The objective of this study was to assess the impact of package size on the contact between medical devices and non-sterile surfaces (i.e. the hands of the practitioner and the outside of the package) during aseptic presentation to a simulated sterile field. Rationale for this objective stems from the decades-long problem of hospital-acquired infections. This work approaches the problem from a unique perspective, namely packaging size.Randomized complete block design with subsampling.Research study conducted at professional conferences for surgical technologists and nursing professionals.Ninety-seven healthcare providers, primarily surgical technologists and nurses.Participants were gloved and asked to present the contents of six pouches of three different sizes to a simulated sterile field. The exterior of pouches and gloves of participants were coated with a simulated contaminant prior to each opening trial. After presentation to the simulated sterile field, the presence of the contaminant on package contents was recorded as indicative of contact with non-sterile surfaces and analyzed in a binary fashion using a generalized linear mixed model.Recruited subjects were 26–64 years of age , with 2.5–44 years of professional experience. Results indicated a significant main effect of pouch size on contact rate of package contents (P = 0.0108), whereby larger pouches induced greater rates of contact than smaller pouches .This study utilized novel methodologies which simulate contamination in aseptic presentation. Results of this work indicate that increased contamination rates are associated with larger pouches when compared to smaller pouches. The results add to a growing body of research which investigate packaging's role in serving as a pathway for product contamination during aseptic presentation. Future work should investigate other packaging design factors  and their role in contamination. Stone et al. Published work focused on medical devices as a potential indirect route for contamination is limited to a study of aseptic technique with surgical clamps Another potential source of indirect contamination is the result of package handling during opening and presentation of devices to the sterile field. Packages that contain sterile devices are only sterile on the inside because the outside has been exposed to non-sterile personnel, environments, etc. As such, any contact of the sterile medical device with the outside of the package, or the hands of the person opening the package, is potentially an indirect route of contamination for the medical device, and, ultimately, the patient.Sterile items vary significantly by size and shape, are packaged in an array of package types, and these packages can be composed of an array of material. Sterile items are primarily packaged in: (1) flexible pouches made from varying materials or (2) lidded trays . Materials comprising the sterile barrier system (SBS) may be hydrophilic or hydrophobic; porous or non-porous; transparent or opaque as well as rigid or flexible. Designs may include: peelable or welded seals; have varied seal patterns and composed of single or multiple layers There is a paucity of information on how package factors affect contamination. The few studies that do exist are hampered by small sample sizes and do not directly investigate how differing factors, such as size, influence contamination rates of packaged medical devices. Crick et al. (2008) investigated medical device contamination using a simulated contaminant and five operating room (OR) nurses Herein, we focus our efforts on understanding the effect of packages size on the rate of contact between a simulated device and two non-sterile surfaces (the outside of the package and the hand of the person opening the SBS) using three sizes of flexible peel pouch. Understanding flexible peel packs in the aseptic technique process is relevant to surgical site infections (SSI), but studies of central line catheter kits and removal of the items within may also be relevant to central line associated bloodstream infections (CLABSI). Work has been conducted on the effect of packaging several items together and the likelihood of making technical mistakes The specific goal of this research was to assess the impact of a single packaging design factor, specifically pouch size in flexible peel packs, on rates of contact between package contents and the outside of the pouch or gloves of the circulator (both of which are considered non-sterile) during aseptic presentation to a simulated sterile field. See .Subjects provided their written informed consent to IRB trained personnel. This study was approved by the Biomedical and Health Institutional Review Board (BIRB) at Michigan State University under approval letter #11–102. All collected data was anonymous.th Annual Association of peri-Operative Registered Nurses (AORN) Congress , the 2011 Annual Meeting of the Association of Surgical Technologists  and the Pontiac Regional Medical Center .A total of 97 healthcare providers were recruited at three locations, namely the 58To participate, individuals needed to: be at least 18 years of age; have no history of skin conditions such as latex allergies or eczema; currently be working as, or have worked as, a healthcare professional; and be willing to be digitally video recorded.Following the informed consent process, participants were asked to complete a survey with demographic information such as age and gender, and to answer several questions regarding their professional experience as a healthcare provider . All data were de-identified; information was affiliated only by subject number.2/24.2 cm2).Each participant opened and aseptically presented the contents of three sizes of pouch twice, for a total of six trials per participant. Pouch sizes were: 7.62 cm × 20.32 cm , 25.4 cm × 24.45 cm (medium), and 40.64 cm × 26.67 cm (large). To maintain a consistent ratio between the size of the package and the amount of product in the package, pouches were filled with tongue depressors such that the “aspect ratio” (i.e. the pouch area/surface area of the tongue depressors) was equal for all sizes. A target aspect ratio of 6.4 was obtained by including 1, 4 and 7 tongue depressors in small, medium and large pouches, respectively. The length of the medium and large pouches were cut so that their aspect ratios were equal to 6.4, the aspect ratio of the small pouch when it contained one tongue depressor . These devices also have a simple physical profile, making it possible to inspect all areas of the device quickly upon completion of each trial. Each pouch was filled with the appropriate number of devices and then sealed using an impulse sealer .We adapted the methodology developed by Crick et al. For each trial, one of the six openings, participants were provided with a new pair of gloves; participants selected their own gloves from sizes that ranged from small to large. The contamination simulant was applied to the exterior of the gloves (with the exception of the pads of the digits involved in opening) immediately preceding a given trial. Test pouches also received a thin coating of the simulated contaminant just prior to being handed to test participants. Coating of the working digits of hand and of the seal area of the pouch were purposefully avoided in order to ameliorate any changes in handling that could have resulted from changes in friction as a result of the simulated contaminant which was a paste-like substance. The gloves and pouch were selected to be coated because these were the two primary contact risks for the package contents .To minimize the risk of cross contamination, research personnel were assigned to either “clean” or “contaminated” tasks. “Clean” personnel did not handle the simulated contaminant nor any contaminated objects. Their roles were to: prepare drapes  representing the sterile field for each trial, record the process with the camcorder, mark the data sheets, and slide the drape carefully into the scanning area. Clean personnel were trained by a single researcher to scan all sides and edges of each tongue depressor, holding the UVA light 3–4 inches away from the itemto assess whether transfer of the simulated contaminant had occurred during presentation. By contrast, “contaminated” personnel were responsible for applying the simulated contaminant, as well as coating pouches and gloves prior to each trial and removing them after each trial.Each subject participated in a total of 6 trials , for a total of 582 trials (6 pouches × 97 subjects). Order of pouch size was randomized for each participant to mitigate the effects of fatigue or run order. Immediately following presentation to the sterile field, all tongue depressors were examined under black light for signs of contamination. A trial was recorded as having made contact with a non-sterile surface if at least one of the presented tongue depressors from a package fluoresced upon exposure to black light  was analyzed using a generalized linear mixed model fitted with a logit link function. The linear predictor in this model included the fixed effect of pouch size and the random blocking factor of subject in order to recognize repeated observations on each participant. The cross product of participant and pouch size was evaluated for model inclusion as a random effect but was excluded from the final model as its corresponding variance component converged to zero during the estimation process. Additional explanatory variables, including: gender, education and profession, as well as the covariates age, years of working experience, years of experience with aseptic presentation, hand breadth, and number of repositions, were evaluated for inclusion in the statistical model. Relevance of these explanatory variables to model fit was assessed using maximum-likelihood-based Bayesian Information Criteria and in some cases, P-values. None of these explanatory variables were included in the final model as there was no evidence that any of them contributed to enhance model fit. The final model used for inference was fitted using proc GLIMMIX of SAS  with residual Pseudo-likelihood as the estimation method, implemented with Newton-Raphson with ridging as the optimization technique. Results are presented as least square mean estimates (LSME) and corresponding estimated standard errors (SEM). Kenward-Rogers procedure was used to estimate degrees of freedom and to make the corresponding correction in the estimation of standard errors. Post-hoc pair-wise comparisons utilized Tukey-Kramer adjustments to prevent inflation of Type I error due to multiple comparisons.Data from 81 females and 16 males were available for analysis. Females ranged in age from 26–64 (SD = 9.5 years) and males from 28–62 (SD = 16.2 years). Professional occupation frequencies were: 55 nurses, 40 surgical technologists, one doctor and one “other” healthcare provider. For the purpose of data analysis, the surgical technologists were combined with the two other participants in a “non-nurse” category. Nurses averaged 27.0 years  of professional experience, with an average of 22.8 years of experience presenting to sterile fields . The participant group comprised of non-nurses reported an average of 14.0 years of experience in healthcare  and 12.9 years of experience presenting to sterile fields .Results indicate evidence for a significant main effect of pouch size on the probability of contact between the package contents and a non-sterile surface during presentation to the simulated sterile field (P = 0.0108). More specifically, larger pouches induced greater rates of contact of package contents than smaller pouches . Contact rates for medium-sized pouches were intermediate (8.3±2.1%) relative to that of larger and smaller pouches, and there was no evidence of significant difference from either comparison  See .After accounting for pouch size effects, none of the demographic factors considered, namely: gender, age, education, profession, years of working experience, years of experience with aseptic presentation and hand breadth were found to be associated with probability of contamination of package contents during aseptic presentation to the simulated sterile field (P>0.05).Our study is among the first to examine the impact of package size on successful aseptic presentation of medical devices to the sterile field. Invasive medical devices constitute a potential source of contamination for HAIs Much of the current efforts intended to mitigate the risk of an HAI focus on gloving techniques Our study provides evidence that pouch size has the potential to impact rates of contamination of package contents during aseptic presentation to the sterile field. Understanding the role of package factors in HAI is a rich area for future investigations. Although the contamination rates between the small and large pouches were significantly different, specific reasons for these differences remain unclear. One theory of the investigative team is that the larger pouches were handled more frequently (i.e. required more repositioning of the hands) during the opening process as compared to the small pouch. In other words, as the participant was opening the small package, he/she would pull it from the center and immediately dump the contents into the simulated sterile field. In contrast, for the larger package, participants often pulled apart one section of the pouch, then slid their hands across the top to pull open another section and repeated this movement until the entire pouch top was open. Through post-hoc analysis of video data, we attempted to characterize differences in handling as a possible explanation. However, the subjective nature of video analysis and of defining what constituted a “hand repositioning event” made quantifying these movements in a repeatable fashion challenging. Further work is currently in progress to better characterize this phenomenon using additional, objective means such as motion capture.The authors acknowledge that controlling components of the experimental testing conditions, such as the package contents, poses a limitation in the relevance of these results for a realistic surgical setting. For instance, tongue depressors would not usually be packaged in large pouches. However, we chose to use them here to avoid confounding the potential effects of product shape, volume or size with the factor of interest, namely pouch size. Further testing is required to understand the role that the design of the medical device itself may play in rates of contamination (e.g. devices that are thin and flexible like catheters). Additionally, to keep the aspect ratio (surface area of pouch/surface area of product) consistent, the small pouch contained a single tongue depressor, while the medium held four and the large, seven. This resulted in a scenario where the multiple tongue depressors tended to “flow” from the package, while the single one did not. The authors suggest future experiments to determine whether or not the flow of items in this manner impacts contact between product and “non-sterile” surfaces.Additionally, we limited the scope of the study to the practice of dumping pouch content into the sterile field. Further investigation will need to be conducted to understand how contamination rates for “picking” (transferring a sterile item to sterile personnel who place it in the field) compare to dumping, and the types of packages and devices that should be transferred this way. The authors acknowledge that the simulated contaminate may not be an accurate representation of microbial activity, but that it provides evidence of indirect contact pathways through which such an event could occur. The authors also acknowledge that a positive transfer of the simulated contaminate might not result in an infection; our intention was that it serve as a means to verify contact between the device and a non-sterile surface (i.e. the outside of the package or the gloved hand of the circulator). Finally, the authors acknowledge that the recruitment of subjects attending professional conferences may not be representative of a real scenario in an operating room. However, our setup allowed for assessment of many subjects with high levels of experience. Similar work in a simulated operating room may be worthwhile since operating room traffic and the responsibilities of the healthcare professional may further influence the opening process.In summary, this research evaluated the effects of pouch size on contamination rates. The results support the conclusion that larger pouch sizes produced higher contamination rates of the contents. However, the source of the contact (pouch or hands) was not addressed in this work and warrants further investigation.


In most studies migraineurs have an interictal habituation deficit of visual evoked potentials (VEP) that normalizes during the attack. This, however, was not confirmed by some who suggested that it is due to non-blinded analyses.To compare blinded and non-blinded analyses of raw VEP single-trial signals by two different investigators in healthy volunteers (HV) and migraineurs.Pattern-reversal VEP were recorded in 22 HV , 44 migraineurs without (MO: n=23) or with aura (MA: n=21) and in 24 patients during an attack. Two researchers, one of which was totally blinded to subjects and diagnosis, independently analysed single trials and calculated habituation slopes.In both the blinded and the non-blinded analysis VEP habituation was normal in HV (slope -0.12 & -0.2 respectively), but deficient in both migraine groups: MO (+0.02 & +0.09), MA (+0.03 & +0.03). The difference between HV and MO or MA was significant for the blinded (p=0.03 or p=0.001) and the non-blinded procedure–(p=0.03 or p=0.003). Ictal VEP habituation was normal in both blinded and the non-blinded analyses . Intraindividual habituation slope was similar between blinded and non-blinded analyses. Data obtained by non-blinded and the blinded procedure significantly correlated .We confirm in a blinded analysis of raw signals that migraineurs present interictally a significant deficit of VEP habituation, similarly to non-blinded analysis of the same traces. The discrepant results found in some studies can thus not be explained by blinding, but rather by patient-related differences.No conflict of interest.


Computer simulations using periodic error functions show that we are dealing with a convergent series, and the error-correction technique is highly successful. This is demonstrated for a triply periodic function for errors in each of the spherical coordinates. Appropriate graphical representations of the error-contaminated, error-corrected and error-free near fields are presented to enhance understanding of the results. Corresponding error-contaminated and error-free far fields are also obtained.A general theoretical procedure is presented to remove known probe-position errors in spherical near-field data to obtain highly accurate far fields. We represent the measured data as a Taylor series in terms of the displacement errors and the ideal spectrum of the antenna. This representation is then assumed to be an actual near field on a regularly spaced error-free spherical grid. The ideal spectrum is given by an infinite series of an error operator acting on data containing errors of measurement. This error operator is the Taylor series without the zeroth-order term. The  In planar geometry the spatial derivatives are obtained using fast Fourier transforms (FFT) . The integrand in θ, and can be expanded in a Fourier series,lnmc can be obtained by Fourier transforming the data. Since only the coefficient To obtain the coefficients ϕ are the simplest, since the ϕ dependence is only through the factors exp(imϕ) in the vector basis functions. Hence, a kth-order derivative with respect to ϕ will merely alter the coefficients in kth-order derivatives of Hankel functions with respect to x after repeated differentiation of the recursion relation  must be extended to the interval  or  using the symmetry properties of the basis functions [The coefficients unctions ,5.tE, we must be able to analyze it to obtain the coefficients nmα, andGiven a spherical vector function nmα, we must be able to synthesize the spherical vector function tE by performing the sum.Given a set of coefficients Focusing on a specific term of the full error-correction expression as given in r coordinate,t.Ê The following six steps must be executed to evaluate this expression numerically:tÊ to obtain coefficients nmα, as defined in We analyze the components of tÊ by performing the summation in We obtain the second-order radial derivatives of the components of δr)2, thereby obtaining a new spherical near field.We multiply the result by the function  to get a new set of coefficients tÊ by performing the summation in We obtain the first-order radial derivatives of the components of δr to obtain the part of the error-corrected spherical near field denoted by We multiply the result in step (5) by 0.5 Similar sequences of steps will correctly evaluate any and all of the terms in θ and ϕ coordinates.As is evident from the discussion in the preceding sections, we need efficient numerical procedures for two basic computational problems arising from nmα [ to be studied, and choose its amplitude.We define a probe-position error function |irregular grid points x + δx. This requires a direct sum at each point of the grid, since no efficient method of summing is known to exist on an irregular grid.We construct an error-contaminated near field by performing the summation in We perform the computations in We calculate error-free, error-contaminated, and error-corrected far fields.We compare error-free, error-contaminated, and error-corrected fields to study the effectiveness of the error correction.Computer simulations were performed for probe-position errors in a single spherical coordinate only; simultaneous errors in two or three coordinates were not considered. The following sequence of steps were performed for errors in each of the spherical coordinates:θ and ϕ components of the error-free near field. The near field was obtained by summing the terms in n =30, after the original near-field data were analyzed to obtain coefficients up to n = 87. With n = 30, direct summations on irregular grids could be performed in about 6 hours on a personal computer. θ and ϕ components of the error-free far field.The near field used in all the simulations was generated by a microstrip array antenna consisting of four 16 × 16 element subpanels operating at 3.3 GHz. The scan radius was 128 cm. s = r, θ, or ϕ, and α = β = 3. For errors in the radial coordinate we chose A = 0.1 λ ≈ 1 cm, and for errors in the angular coordinates, we chose A = 0.01 λ, which corresponds to a maximum angular error of 3.6°. The magnitude of these errors are unrealistic, since, on the NIST spherical near field scanner, the probe’s position errors are estimated to be less than δr ≈ 0.1 cm, and δθ ≈ δϕ ≈ 0.5°. Periodic probe-position errors were chosen, because such errors in the near field could lead to large errors in the far field. This is a well known phenomenon in planar near-field to far-field transformations [We chose periodic probe-position error functions of the formrmations . The proThe results of the simulations are presented in the figures 3θ = 0 in all cases. This is true for both the near and the far field.The correction is most successful in the forward hemisphere, especially around the main beam at θ = ± 180°, where the data are ill-determined and small in amplitude.The correction is least successful in the back hemisphere, especially around There are no large regions on the sphere where the correction technique fails.At isolated points the correction seems to be less successful as evidenced by peaks in the perspective plots. These points correspond to deep nulls in the original error-free near field, and, consequently, can be understood as artifacts of the ratio field, rather than some more serious problem with the technique.δr clearly shows up in ikr)/r at r + δr and r, with δr ≤ rThe radial error function θ and ϕ shows up clearly in all the error-contaminated plots, as expected. This structure also shows up in the error-corrected plots, indicating that the error-correction procedure is a systematic global reduction of the error without altering the functional form of the error. This agrees with the structure of The three-lobe structure of the periodic error function over an angular interval of 180° in An examination of the plots immediately reveals the success of the error correction. By comparing the amplitudes of the error-contaminated and error-corrected ratios, we immediately observe insignificant levels of residual errors almost everywhere on the sphere. The same quantitative observation can be made about the phase difference plots, where the residual error in the error-corrected phases approaches 0. The following additional qualitative observations are worthwhile:Both the qualitative and quantitative features of the results show that the error correction outlined in this study can be very useful in providing more accurate spherical near-field data to determine accurate far fields of antennas.r, θ, or ϕ from spherical near-field data. For completeness, the technique should be applied when errors in all three coordinates are present simultaneously. This is the most realistic case. Such a complete error-correction technique would be computationally more complicated and extensive, but in principle not more difficult, and should also be effective and successful. Finally, more realistic probe-position error functions should be used, and the correction technique should be applied to real error-contaminated spherical data. The success of this error-correction technique is especially desirable at higher frequencies, where the realistic amplitudes of the probe-position errors on a spherical near-field range are a significant part of the wavelength.Here we have demonstrated the effectiveness of a novel error-correction technique that removes probe-position errors in


Anyone living beyond middle age is inevitably affected by presbyopia, an inability to focus on near objects, due to the loss of flexibility of the ocular lens. It is estimated that over half of the one billion people affected globally cannot afford the spectacles needed to correct their eyesight. Most of the people with uncorrected visual impairment live in low- and middle-income countries.International statistical classification of diseases and related health problems (ICD).–In 2002, the World Health Organization (WHO) estimated that more than 161 million people had visual impairment and that cataract was the leading cause.Research that has specifically set out to investigate the prevalence and impact of uncorrected refractive error has often only considered impairment of distance vision.Near vision is often perceived to be less problematic than impaired distance vision, particularly for people in low- and middle-income countries. It could be argued that reduced literacy, differences in vocation and lower life expectancy reduce the need for near vision correction – but recent studies indicate the contrary. Studies in rural Africa have shown that near vision impairment greatly impacts quality of life despite very low literacy levels.Uncorrected presbyopia is the most common cause of visual impairment. WHO has recommended the measurement of near vision in population-based surveys. Formal inclusion of near vision impairment in the ICD is an overdue and crucial step in dealing effectively with this common but easily mitigated disability.


Although self-esteem is related to problematic drinking, the mechanisms by which it affects drinking remain unclear. The purpose of this study was to determine whether coping mechanisms mediate the relationship between self-esteem and problematic drinking among Chinese men and women with alcohol use disorders and to recommend appropriate interventions for drinking problems.A cross-sectional survey was conducted in Harbin, Heilongjiang Province, China. A sample of 5,689 community residents was screened, and 517 male and 172 female problematic drinkers were chosen to participate in this study. A self-esteem scale, a coping questionnaire and an alcohol use disorder identification test were completed in order to assess participants’ self-esteem, coping mechanisms and alcohol use disorders, respectively. Participants’ socio-demographic data were also gathered at this stage. The resulting data were examined via descriptive statistics, correlations and bootstrap analyses.Lower self-esteem levels were related to problematic drinking, and there were no gender differences in the relationship between self-esteem and problematic drinking. A relationship between low self-esteem and negative coping was observed only in men. Negative coping thus mediated the relationship between self-esteem and problematic drinking among men, but this was not the case for women. Positive coping did not mediate the relationship between self-esteem and problematic drinking among the participants, regardless of gender.Self-esteem and coping strategies are correlated among problematic drinkers. In addition, there are gender differences in the manners in which negative coping mediates the relationship between self-esteem and problematic drinking. Problematic drinking interventions directed at males should simultaneously address low self-esteem and negative coping. Alcohol use disorders are a major public health issue and a leading cause of death worldwide; they account for 3.2% of deaths (1.8 million people) per year. Of these deaths, 80% occur in developing countries . AlthougPeople in China are known to engage in self-suppression to maintain harmony . Their sHaving low self-esteem often increases the likelihood that individuals will use alcohol to manage increases in negative feelings . IndividAlthough self-esteem and alcohol problems frequently occur together, alcohol problems may not necessarily be a consequence of self-esteem levels. Coping may serve as a mediator between self-esteem and alcohol consumption. D’ Zurilla found that low self-esteem can promote anger and hostility, which can cause individuals to address problems in an unhealthy manner and to employ impulsive and escapist defense mechanisms . IndividPrevious studies have neglected to account for the mediating effects of self-esteem on alcohol consumption, which has led to conflicting conclusions regarding the effects of self-esteem and coping on problematic drinking. The current study examines the relationships between self-esteem, coping mechanisms and problematic drinking, and it specifically investigates the effects of coping mechanisms on self-esteem and problematic drinking. Thus, our goal is to present comprehensive findings on the relationships between self-esteem, coping mechanisms and problematic drinking. Analytic models are tested in a sample of individuals with drinking problems. We hypothesize that self-esteem levels are related to problematic drinking and that the mediating effects of coping differ in males and females.The research described in this paper meets the ethical guidelines of the ethics committee of Harbin Medical University. Approval for this study was granted by the Ethics Committee of Harbin Medical University. The nature and purposes of the study were explained to all of the participants. Participation was completely voluntary, with no economic or other motivations involved, and each participant signed a written statement of informed consent. The sample was drawn from the Ministry of National Science and Technology plan survey, which is a large community survey of health and psychological health information awareness. A cross-sectional study was conducted using residents of Harbin, which is a city in northeastern China. A multi-stage randomized cluster sampling method was employed to select the sample. In the first stage, after considering the operational and scientific aspects of the study, we selected two roads (Nangang and Dacheng) using a simple random sampling method. Then, we employed a probability proportionate to size sampling method to select four neighborhoods located along each road. In each neighborhood, we selected 5 residential buildings. The participants were local residents of the area or had lived in the selected buildings for more than half a year and were at least 15 years of age. The researchers entered the respondents’ homes to conduct the face-to-face surveys. Before completing the questionnaires, all of the participants provided their consent to participate in the survey. The researchers read the survey questions aloud to respondents who could not read and answered any questions that respondents had regarding unclear questions. The questionnaires were returned to the researchers immediately after they were completed. Interviewees who were not home during the first visit were visited two additional times. Individuals who were not home on three occasions or who did not wish to participate were excluded from the study. Although we initially planned to invite 5,000 community residents to participate in the survey, we ultimately invited 5,689 individuals to account for refusals.We collected sociodemographic information from the participants regarding their gender, age, marital status, educational background and household income.As part of the survey, a translated version of the Rosenberg Self-Esteem Scale (RSE) was administered in order to assess each participant’s self-esteem . It inclCoping styles were assessed using the Simplified Coping Style Questionnaire, which is based on the Ways of Coping Questionnaire (WCQ) by Folkman and Lararus , 27. BecWe used the Alcohol Use Disorders Identification Test questionnaire (AUDIT) to identify respondents who had drinking problems . Of the Analyses were conducted to determine the mediating effect of coping mechanisms on the relationship between self-esteem and problematic drinking. We used SPSS 18.0 and SPSS Bootstrapping to analyze the data using the following procedure.First, marital status, educational level and household income distributions were determined via descriptive statistics. Second, we analyzed the associations among age, self-esteem, negative coping, positive coping and problematic drinking using correlation analyses. We then tested whether self-esteem predicted problematic drinking (path c) and coping strategies (path a). For path b, coping strategies were added to the regression model that controlled for sociodemographic variables  in order to determine the relationships between various coping mechanisms and problematic drinking. With path c’, we determined the association between self-esteem and problematic drinking when controlling for age, marital status, educational level and household income. The main effects of paths a, b, c and c’ were determined based on four criteria. After all four criteria for testing mediation were fulfilled, we calculated the (a*b)/c value to identify the mediating roles of the different coping strategies. When all of the pathways suggested mediation, SPSS Bootstrapping was employed. In this study, 5,000 bootstrap samples were used.2 = 5.51, P<0.05; χ2 = 6.41, P<0.05 and χ2 = 5.55, P = 0.14, respectively); these results are displayed in A total of 5,689 community residents were investigated, and we ultimately collected 5,466 valid and complete questionnaires. Of these participants, 689 participants  had alcohol use disorders. The average age of the respondents with drinking problems was 39.15±12.09 years; the average age of the males was 39.78±11.57 years, with a range of 15 to 77 years, and the average age of the females was 37.27±13.40 years, with a range of 16 to 71 years. Differences between males and females with respect to marital status, educational levels and household incomes were significant  was significant for the male respondents when negative coping mediated the model , which indicates that negative coping served as a partial mediator of the relationship between self-esteem and problematic drinking among the male respondents. Therefore, we tested the total effect of the independent variable on the dependent variable for path c and employed the (a*b)/c formula to calculate the effect size of the mediation. For the male respondents, the negative coping mediation effects for the self-esteem to problematic drinking path were found to be 18.32%.Self-esteem is considered a predictive variable for problematic drinking , and negPrevious studies have demonstrated that self-esteem is associated with alcohol use problems ,9,11. HoWe found associations between self-esteem and negative and positive coping mechanisms. Among problematic drinkers, those with lower levels of self-esteem frequently engaged in negative coping, whereas those with higher levels of self-esteem typically utilized positive coping. This pattern is consistent with Stein and his colleagues’ finding that lower levels of self-esteem are positively associated with negative coping strategies and negatively associated with positive coping strategies . People The nature of the associations between self-esteem, coping mechanisms and problematic drinking suggest that negative coping only mediates the relationship between self-esteem and problematic drinking in men. It appears that when men with lower levels of self-esteem adopt negative coping mechanisms, they may be more likely to consume alcohol. According to the self-discrepancy theory, the discrepancy between the actual and ideal self is uniquely presented via personal self-esteem. This discrepancy often promotes the development of dejection-related emotions . Men witDespite these significant findings, the current study also has a number of limitations. First, the study involved a cross-sectional investigation, which meant that we could not determine the directions of causality among self-esteem, negative coping, positive coping and problematic drinking; however, our results are consistent with our hypotheses and are based on firm theoretical foundations. Second, we only studied residents of Harbin, despite being interested in problematic drinking in China as a whole. Regional differences in China should be considered in future studies. We plan to examine this issue further by studying problematic drinking in other regions and by conducting a cohort study.In summary, self-esteem and coping strategies not only have correlations with each other but also have independent associations with problematic drinking. People with drinking problems often have low self-esteem, are more prone to using negative coping and are more reluctant to use positive coping. In men, low self-esteem and negative coping play important roles at the same time, and negative coping can mediate the association between low self-esteem and problematic drinking; this finding was not observed in women. Psychotherapy focused on self-esteem and coping strategies can benefit problematic drinkers and improve clinical results. People, and men in particular, who have low self-esteem and rely on negative coping should alert alcohol treatment professionals to the possibility of problematic drinking.Clinicians should pay attention to self-esteem and coping strategies when working with individuals who are facing negative life events and indulging in poor mood and should actively utilize proper interventions. This could include using the “deficit model” to teach individuals skills that can improve self-esteem , 35 and


NIPA2 in which we have found three mutations  within a population of patients with childhood absence epilepsy (CAE). In this study, immunofluorescence labeling, inductively coupled plasma-optical emission spectroscopy (ICP-OES), MTT metabolic rate detection and computational modeling were utilized to elucidate how these mutations result in CAE. We found in cultured neurons that NIPA2 (wild-type) proteins were localized to the cell periphery, whereas mutant proteins were not effectively trafficked to the cell membrane. Furthermore, we found a decrease in intracellular magnesium concentration in the neurons transfected with mutant NIPA2, but no effect on the survival of neurons. To understand how low intracellular magnesium resulted in hyperexcitability, we built and analyzed a computational model to simulate the effects of mutations. The model suggested that lower intracellular magnesium concentration enhanced synaptic N-methyl-D-aspartate receptor (NMDAR) currents. This study primarily reveals that a selective magnesium transporter NIPA2 may play a role in the pathogenesis of CAE.Recently many genetic mutations that are associated with epilepsy have been identified. The protein NIPA2 (non-imprinted in Prader-Willi/Angelman syndrome region protein 2) is a highly selective magnesium transporter encoded by the gene  CACAN1H2+ channel. Recently, some non-ion channel genes leading to the CAE have also been identified, such as NIPA2NIPA2 is located at 15q11.2, a region associated with GGE. In our previous study, we found three NIPA2 mutations in a population of patients with CAE. They included two novel missense mutations  and one novel small insertion  Epilepsy is a collection of neurologic diseases characterized by unprovoked and recurrent seizures. Childhood absence epilepsy (CAE) is considered a crucial type of genetic generalized epilepsy (GGE). Previous studies have only found mutations in ion channel genes associated with CAE, such as NIPA2 encodes the non-imprinted in Prader-Willi/Angelman syndrome region protein 2 (NIPA2) 2+ as well as other cations. NIPA2 is a highly selective magnesium transporter located in the cytomembrane and the early endosome 2+ into the cytoplasm NIPA2 mutations has been reported. Functional studies from NIPA1 mutations have shown that mutations disrupt transport of the protein to the extracellular membrane, resulting in an accumulation of the proteins in the cytoplasm NIPA2 mutations also affect transport, resulting in accumulation of the proteins in the cytoplasm and a decreased intracellular Mg2+ concentration.2+ participates in the gating and activation of channels and receptors, such as N-methyl-D-aspartate receptors (NMDARs) 2+ concentration caused by the NIPA2 mutation may result in epilepsy.MgNIPA2 Mg2+ transporter gene associated with a form of childhood absence epilepsy NIPA1 mutations found that the mutations prevented transport of the NIPA1 protein to the extracellular membrane, resulting in an accumulation of the proteins in the endoplasmic reticulum (ER) 2+2+ dependent; when extracellular Mg2+ was low the cell compensated with a significant increase in membrane expression of NIPA2 2+ concentration. In this study, we transfected primary cultured neurons with three different NIPA2 mutations  and wild-type with HSV-RFP vectors (Herpes Simplex Virus - Red Fluorescence Protein).In a previous genetic study, we discovered three mutations in the The first goal was to determine the location of the mutant NIPA2 proteins expressed in the cells. To do this, they were marked with red fluorescence protein (RFP) and the cell's plasma membrane was labeled with a green fluorescence marker (DIO). We found that wild-type proteins were localized to the cell border, but all three mutant proteins were retained in the cytoplasm .NIPA2 mutations decreased. MTT -2, 5-diphenyltetrazolium bromide) is a yellow substrate that is enzymatically cleaved in living cells to yield a dark blue formazan product. This process requires active mitochondria, and cells that have recently died do not cleave significant amounts of MTT. Primary cultured neurons were transfected with the wild-type NIPA2, three NIPA2 mutants and the NIPA2-siRNA. Cell viability of transfected cells was detected by fluorescence measured with an ELISA plate reader 36–48h after the transfection.A number of proteins accumulating in cytoplasm, especially in the endoplasmic reticulum (ER), may cause apoptosis through the unfolded protein response (UPR) and ER stress NIPA2 and the siRNA to knock down the NIPA2 expression to achieve approximately the normal concentration of the NIPA2; the mutant+siRNA groups, such as the mutant I178F are transfected with the siRNA to promote the mutant and suppress the endogenous protein; and the mutant-only group expressing I178F, N244S, or the small insertion protein, which is expressed along with the endogenous protein; and finally, siRNA alone, to determine the effect of low endogenous NIPA2 expression. There was no significant difference among the groups   .2+ concentration. The four members of the NIPA family all are Mg2+ transporters; however, only NIPA2 is highly selective for Mg2+2+ influx 2+ concentrations significantly. To test this, we applied inductively coupled plasma-optical emission spectroscopy (ICP-OES) to measure extracellular/intracellular Mg2+ concentration. Results were shown in 2+ concentration. However, for the missense mutant N244S and the small insertion (N334_E335insD) mutation there was a significant decrease in the concentration of intracellular Mg2+ by 62% and 53% respectively . Compared to the naïve group the N244S+siRNA , Ins+siRNA , and siRNA  had significantly lower intracellular Mg2+ concentration, but the group I178F+siRNA did not (p = 0.5435). In no case did the mutations significantly alter the extracellular Mg2+ concentration .The accumulation of NIPA2 proteins in cytoplasm did not affect cell viability, but due to the location of the proteins in the cytoplasm, we hypothesized that it might decrease intracellular Mg2+ may affect the NMDAR currents. To test this hypothesis, we used an NMDAR synaptic model 2+. The NMDAR was blocked by intracellular Mg2+2+ increased the NMDAR currents. A simulation of the post-synaptic conductance during three bursts of synaptic inputs in normal and low intracellular Mg2+ was shown in 2+ was set at one-tenth the normal value (0.1 mM), the amplitude of postsynaptic potential during the tonic phase of the burst was increased  and a knock-down model, while the concentration of extracellular Mg2+ was not changed significantly (within the detection precision of ICP-OES).Due to the function of NIPA2, i.e. the transportation of Mg2+ was not seen in all mutants. No significant change in intracellular Mg2+ concentration was detected in the neurons with the I178F mutation, yet these mutant proteins were retained in cytoplasm as the neurons with other mutants. In a previous study it was found that NIPA1 mutant proteins were distributed in the cytomembrane but its function in Mg2+ transport was diminished 2+ transport are affected, while in the mutant I178F only the transport is affected. In the mutant I178F, the small amount of protein in the cytomembrane is able to effectively transport Mg2+ into the neuron. Some protein accumulation in the neurons with the mutant I178F may not significantly affect intracellular Mg2+ concentration. Therefore, we believe that while the I178F mutation may inhibit NIPA2 protein trafficking to cell membranes, it does not also affect the function at the cell membrane. In contrast N244S and N334_E335insD decrease both the cytomembrane concentration and Mg2+ transport.However, decreased intracellular Mg2+ transporter NIPA2 mutations encountered the same problems. In this study, mutant NIPA2 proteins trapped in cytoplasm were observed; however, the accumulation of mutant proteins did not affect the viability of the neurons. We infer that the degree of accumulation caused by NIPA1 mutations may be more serious than that caused by NIPA2 mutations. The apoptosis resulting from excessive UPR and ER stress in the cells with NIPA1 mutations may not occur in the transfected neurons with NIPA2 mutations. Thus we have found no significant change in viability in the transfected neurons with NIPA2 mutations.NIPA1, another member of NIPA family, is similar to NIPA2 in terms of biological features. NIPA1 is a transmembrane protein, and also functioned as an Mg2+ participates in the gating and activation of channels and receptors, such as NMDARs 2+ blocks the activation of NMDAR channels to modulate synaptic strength. Based on our findings that NIPA2 mutations decrease intracellular Mg2+, we hypothesize that the mutations may cause enhanced NMDAR currents. In our computational model, we have observed that low intracellular Mg2+ increases NMDAR-related synaptic currents significantly. It supports our hypothesis intracellular Mg2+ increases NMDAR currents, But further electrophysiological experiments are needed to test this theory. Since there is not a specific blocker of the Mg2+ transporter to build a model of low intracellular Mg2+ for extracellular recording, computational modeling has been used in this study to test the effect of low intracellular Mg2+. We believe a mutant animal model may be ideal and needed to further study the effect of these mutations.MgNIPA2 mutations may play a role in the pathogenesis of CAE. CAE is known as a multigenic disease. CACAN1H and other genes associated with CAE have been reported NIPA2 is no exception. The three NIPA2 mutations identified in our previous study support this issue NIPA2 mutations in a large Caucasian cohort NIPA2 mutation and CAE.We have found the three mutations lead to functional changes, suggesting they may be pathogenic. The 2+. Low intracellular Mg2+ concentration may enhance NMDAR currents. This study describes functional changes of a highly selective Mg2+ transporter NIPA2 mutations. This study may provide insights to the elaboration of pathogenic mechanism and the development of further treatments for childhood absence epilepsy.We demonstrate that NIPA2 mutant proteins accumulate in the cytoplasm, lowering intracellular MgPrimary cultured neurons were prepared from pregnant Sprague-Dawley (SD) rats at the gestational age of 16–18 days. The rats were used in accordance with protocols approved by the experimental animal sciences of Peking University Health Science Center Institutional Animal Care and Use Committee (IACUC).http://www.nc3rs.org.uk/page.asp?id=1357). Pregnant SD rats were anaesthetized by intraperitoneal injection of 10% chloral hydrate, and fetal rats were obtained by the cesarean. The fetal cerebral cortices were dissected with 0.5 mM EDTA and 0.5 mM cysteine-HCl (Sigma) in Earle's balanced salt solution, and then the cortices were gently triturated. The triturated cortices were digested at 37°C for 15–25 min with 1 mg/ml papain  before dissociated cells were suspended in the plating medium . The number of dissociated cells was counted. 2–5 ml of cell suspension was planted on the coverslips (Sigma) in 24-well plates at a density of 1.5–3.0×105 cells/ml. Cells were incubated at 37°C in a 95% O2, 5% CO2 humidified incubator for 4–6 h. Then the plating medium was replaced with the culture medium  medium containing 2% B27 and 0.5 mM L-glutamine (Gibco BRL)). The culture medium was replaced every 3–4 days.Primary cultured neurons were prepared from pregnant SD rats at the gestational age of 16–18 days. The procedures were all in accordance with ARRIVE guidelines (NIPA2 (wild-type), NIPA2-siRNA, missense mutants  and a small insertion (N334_335EinsD) . Herpes simplex virus (HSV) vectors with NIPA2  were conducted by OrienGene Biotechnology Ltd. . To identify transfected proteins all vectors were labeled with red fluorescent protein (RFP). The concentrated liquid containing the vectors was diluted by culture medium Neurobasal A (Gibco BRL) medium containing 2% B27 and 0.5 mM L-glutamine (Gibco BRL). The diluted liquid was added to coverslips with cultured neurons, and then the coverslips were incubated at 37°C in a 95% O2, 5% CO2-humidified incubator. The medium was replaced after the first 24 h, and every 3 days thereafter. Transfected cells were either processed for MTT testing, immunofluorescence labeling, or Mg2+ concentration measurement.Different groups of cultured neurons were transfected with To observe the localization of NIPA2 proteins, cultured cells were washed with 0.1M phosphate-buffered saline (PBS) three times before being fixed in 4% paraformaldehyde for 10 min. After that, the cells were incubated with DIO , a specific cytomembrane marker, for 40 min at room temperature. After washing with PBS, stained coverslips were observed by a fluorescent microscope . The steps were all performed at room temperature.Viability of the transfected cells was measured by the MTT -2, 5-diphenyltetrazolium bromide) assay as described by Hussain et al. trA is the mean absorbance of cells in the transfected group, ctlA is the mean absorbance of the basal temperature control, and nvA is the mean absorbance of the naïve group.where 2+ was measured by the inductively coupled plasma mass spectrometry optical emission spectrometry (ICP-OES). The culture medium was collected to measure extracellular Mg2+. 1 ml culture medium of each group was sent to the department of toxicology  for ICP-OES measurement. The extracellular Mg2+ concentration was calculated by mg/ml. Plated cells were washed by the phosphate buffer saline (PBS) medium (which was Mg2+ free) to purge residual culture medium at the surface of plated cells, and were then scraped in a small amount of PBS medium and collected into centrifuge tubes. The medium with cells was centrifuged at 3000 rpm for 10 min. The cell mass pellet was air dried and the cell mass was weighed. The cell mass was then sent to the department of toxicology for ICP-OES measurement. Mg2+ concentration of each group was measured by the plasma atomic emission spectroscopy . The testing conditions were as follows: incident power 1.15 KW, auxiliary gas 0.5 L/min, observation height 12 mm, wavelength 279.6 nm, detection limit 0.91 ng/ml. The Mg2+ concentration of the cell mass was used as an estimate of the concentration of intracellular Mg2+2+ concentration of each group was normalized as: Extracellular/intracellular MgMg]measured is the Mg2+ concentration measured by ICP-OES, and cellsWeight is the weight of the cell mass of each group.where [2+2+ block of NMDAR receptors 2+ but not intracellular Mg2+. To incorporate the influence of intracellular Mg2+ concentrations on NMDAR synaptic transmission, we modified a term in the model to account for the intracellular and extracellular Mg-block. The equation describing Mg-block in the NMDAR model was as follows:The NMDAR glutamate receptor played a vital role in synaptic plasticity and development as well as epilepsy. NMDAR was activated by glutamate and either D-serine or glycine and was blocked by extracellular and intracellular MgoiK of intracellular Mg2+ = 3.4 iδ of intracellular Mg2+ = 0.95 where 2+ block on NMDAR conductance NMDAG was modeled as follows The effect of MgO is the proportion of ligand-gated channels that are open where


Background. Malnutrition in children has serious health and economic consequences. We studied documentation of malnutrition, actual prevalence, and treatment given in children admitted to surgical wards. Methods. Retrospective study of 154 patients aged <5 yrs admitted to general surgical, orthopedic, and otorhinolaryngology wards. Records were evaluated for completeness of data, way of documentation, and data quality. Descriptive analysis was done. If malnutrition was not identified and/or proper action was not taken, it was defined as a “missed opportunity.” Results. Of 154 records audited, 100 (64.94%) were males, 108 (70.13%) were from general surgery ward, and 78 (50.65%) were residing in suburban area. The mean (SD) age of the study population was 2.32 (1.16) years whereas mean (SD) duration of stay was 5.84 (6.29) days. Weight and height were mentioned in 116 (75.32%) and 8 (5.19%) records, respectively, mostly by nonsurgical personnel. Documentation and treatment of malnutrition were poor. Out of 106 apparently correct weight records, 19 (17.93%) children were severely undernourished and 30 (28.30%) were moderately undernourished whereas 20 (18.87%) children were not undernourished but required nutritional attention. Conclusion. There is poor documentation of nutritional indicators of children admitted to surgical wards. From data that was available, it is apparent that malnutrition is at high levels. “Identification” and hence management of malnutrition need more attention. Approximately 60 million children, under five, accounting for nearly 50% of all India's children are underweight, about 45% children are stunted, and 20% are wasted, suggesting acute malnutrition . MalnutrMalnutrition has been identified in the hospitalized population, up to 25–50% in industrialized as well as developing countries, for more than a decade . About 4Malnutrition is common among hospitalized children and failure to address it at every contact will place the child at a disadvantage in course of time. It will lead to decreased learning abilities and productivity, increased school dropouts, increased susceptibility to infections, decreased immunity, higher morbidity, and mortality rates in children, which in turn hampers economic strength and human development of the country .There have been few studies which have explored malnutrition in hospitalized pediatric patients in India and none in children admitted to surgical wards. As the nature of training in a surgical department is focused on surgical techniques and postoperative care, while maintaining nutritional status is likely to be taught, we postulated that there would not be any focus on malnutrition presence prior to admission.study the documentation of nutritional parameters and its quality,identify malnutrition prevalence in particular setting and compare with documented malnutrition,demonstrate actual missed opportunities for diagnosis of malnutrition and nutritional rehabilitation by follow-up cases.Hence we aimed toBeing less than five years of age.Being admitted to the General Surgical/Orthopedic/Otorhinolaryngology Wards of Shree Krishna Hospital, a tertiary care hospital located in rural setup.Being admitted during the period 2009–2013.In setting of high mortality among children, a large number of deaths occur before 5 years of age [http://www.brixtonhealth.com/pepi4windows.html).An audit of patients' record was performed for patients having following inclusion criteria:s of age . Thus weThis sample size is selected in context to our primary objective to find the missed nutritional rehabilitation opportunities  and not to calculate the prevalence of malnutrition. (i) of nutritional parameters  duration, and any biochemical profile pertaining to nutrition).185 records were checked first for written documentationIn our tertiary health care center, surgical settings are provided with traditional height and weight measuring devices in both outpatient and inpatient setting. Infantometer and infant weight scale are available upon request.Meanwhile pediatric outdoor and indoor settings are fully equipped with tools to measure child's length/height, weight, and additional nutritional parameters if required including infantometers, stadiometers, digital weight scales for baby, and traditional height and weight measuring tools. Usually nurses and surgical/pediatric residents measure anthropometry of children. (ii) assessment done by which hospital department/personnel  and which staff member (resident/staff nurse) recorded above-mentioned parameters); (iii) detailed assessment of nutritional status and diagnosis of malnutrition; (iv) the final corrective action carried out for nutritional rehabilitation.The 185 records were also checked forCorrect action was defined as (1) dietary counseling to parents, (2) referral to pediatrics department or dietary department and/or referral to PHC /CHC  during hospitalization or upon discharge, and (3) immediate nutritional management in terms of increased caloric and protein content of hospital diet, vitamin and mineral supplements, and follow-up plan for monitoring nutritional status.Sociodemographic data  were audited to find any relationship with malnutrition if any.Accuracy and reliability of the recorded nutritional data were checked by finding data beyond 4 SD of age limits and finding presence of more than one documented data piece for same parameter, respectively.Assessment of nutritional status based on mentioned parameters was done, using World Health Organization's growth charts. But as the height/length was not mentioned in most records, weight for age criteria was used to assess the nutritional status. Comparison was made between documented malnutrition diagnosis and the assessed one. If malnutrition was not identified and/or proper action was not taken, it was defined as a “missed opportunity.”Medical records of patients who had more than one admission were also assessed for their comparative follow-up nutritional status and missed opportunities were actually “demonstrated.”The study was approved by the institutional ethics committee. Considering the nature of the study, waiver of informed consent was granted.Out of 185 admissions included in the study, 154 admission files could be located in the medical records department. Thirty-one files could not be located due to various reasons like medicolegal case, readmission of the patient in the ward, file being used in different study, and so forth. Sociodemographic data of 154 records is shown . No signZ) undernourished and 30 (28.30%) were found moderately (weight for age <−2Z) undernourished whereas 20 (18.87%) children were not undernourished but required nutritional attention (<15th centile but >−2Z), according to WHO growth chart for weight for age and undernourishment criteria. Out of 14 apparently correct records of 18 infants, 5 infants (27.28%) were moderately undernourished, matching 28.30% moderate malnutrition of main study population. Separate infant severe malnutrition analysis was not possible owing to insufficient or spurious data. “Exclusive breastfeeding” details were not found in any infant's record. Information on appetite was not available in 112 (72.7%), and information regarding dietary intake prior to hospitalization was not available in 113 (73.4%). Nil by mouth (NBM) was mentioned in 108 (70.13%) cases, where NBM means essentially no fluids and food till further order given by surgical personnel before and after surgery. NBM was less than one day in 103 (66.88%), indicating the nutritional deficiency (if any) is chronic and not due to acute illness. Diet advice during hospital stay was not advised in 48 (31.2%) cases. Usually without any diet advice, there is no additional measure taken by hospital pantry. But, when referred to pediatrics or dietitian, they do provide calculation of calories required, necessary diet from hospital , required vitamins and tonics supplementation, and advice to parents on nutritional rehabilitation. In the remaining 106 (68.8%) cases, these dietary advices were in the form of pre-op/post-op diets by surgeons, regarding their surgeries. These dietary advises were basically instructions of starting/stopping food/oral fluids before and after surgery.Total 10 weight data and 4 height data pieces were found to be spurious (beyond 4 SD limits for the respective age). For example, 55 kg weight and 160 cm height of 3-year-old child were noted suggesting poor and inattentive documentation. Few records had 2 significant different measurements of weight on the same day. Only single record (0.65%) mentioned analysis of weight meaning if underweight for age or not. The similar record also showed analysis of height (0.65%), which was the only record in entire study to show analysis of height. Out of the 106 apparently correct weight records, 19 (17.93%) children were found severely  had mentioned the diagnosis of low-weight-for-age and referral to dietary department for nutritional rehabilitation.Out of 154 admissions, 61 patients were identified to have multiple admissions based on unique hospital number. Out of these, 38 patients initial and final admission records were complete for nutritional assessment. Of these 38 patients, 15 (39.47%) lost previous centile weight, 12 (31.58%) gained, and 11 (28.95%) maintained status quo. Further 27 (71.05%) of these 38 patients needed nutritional rehabilitation based on their last admission record.24, out of 106, admissions (22.64%) were found to be having chronic conditions/conditions affecting nutritional status. The most common diagnoses for the same were, in descending order of their prevalence in study population, esophageal stricture, ureter stricture, diabetes mellitus type 1 (1 patient), cancer (1 patient), gastrectomy (1 patient), unilateral nephrectomy (1 patient), and spina bifida (1 patient). 13 (54%) of these 24 children had malnutrition, which makes contribution of 13 (26.53%) children to total malnourished 49 children. We could not establish any significant correlation between chronic condition and malnutrition status in our study.The current study showed that most patients were admitted to general surgery ward (70%) which makes it most feasible and applicable site for future intervention, if any. We had 46% of hospitalized children who had malnutrition. This figure is expected as the overall prevalence of malnutrition in the Indian population is high. A similar study carried out in Pune, India, showed 39.8% of children in pediatric ward were malnourished . HoweverThese missed opportunities ought to be addressed by nutritional screening on admission by ancillary staff. There are various tools for screening in children admitted to hospital such as the Pediatric Yorkhill Malnutrition Score (PYMS), Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP), and Pediatric Subjective Global Nutritional Assessment (SGNA) . HoweverFurther studies can be done on application and efficacy of nutritional screening tools, early recognition of hospital malnutrition, rate of references to pediatricians after tool application, and treatment of the same. While resolving malnutrition in a developing country may be a moving goalpost, using checklists to screen for malnutrition and rehabilitative management need to be explored to improve the health of the admitted children.The current study shows the lack of attention towards nutritional status of pediatric patients admitted in surgical wards, which are responsible for “missed opportunities of diagnosis of malnutrition and nutritional rehabilitation.” More attentive approach of nonpediatric specialties towards pediatric patients would help in reducing burden of hospitalized malnutrition as well as general malnutrition. Screening tools and checklists may be explored to simplify the diagnosis and management process and should be a part of routine hospitalization process to demonstrate its widespread effects. The core message here nonetheless would be “treat the patient and not just the disease.” Holistic approach should be the guiding principle of medical practice.


This paper presents a twin-class unequal protected video transmission system over wireless channels. Video partitioning based on a separation of the Variable Length Coded (VLC) Discrete Cosine Transform (DCT) coefficients within each block is considered for constant bitrate transmission (CBR). In the splitting process the fraction of bits assigned to each of the two partitions is adjusted according to the requirements of the unequal error protection scheme employed. Subsequently, partitioning is applied to the ITU-T H.263 coding standard. As a transport vehicle, we have considered one of the leading third generation cellular radio standards known as WCDMA. A dual-priority transmission system is then invoked on the WCDMA system where the video data, after being broken into two streams, is unequally protected. We use a very simple error correction coding scheme for illustration and then propose more sophisticated forms of unequal protection of the digitized video signals. We show that this strategy results in a significantly higher quality of the reconstructed video data when it is transmitted over time-varying multipath fading channels. The wireless revolution in the 1980s was primarily driven by market demands for mobile radio voice communications. The first generation analog wireless communication systems used old radio technologies combined with novel cellular network planning [The second generation wireless systems were introduced in the 1990s and were primarily an evolutionary step towards improving the capacity of cellular systems through digitization of voice and efficient digital modulation schemes. These systems also provided additional features such as security, short messaging, and circuit-switched data.We are now in the midst of another evolution planned for deployment in the 2000s. This evolution is once again driven by the need for greater bandwidth in anticipation of further demand for voice services. However, the new wireless standards will also provide a pipeline for broadband services such as enhanced high rate data and multimedia services. The global growth of interest in the Internet and in digitized audio and video, and the demand for such services through the fixed communications networks, is an important factor. Although there are currently no applications with great mass market appeal that require broadband wireless access, it is anticipated that the popularity of these services in fixed networks will eventually impact the market for wireless communications.The next generation wireless systems are required to have voice services of wireline quality and to provide high bit rate data services of 144 kbit/s to 2 Mbit/s depending on the radio environment. At the same time, they are to operate reliably in different types of environments: macro, micro, and pico cellular; urban, suburban, and rural; indoor and outdoor. In other words, the next generation systems are supposed to have better quality and coverage, be more power and bandwidth efficient, and be deployed in diverse environments. These high data rates make video transmission possible for a number of applications such as video conferencing, emergency medical services, and site surveys. However, since most existing video compression standards ,9,10,11 The paper begins with an overview of the WCDMA radio standard . Then, aIt seems that a common international standard for the third generation wireless communications systems may soon be adopted. The international standard may have three radio access schemes and is currently being harmonized by the Third Generation Partnership Project (3GPP). The three radio access schemes are the Frequency-Division-Duplex (FDD) mode, the Time-Division Duplex (TDD) mode and the Multi-Carrier (MC) mode. The FDD mode is a direct sequence (DS) CDMA scheme initially proposed by Japan’s Association of Radio Industries and Businesses (ARIB) and the European Telecommunications Standards Institute (ETSI). The original proposed radio standard was called the UMTS Terrestrial Radio Access or UTRA which included a TDD mode for deployment in unpaired bands. The multi-carrier mode is based on the Telecommunications Industry Association (TIA) standard known as CDMA2000 or IS2000.In the next section, we discuss the physical layer parameters and spreading and modulation for the FDD mode of 3GPP radio access scheme and we will refer to it as WCDMA . Please The modulation chip rate for WCDMA is 3.84 Mega Chips Per Second (Mcps)The transmissions from all the physical channels within a 5 MHz band are code division multiplexed and transmitted over the same band. We discuss two channels in this paper: i) Dedicated Physical Data Channels (DPDCH) and, ii) Dedicated Physical Control Channels (DPCCH). The frame structure for the downlink DPCCH/DPDCH channel is shown in The DPCCH channel consists of pilot symbols, transmit power-control (TPC) bits and transport format combination indicator (TFCI) bits . The DPDCH channels contain bearer data. The number of bits transmitted in a single slot depends on the data rate of the channel.n bits of information in every 10 ms frame. The actual number of bits depends on the data rate and hence the spreading factor. The 2n bits are mapped onto n QPSK complex symbols. The QPSK (quadrature Phase Shift Keying) symbols (in the ith channel) are first spread using a spreading code, iC of length L, to produce 38 400 chips. In other words, nL = 38 400. The resulting chips on the I and Q channels are then treated as a single complex value and are chip-wise scrambled by a complex long code Sscramb of length 38 400. The resulting chips are then weighted and combined with chips from all the other downlink channels. The complex valued chips are then separated into I and Q symbols and are passed through square root raised cosine filters (SRRC) with roll-off factor a = 0.22. The I-channel and Q-channel signals are then RF converted using quadrature (cos ωt and sin ωt) carriers, and finally transmitted through the air. The spreading codes are orthogonal sequences whose elements are either 1 or −1, and so are the elements of the non-orthogonal long scrambling codes.The frame structure for the uplink DPCCH/DPDCH channel is shown in n information bits from the DPDCH channel are BPSK modulated resulting in n symbols which are then spread using a spreading code iC of length Ld to produce 38 400 chips. Similarly, m DPCCH bits are mapped onto m BPSK (Binary Phase Shift Keying) symbols which are spread using a spreading code jC of length Lc to produce 38 400 chips. In other words, nLd = mLc = 38 400. The chips from the DPDCH are mapped onto the in-phase axis and those from DPCCH are mapped on to the quadrature axis of the signal constellation. This is shown in j multiply followed by an add operation. The signal constellation is, in effect, a QPSK constellation. Therefore, the modulation scheme for the reverse channel is called dual-channel QPSK. The resulting chips are then scrambled by a complex scrambling code Suplink. The uplink scrambling code is either a complex short code which is 256 chips long or a complex long code which is 38 400 chips long. When the short code is used, the code is repeated 150 times in order to scramble the 38 400 chip frame. The resulting chips are then passed through a square root raised cosine filter (SRRC) with roll-off factor a = 0.22, are IF/RF converted and then transmitted through the air.The There are two major types of codes specified for WCDMA channels: orthogonal spreading codes and non-orthogonal long and short scrambling codes. The orthogonal spreading codes are used for channelization and the short and long scrambling codes are used for reducing inter-cell and intra-cell interference. In this paper, we do not discuss the detailed specifications of these codes. Instead, we will give you an overview of the different families of codes and their functions.These spreading codes, also known as channelization codes, are used to ensure orthogonality between the channels with different spreading factors and rates and are hence called Orthogonal Variable Spreading Factor (OVSF) codes . On the 4,1 is used, then C2,1 and C1,1 may not be used in the same cell as they are in the path to the root. Also, C8,1 and C8,2 and all other codes derived from C4,1 cannot be used in the same cell. Depending on the required data rate, the length of the spreading code applied on a given DPCCH/DPDCH channel may vary from 4 to 512 on the downlink and 4 to 256 on the uplink  downlink long scrambling codes, 2) uplink short scrambling codes, 3) uplink long scrambling codes. In order to reduce the interference from the channels in adjacent cells in the downlink, every base station uses a long scrambling code. The downlink long scrambling codes are from the well-known family of Gold codes  built by25−1 Gold Code. The quadrature component of the code is a decimated and shifted version of the in-phase component of the same Gold code. The quadrature component is also multiplied by repetitions of a 1 and −1 sequence to improve the envelope properties of the signal. The WCDMA has provisions for multi-user detection where a base station can detect multiple users at the same time, hence, increasing the effective signal-to-noise-ratio (SNR) of all the users. Only short scrambling codes are applied when multi-user detection is used at the base station receiver. Otherwise, only long scrambling codes are used.The uplink short and long scrambling codes are used to suppress intercell and intracell interference from the various mobile stations at the base station receiver. The mobile stations in a given cell are each assigned a unique short scrambling code. These short scrambling codes are from the periodic extended S(2) code family of length 256. Because of the large number of these codes, it is possible to have a unique code for each mobile station in a given cell and also to make sure that the mobile stations in the neighboring cells are assigned different codes. The long code used on the reverse DCDPCH/DCCPCH is 38 400 chips of a complex 2Given a certain total bitrate budget, use of strong error-correction coding increases the error resilience of the video transceiver scheme at the cost of reducing the number of bits available for video coding. Similarly, it is possible to increase the power of the channel codec assigned to the protection of the perceptually most important video bits at the cost of reducing the protection of the less important video bits. However, it is intractable to directly optimize the associated partitioning. Furthermore, it is possible to assign the video bits to a high number of bit protection classes; however, in most practical cases, it is sufficient to employ two or three protection classes .The partitioning process is, in general, described with the aid of the percentage of bits assigned to the individual partitions. The number of different bit-sensitivity classes and the video bits assigned to them has to be decided on the basis of the visual importance differences of the various video bits, although the rigorous formal evaluation of these sensitivities is an arduous and time-consuming task. Hence, in a somewhat simplistic, but plausible approach, it is often argued that in a subjective sense, the visual importance of the various video parameters is related to the spatial frequency of the video features described by the parameters. This is also true in the case of interframe coding, when the objects move at a high velocity, since the combined effects of high-velocity, high-frequency video contents cannot be accurately resolved by the human eye due to its relatively low so-called fusion frequency.The above observation is inherently exploited in subband  and DiscThe basic block diagram of an interframe hybrid DCT video encoder is depicted in For interframe prediction, a larger block of typically 16 × 16 pixels consisting of four neighboring 8 × 8 luminance DCT blocks—referred to as a macroblock (MB)—is used to perform block matching motion estimation and compensation. We note, furthermore, that a color MB also contains the so-called color difference components, which are processed at half the luminance resolution in vertical and horizontal directions. Since there are two color difference components, a MB can be viewed as though it was represented by six blocks. The estimated displacement motion vectors are multiplexed with the DCT coded data and transmitted as a part of the hierarchically ordered macroblock information.The multiplexing structure of all existing video standards is generally based on a hierarchical, self-descriptive structure of the encoded parameters. For example, in the H.263 standard the video-coded information for each frame is arranged in four hierarchical layers. The top layer is the picture layer followed by a Group of Block (GOB) layer comprising a number of consecutive macroblocks, then the Macroblock layer, and finally a block layer. Each layer is furnished with some header information that may include synchronization bits such as picture start code, PSC, and GOB start code (for the two top layers), and that defines the nature of the information associated with each layer . If the header information of a specific video frame is lost during transmission, the decoder will have no indication as to how the frame, GOB, or MB has been coded. Therefore, any further data received will be undecodable, until the next PSC is recognized in the received bit pattern, e.g., by invoking correlation techniques.As expected, the DCT coefficients associated with the particular video blocks are transmitted at the block layer and errors occurring in the DCT coefficients imply that the corresponding DCT coefficients are lost, since this information was variable length coded. If the transmission errors affected only higher frequency coefficients, the damage would be less catastrophic, since the more visually important low-frequency coefficients may have been recovered already. It is, however, important to protect the most error sensitive header information and as many lower frequency DCT coefficients as possible. The coding parameters hence have to be partitioned into a number of bit protection classes, in order to facilitate source-sensitivity matched error protection.We should point out, however, that partitioning could result in a significant increase in the overall bitrate. This is caused by not only the additional partitioning overhead required for synchronization, but also by the coding inefficiencies that can arise from separating the DCT coefficients prior to variable length (VL) coding. For this reason, we argue that it is advantageous if partitioning can be accomplished in terms of the VL-coded DCT coefficients. In addition, we are concerned with developing a video stream partitioning scheme based on constant bitrate (CBR) transmission. We note, furthermore, that there are no fundamental requirements for the partitions to be of equal size. In fact, the partitions are often of differing sizes depending on the error protection strategy with respect to the channel conditions.As mentioned earlier, the separation of the quantised DCT coefficients into different protection classes can be arranged either before or after VL-coding. In the former case, i.e., when partitioning before VL-coding, which we refer to as fixed-zone partitioning, a given number of lower frequency DCT coefficients generated by the standard zigzag scanning process  is earmam that is selected for the current coding block. In addition, suppose that, when the motion compensated block (reference block) was partitioned during the transmission of the previous frame, the number of its DCT coefficients for the first partition resulted in an “n” number of coefficients where n < m. The upper-zone difference between the two blocks is shown in m − n [In our experiments we observed, however, that this arrangement could significantly increase bits per block, mainly due to the breakup of the run-level symbol near the DCT cutoff region . Alternain m − n . HoweverIn order to develop a robust partitioning scheme, the splitting mechanism should take into consideration the instantaneous variations of the coded video. Since we are dealing here with CBR transmission, this is arranged in accordance with the measure of buffer fullness, as each partition is equipped with a separate buffer. The control management of these buffers is handled by the buffer control unit (BCU) . Its funTo avoid frequent buffer overflow/underflow we have observed that the cut-off value can be reasonably accomplished at the GOB level. More importantly, the cut-off value can be embedded into the Group Number (GN). The GN is a fixed length codeword of 5 bits. The bits are the binary representation of the GOB numbers in a frame. For a QCIF format (176 pixels by 144 lines per frame) there exist altogether nine GOBs. Since the first group of blocks do not require GOB information (as it is placed immediately after the picture information), three bits would be sufficient to transmit the group number (excluding the first GOB number). In our simulation model this has been arranged by sending the group number for the first two GOBs as “0” and the remainder as sequential numbers. With this arrangement, the two most significant bits of the 5 bit GN will be free and thus, can be utilized for transmitting the cut-off values. To preserve the integrity of the H.263 syntax, in the re-assembling process  the group numbers will be put back to their original format before being decoded by the H.263 standard decoder. Under this arrangement, no extra bits will be added to the bitstream [Next, we discuss the manner in which the two partitions are formed. For this purpose, let’s consider a scenario where the cut-off value indicates that at least two VLCs should be selected for the upcoming GOB. In this case, as shown in At the receiver, the two bitstreams are joined together to form the original H.263 bitstream via a pre-decoder unit. The pre-decoder’s initial task is to read the two most significant bits of the GN number to extract the cut-off value. From the cut-off value, the pre-decoder can determine from which of the two bitstreams it should obtain the macroblock information if the option-0 (split-header) has been identified. Otherwise, the pre-decoder can determine from the cut-off value how many VLCs it should read from the first bitstream. If the last VLC is not coded as a LAST-VLC (please note that a separate codeword is assigned to the last run-level symbol in a DCT block to signify the end-of-block), the remaining VLCs will then be read from the second bitstream until the last LAST-VLC is reached.If an uncorrectable error has occurred in the second bitstream, the program is able to detect it but unable to pinpoint the exact location. Under such a condition, the second bitstream will be ignored for the entire GOB. However, to reconstruct the legal H.263 bitstream, every block within a GOB that does not contain a LAST-VLC  decoder. The output of the ML decoder is sent for bit stream reassembly. The bits corresponding to the uncoded stream are directly passed through for bit stream reassembly. The reassembled video stream is then sent to the video source decoder to reconstruct the video signal.The simulation model for the transmission system was set up using the Signal Processing Worksystem (SPW)X = 1/3 . For every one information bit (or 3 encoded bits) from stream 1, three uncoded bits of stream 2 are transmitted and the source coding rate is, therefore, 3/5 times the effective data rate. In other words, the data rate for the partitioned video signal is 57.6 kbit/s with a splitting fraction of  1/3 see . This woX = 1/3 for the first partition, the coding frame rate was set at 10/s [For the above splitting factor, the ITU-T H.263 based partitioning scheme discussed in Sec. 3, was then applied to split the first 405 frames of three sequences known as “Salesman”, “Claire”, and “Carphone” . As discussed, to embed the cut-off value in the GN codeword, these sequences conformed to the QCIF format. However, to comply with the low splitting fraction of  at 10/s . FurtherX = 1/3, which includes detailed values of the coding and splitting parameters (excluding the GOB synchronization). In order to provide some subjective evaluations with regards to the distortion built up, we considered a situation where the entire second bitstream was corrupted by errors. The final stage of our experiments was concerned with the transmission aspects of the partitioned video signal over WCDMA. The “Salesman” sequence with QCIF format and at the original frame rate of 30/s, was used as an input video in these experiments. The sequence contained 405 original frames and was encoded at a rate of 10/s. For a thorough evaluation of our transmission system, the sequence was repeated a hundred times to generate longer data. After the last frame was encoded (frame 136), the first frame of the repeated sequence was intraframe coded (I-frame). Thus, resulting in the I-frame reset period of 136 frames. In the process of reconstructing video, if errors were detected in the first bitstream, the entire data in the GOB (group of blocks) was replaced by the reconstructed GOB from the reference frame. This may, consequently, cause a drift between the local and remote decoder that tends to propagate until it reaches the next I frame. Such a drift would result in more severe distortion, particularly if errors occur on the I-frame data leading to the elimination of a portion, or even the entire, video data.In the process of reconstructing video, if errors were detected in the first bitstream, the entire data in the GOB (group of blocks) was replaced by the reconstructed GOB from the reference frame. This may consequently cause a drift between the local and remote decoder that tends to propagate until it reaches the next I frame. Such a drift would result in more severe distortion, particularly if errors occur on the I-frame data leading to the elimination of a portion, or even the entire, video data.If errors were detected in the second bitstream , its entire data within the corrupted GOB was eliminated. Consequently, all the blocks within the same GOB were reconstructed using the data received via the first bitstream. This was done by replacing every codeword by its equivalent LAST-VLC codeword. If the cut-off value was identified as a split-header, all the blocks in the GOB were considered uncoded .For the sake of comparison, the transmission of a non-partitioned H.263 coded bitstream was also carried out and the results are included in r1, r2, r3, corresponding to the transmitted and repeated symbol s  are combined to give r = r1 + r2 + r3, and r is then sent to the QPSK demodulator to obtain an estimate of the transmitted signal s.Finally, as the simulation results show, using this simple, hard-decision coding scheme results in a significant improvement in the recovery of the video signal compared to when no partitioning is applied. However, with more sophisticated FEC coding schemes, such as turbo codes and using better decoding schemes at the receiver, the performance can be expected to improve considerably. One obvious improvement would be to introduce an interleaver after the repetition encoder, and to use soft decision decoding to allow variable-bit-rate (VBR) video transmission together with the multi-priority scheme at the receiver. That is, instead of doing majority logic decoding, the outputs of the Rake receiver Another effective FEC coding technique would be to use different FEC codes for each stream. For instance, stream 1 may be coded using a rate 1/2 turbo code, while stream 2 uses a rate 3/4 turbo code. Moreover, the 3GPP physical layer allows the change of data rate from frame-to-frame, in which case different rates and coding schemes may be used for each partitioned bitstream.This paper presents a robust dual-priority video partitioning method suitable for twin-class unequal protected video transmission over IMT-2000 channels. The partitioning advocated is based on a separation of the Variable-length (VL) coded Discrete Cosine Transform (DCT) coefficients within each block. The method was shown to be suitable for constant bit rate (CBR) transmission, where the fraction of bits assigned to each of the two partitions can be adjusted according to the requirements of the unequal error protection scheme employed. The distribution of the VL-coded (VLC) information amongst the two partitions is performed adaptively. The results illustrate that if the second partition is corrupted by errors, the propagation of distortion does not cause a severe degradation to the reconstructed video. The partitioned video was then applied to one of the leading third generation cellular radio standard proposals, often referred to as the WCDMA system. A simple error correction coding scheme was employed to evaluate the performance of unequal error protection for transmission of ITU-T H.263 compressed video over IMT-2000 channels. The results were compared with non-partitioned video using more periodic I-frame encoding to reduce the propagation of distortion.