowering drug even though African Americans had more clinic visits and lipid tests. The autPhysicians have indicated that oversight is a common reason for failure to adhere to lipid testing guidelines. WhetherPhysician-patient interactions are influenced by race and cultural factors related to race. African-American and Caucasian patients may differ with respect to cultural perceptions of health and disease and the ability of patients to influence or control their health outcomes. AfricanThe relatively poorer lipid management for African Americans compared to Caucasians may be partially explained by racial differences in the prevalence of co-morbid conditions. African Americans in the QAP were more likely than Caucasians to suffer from multiple chronic conditions including diabetes and heart failure. It has been shown that patients with diabetes compared to those without diabetes receive poorer lipid management and are less likely to be at goal. An earlThere are a number of limitations in the QAP study design and its population that potentially pose a threat to internal and external validity. These limitations suggest that our findings may not reflect the experiences of the general population. The medical practices included in the QAP were restricted to those writing large numbers of prescriptions for cardiovascular disease drugs. It is difficult to evaluate the impact of this selection bias, but we suspect that medical practices included in the QAP represent the larger and more sophisticated providers of care. Thus, lipid management among QAP participants may be better than that found in the general population. Another limitation to our study is the lack of information characterizing medical practices, physicians, and patients with respect to factors related to race, sex, and lipid management. Because of the unavailability of this information, we could not identify underlying factors potentially explaining our findings. Lipid management data for the QAP patients seeing multiple physicians were unavailable from physicians not participating in QAP and this may have influenced results in an unpredictable manner.Considering the relatively small proportion of the study population identified as African American (<5%), it is likely that African Americans in this study do not represent the national population. We have no specific information about QAP medical practices or their patient populations, but we speculate that African Americans in the QAP were likely receiving better care on average than their counterparts in the general population, especially those with little or no access to outpatient care. If this is true, then racial disparities in lipid management in the general population may be even greater that those suggested by our findings.The time frame for this study includes years 1995 through 1998. Despite changes in guidelines and therapies since that time, our findings remain relevant to current practices. They provide historic context and baseline measures of lipid management disparities necessary to evaluate trends. In addition, they direct attention to the persistent need to provide aggressive treatment to high risk populations with CAD, especially African Americans and women who continue to be underserved. Finally, they highlight the growing view that public health strategies in lipid management must shift focus from testing to treatment and goal attainment.Clearly, a multi-pronged approach including all three elements of the process of care  is needed to improve lipid management for all race-sex groups, and particularly for African Americans. Although beyond the scope of this report, the application of conceptual models to the process of care may be useful in understanding how racial disparities arise at each step of the process. Furthermore, policies addressing health promotion and non-medical determinants of health such as socioeconomic status, community environment, and lifestyle choices need also be considered in confronting these disparities,45.Successful lipid management likely depends on a variety of processes that determine the provision of medical services including their availability, accessibility, and acceptability. The substantial racial disparities in lipid management among patients in contact with medical providers suggest that the effectiveness of medical services and patient characteristics play a prominent role in lipid management. Policies promoting appropriate delivery of care through system change as well as those ensuring equal access to care are required to eliminate lipid management disparities in the population of high-risk CAD patients,46.Our results suggest that policies and programs focusing solely on the elimination of lipid testing disparities can have only limited benefit in reducing the major disparity in lipid management. The elimination of lipid management disparities will require policies that view untested, untreated, and under-treated individuals as separate populations with unique challenges and solutions.Disparities in testing are just one element in explaining overall disparities in lipid management and ultimately, in cardiovascular outcomes. Future research should address patient, physician, and health system factors that lead to lower rates of testing, treatment and goal attainment for African Americans. Disparities in treatment and goal attainment must be better understood and reflected in policy in order to improve the health of underserved populations through optimal lipid management.CAD Coronary Artery DiseaseLDL-C Low-density lipoprotein cholesterolQAP Quality Assurance ProgramGEE Generalized Estimation EquationAnalyses were funded by an unrestricted grant from Merck & Co., Inc. No other competing interests are declared.MM conceived of the study, provided analytic and statistical support, and was the leading contributing author. KF participated in the design of the study and provided analytic support and interpretation of findings. LCE provided critical technical review and major contributions to the discussion section. CS provided conceptual guidance, assistance with QAP project database, and interpretation of analytic findings. CA provided critical review, QAP project experience, and contributions to the presentation and interpretation of findings. RS provided critical review, QAP project experience, and contributions to discussion and interpretation of findings. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Crocus sativus L. is used to treat depression. Many medicinal plants textbooks refer to this indication whereas there is no evidence-based document. Our objective was to compare the efficacy of stigmas of Crocus sativus (saffron) with imipramine in the treatment of mild to moderate depression in a 6-week pilot double-blind randomized trial.The morbidity and mortality associated with depression are considerable and continue to increase. Depression currently ranks fourth among the major causes of disability worldwide, after lower respiratory infections, prenatal conditions, and HIV/AIDS. th edition for major depression based on the structured clinical interview for DSM IV participated in the trial. Patients have a baseline Hamilton Rating Scale for Depression score of at least 18. In this double-blind, single-center trial, patients were randomly assigned to receive capsule of saffron 30 mg/day (TDS) (Group 1) and capsule of imipramine 100 mg/day (TDS) (Group 2) for a 6-week study.Thirty adult outpatients who met the Diagnostic and Statistical Manual of Mental Disorders, 4Saffron at this dose was found to be effective similar to imipramine in the treatment of mild to moderate depression . In the imipramine group anticholinergic effects such as dry mouth and also sedation were observed more often that was predictable.The main overall finding from this study is that saffron may be of therapeutic benefit in the treatment of mild to moderate depression. To the best of our knowledge this is the first clinical trial that supports this indication for saffron. A large-scale trial with placebo control is warranted. Depressive disorders are very common in clinical practice, with approximately 11.3% of all adults afflicted during any one year ,3. The aCrocus sativus blossom, genuine saffron is worth its weight in gold. This plant belongs to the Iridaceae family. Although once considered a remedy for digestive problems, saffron is no longer used medicinally in the West [Crocus sativus is also used to treat depression [Crocus sativus with imipramine in the treatment of mild to moderate depression in a 6-week double blind randomized trial.Saffron is produced from the tiny, dried stigma of lily-like the West . In Asiathe West -10. Recethe West ,12. Althpression . Many PeThis was a 6-week randomized and double blind clinical trial. The investigation was conducted in the outpatient clinic of Roozbeh Psychiatric Hospital between January 2002 and February 2004.th edition (DSM IV) [Thirty adult outpatients who met the Diagnostic and Statistical Manual of Mental Disorders, 4(DSM IV)  for majo(DSM IV)  score ofThe saffron was used in this study was dedicated by Novin Zaferan Co  and was identified by the Department of Cultivation and Development of Institute of Medicinal Plants, Tehran, Iran. The stigma's extract was prepared as follow: 120 g of dried and milled stigmas was extracted with 1800 ml ethanol (80%) by percolation procedure in three steps then the ethanolic extract was dried by evaporation in temperature between 35–40°C. Each capsule had dried extract of saffron (10 mg), lactose (filler), magnesium stearate (lubricant), and sodium starch glycolate (disintegrant).Patients underwent a standard clinical assessment comprising a psychiatric evaluation, a structured diagnostic interview and a medical history. Patients were randomized to receive capsule of saffron or capsule of imipramine in a 1: 1 ratio using a computer-generated code. The investigation preparations were administrated in red capsules whole indistinguishable in color, size, form and taste. The assignments were kept in sealed, opaque envelopes until the point of allocation. The randomization and allocation process was done by the pharmacist of the Roozbeh Hospital. In this double-blind, single-center trial, patients were randomly assigned to receive capsule saffron 30 mg/day (TDS)(Group A) or capsule imipramine 100 mg/day (TDS) for a 6-week study. The dose of saffron was calculated according to a recent published animal study . All patSide effects were systematically recorded throughout the study and were assessed using a checklist administered by a resident of psychiatry on day 3, 7, 14, 21, 28 and 42  was used. The two groups as a between-subjects factor (group) and the six weekly measurements during treatment as the within-subjects factor (time) were considered. This was done for HAM-D total scores. In addition, a one-way repeated measures analysis of variance with a two-tailed post hoc Tukey mean comparison test were performed in the change from baseline for HAM-D scores in each group. To compare the two groups at baseline and the outcome of two groups at the end of the trial, an unpaired Student's t-test with a two-sided P value was used. Results are presented as mean ± S.E.M. Differences were considered significant with P < 0.05. To compare the demographic data and frequency of side effects between the protocols, Fisher's exact test (two sided) was performed. To consider, a = 0.05, β = 0.2, the final difference between the two groups at least score of 5 on the HAM-D total scores that is clinically detectable, S = 5 and power = 80%, the sample size was calculated at least 15 in each group.No significant differences were identified between patients randomly assigned to the group 1 or 2 conditions with regard to basic demographic data including age and gender (Table The mean ± SEM scores of groups 1 and 2 are shown in Fig. A number of probable side effects were studied Table . Dry mouThe current therapeutic goal in the treatment of major depression is to improve the quality of life by normalizing mood, increasing awareness of personal pleasures and interests, and reversing the functional and social disabilities associated with depression, as well as to reduce suicide rates . SaffronCrocus sativus extracts showed antidepressant effect [In this small preliminary double-blind and randomized comparison of saffron and imipramine in the treatment of mild to moderate depression, saffron at this dose was found to be effective similar to imipramine. Our results are in the line with a recent published animal study that t effect . In addit effect . In addit effect . The limNone declared.SA was the principal investigator and performed statistical analysis. HF and KA were the trialist. AHJ and FKC were the pharmacognosists of this study. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: