Introduction: Various different learning methods are available for planning tuition regarding the introduction to surgical hand disinfection. These learning methods should help to organise and deal with this topic. The use of a video film is an alternative to conventional tuition due to the real presentation possibilities of practical demonstration. Objective: This study examines by way of comparison which form of communication is more effective for learning and applying surgical hand disinfection for medical students in their first year of studies: video-based instruction or conventional tuition. Methodology: A total of 50 first-year medical students were randomly allocated either to the “Conventional Instruction” (CI) study group or to the “Video-based Instruction” (VI) study group. The conventional instruction was carried out by an experienced nurse preceptor/nurse educator for the operating theatre who taught the preparatory measures and the actual procedure in a two-minute lesson. The second group watched a two-minute video sequence with identical content. Afterwards, both groups demonstrated practically the knowledge they had acquired at an individual practical test station. The quality (a) of the preparation and (b) of the procedure as well as (c) the quality of the results was assessed by 6 blind experts using a check list. The acceptability of the respective teaching method was also asked about using a questionnaire.Results: The group performance did not differ either in the preparation  or in the quality . With respect to performance, it was possible to demonstrate a strong treatment effect. In the practical  and in the total score , the group with video-based instruction achieved a significantly better result. In response to the question as to which of the two learning methods they would prefer, the significant majority (60.4%) of students stated video instruction.Conclusion: In this study, the use of the video-based instruction emerged as the more effective teaching method for learning surgical hand disinfection for medical students and is preferable to conventional instruction. The video instruction is associated with a higher learning effectiveness, efficiency and acceptability. Various different learning methods are available for planning tuition regarding the introduction to surgical hand disinfection. These learning methods should help to organise and deal with this topic. A learning method should be selected that is suitable for teaching the topic. The transfer of nosocomial infectious agents takes place most frequently via the hands of staff. The prevalence studies for nosocomial infections revealed that an extrapolated 70,000 patients in Switzerland suffer from nosocomial infection, of whom 2,000 die . The risThe following learning methods are available for the introduction to surgical hand disinfection: Classical theoretical teaching with aims and objectives without any possibility of practical demonstration under guidance. This tuition can be supported by literature and image material. Self-study of the literature and image material without a practical demonstration. Theoretical input on the topic with a demonstration of surgical hand disinfection by a trained specialist (nurse preceptor/nurse educator), with subsequent opportunity for the students to practise in a simulated or real surgical unit. This method with a trained specialist (nurse preceptor/nurse educator) and subsequent opportunity to practise was also named the most often as the first choice for tuition for the skills (Leeper). The use of a video film, an alternative to the real presentation possibilities of practical demonstration. By using a video film, facts and connections can be illustrated better visually with the aid of digital text, graphics and animation and shown in a shorter time. People are visually inclined and visual intelligence plays a most important role . The useTo what extent can video instruction for surgical hand disinfection be just as effective as conventional instruction?In this non-inferiority study we investigated which method a (VI=video instruction) or b  had the better effect for learning surgical hand disinfection among first-year medical students at the University of Bern. Based on the literature mentioned in the introduction, we expect that the students will demonstrate at least an equivalent or better performance after the video instruction (VI) than the students from the conventional instruction (CI). The directional hypothesis is thus: H(1):VI≥KI. The null hypothesis is: H(0):VI<KIhttp://www.psychicscience.org] and divided into the observation groups Video Instruction (VI) and Conventional Instruction (CI). All 208 human medical students in the first semester at the University of Bern were sent a letter in the autumn of 2011 inviting them to take part in a voluntary study to examine two different teaching methods. The participants were not told the exact content of the teaching methods. 50 human medicine students signed up: 27 men and 23 women. The students were randomised [Design: Two different groups of students were compared (between-subjects). The verification of the learning results by the experts was blind.Description of treatment: an educational film regarding conduct in the operating theatre was developed to investigate the question [http://e-learning.studmed.unibe.ch/chirosurf/htmls/slide.html?chirosurf%7Coperation%7Ctheater%7Corganisation%7C1]. This educational film contains a commentated section that is nearly two minutes long (minute: 6:35-8:25) with visual overlays about surgical hand disinfection, which was used for investigating the question. An experienced nurse educator for the operating theatre was provided with the same text and content as in the film. The nurse educator was tasked with teaching the same content in a two-minute instruction with simultaneous demonstration of surgical hand disinfection. A check list for assessing surgical hand disinfection for recording the success of the teaching surrounding surgical hand disinfection was modified according to a template by Wilkinson  and adaphttp://www.e-osce.ch/] application. All six advisors were blind with respect to the students’ instruction method  and were instructed beforehand regarding the check list with the observational criteria and the assessment. The students’ level of knowledge regarding surgical hand disinfection was evaluated using an additional questionnaire. After the investigation, the test persons were asked how satisfied they were with the different learning methods and which learning method  they would prefer.Six experts worked through the items on the check list on tablets (iPad ®) using the OSCE-Eval [Bern interdisciplinary Skills and Simulated Patients Centre (BiSS) at the Institute for Medical Studies at the University of Bern (IML). Six test stations set up identically with the required materials  were provided. Five minutes were calculated for each run (see Table 2 The interventions were started at the same time in two different rooms. The VI group (video instruction) was shown the two-minute video sequence as an introduction to surgical hand disinfection. The CI group  was taught using the conventional lesson as has been customary to date with the same contents concerning the introduction to surgical hand disinfection by the nurse educator with a simultaneous demonstration. Carrying out the conventional instruction was likewise limited to two minutes. Afterwards the students from both groups were called up according to the allocation scheduled beforehand by the random generator to carry out the practical demonstration at an individual practical test state at the The results of the 50 students were analysed. The statistical analysis of the data was carried out with the aid of Microsoft Office Excel 2010 and SPSS 20 for Windows.If one compares the participants in the video instruction (VI) with the conventional instruction (CI) in detail (Table 3), the following picture emerges in the observation areas: in the preparation, the participants from VI group did not perform any differently to the CI group. In the practical, the VI group performed significantly better than the CI group with an effect size of 0.943 (Cohen’s d). In quality, the VI group did not perform any differently to the CI group. In the total score, a significantly better result is demonstrated by VI group with an effect size of 0.751 (Cohen’s d) (see Table 3 p=0.002) and in the total score (p=0.011). In the T-test  answered in favour of the video and 19 (39.6%) in favour of the lesson. Therefore, five students from the conventional instruction group decided on the video having watched the video  . A clearWe can answer our question as to whether video instruction for surgical hand disinfection can be just as effective as conventional instruction in the affirmative and reject the null hypothesis. In the evaluation going beyond the pure question, a positive result is demonstrated in all areas in favour of video instruction. In the preparation and in the quality both groups achieved equally good results. The video instruction demonstrated a significantly better effect in the practical and in the total score. The evaluated sequence of surgical hand disinfection in the educational film demonstrates an effective and efficient transfer of knowledge. In response to the question as to which of the two methods they would prefer, the video instruction was selected clearly. A further relevant aspect is that a video film represents a meaningful enhancement to the choice of learning as a result of more extensive possibilities of presenting the teaching content and can increase cognitive and technical knowledge. Video instruction provides the opportunity to present relevant learning content realistically and for use in independent studies. Videos help the students to repeat learning content from the lesson independently at their own speed. Looking to the future, the study of the long-term effect and the different teaching methods would be of interest.I would like to thank the following people most sincerely for their support during this project: Mr Giovanni Ferrieri, Multimedia Designer VideoMr Jürgen Schmidt, Dipl.-Pflegw. Ms Margrit Catani and Ms Diana SchulerDr. phil. nat. Banu Yürüker, MMEMs Sabine Richter, Technical Assistant Ms Gudrun Stopper, MMEMr Stephan Schallenberger, MAS in HCIDMr Kevin Gaunt, iOS Software Developer and Research Barbara Haldemann, Head of Gynaecological Operating Theatre at the Inselspital BernThe authors declare that they have no competing interests.


The pathogenesis of human intracranial arteriovenous malformations (AVMs) is not well understood; this study aims to quantitatively assess cortical folding in patients with these lesions.Seven adult participants, 4 male and 3 female, with unruptured, surgically unresectable intracranial AVMs were prospectively enrolled in the study, with a mean age of 42.1 years and Spetzler-Martin grade range of II–IV. High-resolution brain MRI T1 and T2 sequences were obtained. After standard preprocessing, segmentation and registration techniques, three measures of cortical folding, the depth difference index (DDI), coordinate distance index (CDI) and gyrification index (GI)), were calculated for the affected and unaffected hemispheres of each subject as well as a healthy control subject set.r = −0.74, p = 0.04).Of the three metrics, CDI, DDI and GI, used for cortical folding assessment, none demonstrated significant differences between the participants and previously studied healthy adults. There was a significant negative correlation between the DDI ratio between affected and unaffected hemispheres and AVM volume (correlation coefficient de novo, dynamic lesions.This study is the first to quantitatively assess human brain cortical folding in the presence of intracranial AVMs and no significant differences between AVM-affected versus unaffected hemispheres were found in a small dataset. We suggest longitudinal, larger human MRI-based cortical folding studies to assess whether AVMs are congenital lesions of vascular development or  Intracranial arteriovenous malformations (AVMs) are the direct communication of arteries to abnormally tortuous and dilated veins without an interposing capillary bed, often described as a tangle or “bag of worms” . The mec2 and O2 levels, mechanical distention and compression, and changes in local neuronal activity  and SubjectSurface[i] was computed. For each hemisphere, a weighted sum of distance was computed across the hemisphere (sum of the distance multiplied by the mean of the area of the vertex’s tiles), but excluding vertices in the fs_LR medial wall. Because this measure was not subject to the hull issues that limited DDI computation to vertices beyond 15 mm from the AVM, we computed it across two regions of interest: One local (within 15 mm of the AVM) and one remote ROI (further than 15 mm from the AVM). We hypothesized that differences in the affected hemisphere might be more pronounced near the AVM. This measure, the coordinate distance index (CDI), was computed by dividing the weighted sum of distance by the surface area of the associated region. CDIs were computed for both affected and unaffected hemispheres and then input to a paired t test.Gyrification index (GI) is defined as the ratio of cortical surface area to cerebral hull surface area , 27. GI We assume and a one-tailed test with statistical significance, α = 0.05 and a study power of β = 0.80. For a moderate effect size (50 %), we would need 21 participants .In order to test whether the affected hemisphere had alterations in cortical folding relative to the unaffected hemisphere, we utilized 3 metrics - depth difference index (DDI), coordinate distance index (CDI) and gyrification index (GI). This data is presented in We next examined the relationship between depth difference  and distance from the AVM center. An example subject depth difference map is shown in r = −0.74, p = 0.04).We also looked at whether there was a relationship between AVM volume and DDI. β) signaling cascade [de novo formation of brain AVMs [This is the first morphometric study to quantitatively assess brain cortical folding differences in human subjects with brain arteriovenous malformations using Human Connectome Project (HCP) methodology , 22, 23. cascade , 30. As  cascade , 32. A main AVMs , potentiain AVMs , 35, leade novo formation theory, as otherwise cortical folding differences would potentially be more evident. However, with only 7 patients at a single time instance, more longitudinal data is needed for such a conclusion. We originally hypothesized that sulcal depth differences would be confined to the cortex adjacent to the AVM. The AVM should provide local mechanical traction to folding and also a relative lack of perfusion caused by the absence of normal intervening capillaries. We were unable to define a spatial relationship of cortical folding differences caused by underlying AVMs, an important result that may suggest a decoupling of cortical folding and AVM pathogenesis. This lack of spatial relationship could be due to a much wider-spread pattern of cortical disruption, but it could also be that folding and AVM formation processes are independent.Our results may support the Previous studies  have shode novo AVM formation [de novo AVM and the subsequent changes in perfusion to the surrounding tissues. Such remodeling has previously been described in patients with cerebrovascular disease [Despite a large body of scientific literature, the pathogenesis of AVMs remains controversial , 41. Ourormation  on seria disease . A longiOur study might be simply underpowered to determine such a relationship with only six subjects with supratentorial AVMs. At our hypothesized moderate 50 % effect size, we would have needed 21 patients to have 80 % power to avoid a type II error. In addition to limiting the power of our study of sulcal depth differences, none of these patients presented with hemorrhage or focal neurological deficit. It is possible that these sequelae are in some way related to the minor folding differences we observed, but a larger study would be needed to determine what, if any, connection there is between the two.de novo entities.This is the first study to quantitatively assess human developmental cortical folding in the presence of intracranial arteriovenous malformations. The study found no statistically significant cortical folding differences in the patient hemispheres with AVMs compared to their own contralateral hemispheres or compared to a previously obtained healthy, control dataset. However, longitudinal studies are recommended to definitively establish whether arteriovenous malformations are developmental, congenital lesions or dynamic,


A 61-year-old right-handed man presented with a 2.5-cm subcutaneous mass to the dorsal radial aspect of the right long finger at the proximal interphalangeal joint. The painless mass had been present for 7 years without appreciable change in size. Pathology revealed an arteriovenous malformation (AVM) with no signs of malignancy.What is an AVM and how is it classified?What are common symptoms of AVM?What imaging modalities can be used to diagnose AVM?What are possible treatments of AVM?AVMs can occur anywhere in the body but most often occur in the head and neck.Patients with symptomatic AVMs most frequently complain of pain, decreased joint mobility, and soft-tissue or skeletal deformity and may have a history of cutaneous changes overlying the area. In asymptomatic individuals who present only with nodular subcutaneous mass, diagnosis is more difficult. The differential diagnosis includes giant cell tumor, glomus tumor, ganglion cyst arising from the joint or tendon sheath, and lipoma. Although often benign, AVMs can cause bone resorption or grow into adjacent tissue, leading to decreased blood flow, necrosis, and digit amputation.Angiography is the current criterion standard, but it is often used to fully characterize the anatomy of the AVM after a diagnosis has been made. Radiographs are most often used as part of the initial workup of the nodular mass but are of limited utility and often nondiagnostic. Plain radiographs may demonstrate swelling around soft-tissue mass, phleboliths within the AVM, or osseous involvement demonstrated by areas of cortical thinning.5Management of digital AVMs is largely dependent on the severity of symptoms. In asymptomatic patients, conservative management with surveillance is often sufficient. Patients who present with pain, ulceration, or signs of nerve compression may require intervention to save the digit and avoid amputation. Embolization or ethanol sclerotherapy may allow for closure of the AVM, but recurrence is common and repeat treatments are often required. In the digit, where AVMs are quite small, surgical resection may be a feasible option, as it removes all of the tissue involved in the AVM and has decreased recurrence.6The low incidence of AVMs in the digit can present diagnostic and treatment challenges to clinicians. Treatment should be guided by the anatomy of the lesion and involvement of surrounding structures. Surgical resection is a curative therapy in symptomatic patients that maintains digit function and aesthetics.


Implementing an accredited quality and patient safety management system is inevitable for hospitals. Even in the case of an obligatory rule system, different approaches to implement such a system can be used: coercive (based on monitoring and threats of punishment) and catalytic . This study takes these different approaches as a starting point to explore whether and how implementation actions are linked to compliance. By doing so, this study aims to contribute to the knowledge on how to increase compliance with obligatory rules and regulations.N = 16) were observed, audit reports were analyzed, and semi-structured interviews were conducted with both the internal auditors (N = 23) and the ward leaders (N = 14) responsible for compliance. Framework analysis was used to analyze the data.The internal audit system (the ‘tracer system’) of a large Dutch academic hospital is used as a case to investigate different implementation approaches and their effect on compliance. This case allowed us to use a multi-actor and multi-method approach for data collection. Internal audits  compliance of all ward leaders. Rather, the catalytic actions contribute to (intended) compliance of ward leaders that are motivated, whereas they do not for the ward leaders that are not motivated. For the motivated ward leaders, catalytic enforcement actions contribute to (intended) compliance by increasing ward leaders’ knowledge of the rules and how to comply with them.Our findings suggest that the effectiveness of implementation actions depends not only on the actions themselves, but also on the pre-existing motivation to comply. These findings imply that there is not one ‘best’ approach to the implementation of obligatory rules. Rather, the most effective approach depends on the willingness to comply with rules and regulations.The online version of this article (10.1186/s12913-018-2865-8) contains supplementary material, which is available to authorized users. Growing concern about the quality of care has resulted in increasing interest in healthcare accreditation –3. In reHaving to implement a rule-based system does not automatically determine the way in which the rules of such a system are implemented. Research by Mikkelsen and colleagues  shows thSo far, research into the link between these implementation approaches and compliance in the organizational context has been limited. Therefore, this paper aims to explore whether and how coercive and catalytic approaches to implementation are related to compliance with rules and protocols. By doing so, this study contributes to the knowledge on effective implementation of obligatory rules in hospitals.To achieve compliance with quality and patient safety regulations that are part of internal compliance systems, a range of implementation – or enforcement – styles can be used. In broad terms, two very different ideal typical enforcement styles are at the basis of most enforcement research: catalytic and coercive –11. A caTo investigate enforcement approaches and their effect on compliance, we used the internal audit and feedback system of a large Dutch academic hospital as a case. The internal audit and feedback system that is used within the hospital is based on the tracing approach of the Joint Commission International  (JCI). WA combination of qualitative research methods was used to investigate all actors involved in the audits. First, 16 randomly selected internal audits – performed by 30 different auditors – were observed. Based on the non-participatory observations, field notes were made that focused on the actions of the internal auditors and the reactions of the ward leaders. Second, the resulting audit reports were analyzed. Third, interviews were conducted with 23 internal auditors and 14 ward leaders. Five of the observed auditors were not interviewed since they had just started as an auditor and two were not willing to participate in an interview. 12 of the observed auditors had their primary job in patient care (3 doctors and 9 nurses), whereas 18 had supportive jobs . We observed 19 female and 11 male auditors. In Additional file The interviews were semi-structured and guided by a topic list based on our theoretical focus  or non-compliant (orange or red score) on the separate quality and patient safety standards. After finishing the reports, the auditors provided feedback about the audit results to the ward leaders and published the audit report on the hospitals’ intranet. The results section focuses on the last step of the audit: the feedback provision to the ward leader.The internal auditors focused on providing feedback to the wards on whether they were complying with the rules and regulations that are part of the internal audit. They did this by filling out an audit report about the ward and by communicating the scores of the audit report to the ward leaders. Overall, the auditors had a facilitative approach, aimed at supporting the wards in improving. Examples included showing understanding for wards that are non-compliant, providing tips and tricks , clarifying policies, explaining the rationale behind or importance of policies, and asking ward leaders what their points of interest for the audit are. “Then I tell them, I know it is a difficult problem, also at my ward. And often I have suggestions about what I’ve seen at other wards or how we do it at my ward” . We did not observe any instances of (threats of) punishments by the internal auditors when performing the internal audit.Small differences were found between auditors in how strict they were in their scoring. Some auditors gave a red score as soon as a ward was not fully compliant with a rule, whereas others gave more green or orange scores, even when wards were not (fully) compliant with rules. Despite these small differences in rule rigidity, auditors’ overall approach towards the ward leaders can be characterized as catalytic. A complete overview of auditors enforcement actions can be found in Additional file This leads to the question whether the overall catalytic enforcement actions of auditors lead to relatively uniform (intended) actions from ward leaders? About half of the ward leaders indicated to (have intentions to) take actions to improve compliance with standards and procedures. In some cases, ward leaders themselves took action, for example by discussing the results in a work meeting. In other cases, they used the ward’s ‘normal’ improvement structure to initiate changes. These improvement structures included actions such as assigning the improvement action to a senior nurse or using lean management strategies.The other half of the ward leaders did not indicate to (have intentions to) take actions to improve compliance. Often, these ward leaders did not even look at the results of the audit. “I didn’t take a look at the results to be honest, so I don’t even know what the results were. I do remember it wasn’t really impressive” (ward leader #4). What stands out is that whereas all auditors used mainly catalytic actions, this led to (intended) actions of only half of the ward leaders. Since all auditors applied a catalytic approach, it needs to be noted that this study does not allow for an evaluation of the effect of a coercive audit approach.So far, the findings indicate that the catalytic enforcement actions of auditors are linked to (intended) actions of only half of the ward leaders. This leads to the question why ward leaders react differently to similar enforcement actions of auditors.One of the most important differences we found between compliant and non-compliant ward leaders was their motivation to comply with the standards and procedures of the accreditation. Ward leaders that indicated to (intent to) take actions had a more positive attitude towards the policies and regulations that are central to the internal audit. They argued that, overall, they understand the importance of the rules and how compliance with the rules contributes to higher levels of quality and patient safety. It is important to note that the ward leaders have been motivated before, and not as a result of, the internal audit. “And then JCI was introduced and, well, the rules made sense, so we agreed on implementing them. And from that moment on we try to keep the standard as high as possible, we set the bar high” (ward leader #5).Ward leaders that did not (have the intention to) take actions, on the other hand, were not motivated to follow the rules and guidelines that are part of the accreditation. Often, these ward leaders indicated that they did not agree on the importance of the rule or protocol they should be compliant with. The argument was mostly that the rule was only there because the accreditation organization requires compliance, rather than as a means to improve the quality of care. As one ward leader argued: “I don’t really like the rules, I’m more about keeping it practical and workable and having high quality, but rules, well, rules are also there to deviate from them” (ward leader #4). In line with the ward leaders’ low motivation regarding the accreditation, the ward leaders did not consider the internal audits useful. According to these ward leaders, the issues that arose during the audit were not in line with the ward’s priorities for improvement.For the motivated ward leaders, the internal audits contributed to their capacity to comply by providing ward leaders with an overview of their level of compliance and concrete input and support for improvement: “It is helpful when people look at your ward critically and show you where you’re at (…). The results were very clear and it were concrete points that help us to improve” (ward leader #12). The audit results contributed to ward leaders’ capacity to comply since they often did not know that the ward was non-compliant or did not know how to correctly implement a rule or protocol. Since all auditors were catalytic in their approach, all audits contributed to ward leaders’ capacity to comply.However, the auditors could not increase capacity in all situations. This was the case when there were structural factors that prevent improvements. Several wards could, for example, not comply with the rules for storage of  equipment because they did not have sufficient storage room to comply with all standards and procedures. The internal auditors could not address these capacity issues.The results indicate that all auditors use catalytic enforcement actions based on dialogue and suggestions. Whether these catalytic actions contribute to ward leaders’ (intended) improvement actions depends on the motivation of ward leaders: only motivated ward leaders indicate to (have intentions to) take improvement actions based on the audit results. For motivated ward leaders, the internal audits contribute to their capacity to comply by increasing their knowledge of the rules. These findings imply that the effectiveness of enforcement actions depends on the pre-existing motivation of ward leaders.Our finding that a catalytic style does not lead to compliance in all cases is in line with previous enforcement studies , 16, 17.The results of our study indicate that it depends on ward leaders’ motivation whether a catalytic approach is an effective means to increase compliance. This finding is also in line with enforcement studies, where it has been argued that the nature of the motivation determines which enforcement actions will be most effective . If reguMoreover, our findings indicate that catalytic enforcement actions contribute to compliance by increasing ward leaders’ capacity to comply. This finding is in line with previous enforcement studies  that havOur findings also indicate that catalytic actions do not always increase capacity to comply; this is the case when structural factors prevent improvements. Previous studies have found similar ‘barriers’ to improvement in cases where the financial capacity to comply is too low . These fThis study may have some limitations. First, a specific type of ‘internal audit’ was used as a vehicle for our investigation of enforcement actions and their effect on compliance. This specific vehicle might prohibit us from generalizing all of the factors that explain why enforcement leads to compliance. However, since most of our findings are in line with the enforcement literature, it is expected that our findings will still be valid in other contexts. Moreover, it allowed us to investigate specific enforcement actions with different methods (observations and interviews) and including all involved actors (auditors and ward leaders). Second, it was not possible to interview all involved ward leaders. This could have led to a selection bias, where especially the wards with positive attitudes towards the internal audits were selected. However, since some interviewed ward leaders were quite critical about the internal audits and the accreditation system of the hospital, no reason is seen to assume a selection bias. Moreover, the ward leaders were not informed about the specific goal of the research and the researcher collecting the data had an independent position. Third, the ‘outcome measure’ of (intended) actions of ward leaders could be unreliable, for example when ward leaders feel pressure to give socially responsible answers or when they over- or underestimate their own actions. However, we think this effect is limited since there were several ward leaders that indicated to take no actions at all, or only on certain items. Moreover, in the interviews, we asked for specific actions and examples, making socially desirable answers less likely.Catalytic enforcement actions based on dialogue and suggestions contribute to compliance with quality and patient safety rules and regulations by increasing capacity to comply. This is only the case, however, when ward leaders are motivated to comply with the rules and regulations. When ward leaders are not motivated, catalytic enforcement actions do not contribute to ward leaders’ compliance.These findings are relevant for the knowledge on the successful implementation of obligatory rules and regulations since they suggest that the effectiveness of implementation actions depends not only on the actions themselves, but also on pre-existing motivation to comply. Our findings are important since they imply that there is not one ‘best’ approach to the implementation of rules in hospitals. Rather, the ‘best’ approach depends on the pre-existing willingness to comply with rules and regulations.Additional file 1:Overview of Auditors. (DOCX 14 kb)Additional file 2:Interview Guides. (DOCX 19 kb)Additional file 3:Data sources for auditor enforcement style. (DOCX 18 kb)


As countries scale up adult voluntary medical male circumcision (VMMC) for HIV prevention, they are looking ahead to long term sustainable strategies, including introduction of early infant male circumcision (EIMC). To address the lack of evidence regarding introduction of EIMC services in sub-Saharan African settings, we conducted a simultaneous, prospective comparison of two models of EIMC service delivery in Homa Bay County, Kenya. In one division a standard delivery package (SDP) was introduced and included health facility-based provision of EIMC services with community engagement for client referral versus in a different division a standard package plus (SDPplus) that included community-delivered EIMC services. Babies 1–60 days old were eligible for EIMC. A representative sample of mothers and fathers of baby boys at 16 health facilities was surveyed. We examined differences between mothers and fathers in the SDP and SDPplus divisions and identified factors associated with EIMC uptake. We report adjusted prevalence ratios (aPR). Of 1660 mothers interviewed, 1501 (89%) gave approval to contact the father, and 1259 fathers (84%) were interviewed. The proportion of babies circumcised was slightly greater in the SDPplus division than the SDP division (27.3% vs 23.7%), but the difference was not significant (p = 0.08). In adjusted analyses, however, the prevalence of babies being circumcised was greater in the SDPplus division  and the factors associated with a baby being circumcised were the mother having received information about EIMC , having discussed circumcision with the father if married or cohabiting  or being single , perceiving herself to be living with HIV , or having a post-secondary education , and the father being Muslim  or circumcised . The median age of 2117 babies circumcised was 8 days (IQR: 1–36), and the median weight was 3.6 kg (IQR: 3.2–4.4). There were 6 moderate adverse events (AEs) (0.28%); 5 severe AEs (0.24%), all involving an injury to the glans penis, requiring hospitalization and corrective surgery; and one death probably related to the procedure. There were no AEs among the 365 procedures performed outside health facilities. Information and education campaigns must reach members of the general population, especially men and fathers, who are influential to the EIMC decision. Serious AEs using the Mogen clamp are rare, but do occur and require efficient, reliable emergency back-up. Our results can assist countries considering scale-up of EIMC services for HIV prevention as their adult VMMC programs mature. Numerous observational studies and three randomized controlled trials have shown male circumcision to be approximately 60% effective in reducing HIV acquisition in heterosexual men in sub-Saharan Africa –4. WHO/UTrichomonas vaginalis, HPV infection and cervical cancer [To date, there have been very few studies attempting to introduce EIMC in communities in East and southern Africa. Although evidence is lacking, many have stated that EIMC in Africa would have numerous advantages over AMC. Compared to AMC, circumcision of an infant is thought to be associated with fewer adverse events, to be faster and less technically challenging, to cost less, to be easier to care for post-operatively, and likely to reduce chances of sexual disinhibition or risk compensation –9. It isl cancer –15. Howel cancer –18. Manyl cancer –8, but tl cancer ,19. ThesTo address the lack of evidence regarding introduction of EIMC services in sub-Saharan African settings, we conducted a simultaneous, prospective comparison of two models of EIMC service delivery: a standard delivery package (SDP) that included health facility-based provision of EIMC services with community engagement for client referral versus a standard package plus (SDPplus) that included community-delivered IMC services. We assessed differences between the two packages in EIMC uptake, adverse event rates, knowledge of EIMC and various parental behavioral and demographic characteristics.The study area lies within Homa Bay County in western Kenya adjacent to Lake Victoria. The predominant ethnic group is Luo, a southern Sudan-speaking people who do not traditionally practice circumcision. Adult HIV prevalence in Homa Bay County is the highest in Kenya at 27.1% compared to 5.6% for the country overall . Homa BaThe study was a simultaneous, prospective comparison of two models of EIMC service delivery—the Standard Delivery Package (SDP) and the Standard Delivery Package Plus (SDPplus)—comparing rates and safety of EIMC, and barriers and facilitators of EIMC uptake between packages before and after implementation of EIMC services. Both models employed a community-based strategy for disseminating information about EIMC to adult men and perinatal women utilizing the existing structure of community health workers (CHWs) and health educators who are attached to every health facility. The community-based education strategy, facility health talks and facility-based provision of EIMC surgery form the SDP. The SDPplus included the same activities as in the SDP, with the added component of training retired and unemployed nurse-midwives residing in the community to identify pregnant women, to supplement the EIMC education provided by the CHWs, to actively engage fathers pre-delivery, and to perform EIMCs in the community for those not seeking the services in a health facility. We hypothesized that the SDPplus package of services would result in greater uptake of EIMC and have the same level of safety as the SDP model, measured by adverse events (AEs).Both the SDP and SDPplus models employed a comprehensive community strategy for recruitment of infants for EIMC. Under both models, MOH providers at four facilities were trained to provide comprehensive IMC services. Since most government facilities suffer from understaffing, to ensure adequate human resource capacity to provide EIMC services, we used an existing MOH model, termed “direct hire,” to engage an additional clinical staff person  who worked as an MOH employee at the health facility. At the two largest health facilities , all nurses and clinical officers on the maternity ward and in the MCH clinic were trained in EIMC service delivery. At smaller facilities, at least one staff in addition to the direct hire was similarly trained. The responsibilities of the direct hire staff were not solely performance of EIMC services, but were to contribute to all activities at their workstation, providing the time necessary for any of the trained qualified staff to perform EIMCsVarious strategies were employed to sensitize the communities of both divisions about the risks, benefits and availability of EIMC. A sensitization campaign targeting village elders, chiefs, and men who had chosen MC for themselves was employed to reach men. Educational talks were delivered in chiefs’ barazas (meetings), at football matches, in markets, in popular bars and restaurants, and at other venues where men congregate. The educational fliers were distributed and men were encouraged to tell friends about the service. At the health facilities, MNCH staff were trained on the benefits and risks of EIMC and how to provide information about EIMC in a culturally appropriate and supportive manner. Mothers accessing antenatal, delivery, and postnatal services were given informational talks about EIMC in groups and, as needed, individually. An already existing network of CHWs attached to health facilities were trained to provide information at the household level on the benefits and risks of EIMC. In Kenya, each CHW is responsible for between 20 and 100 homes. The role of the CHW is to visit each home at least once per month and serve as a link between the community and the health facility, and their functions include recording the number of pregnant women, the number of recent deliveries and the vaccine coverage of any children in every home. CHWs in both divisions were trained to counsel pregnant and postnatal mothers and their male partners at home about EIMC. The CHWs were provided with referral cards, stamped with the name/ID number of the CHW, and when parents brought their child with the referral card to the health facility for circumcision, the CHW was compensated 200 Kenyan shillings (approximately $2.00US) for his or her time and effort. A similar system of compensation to CHWs for recruiting adult MC clients was already in place.Additional compensation was provided to the health facility to cover the costs of water, electricity, cleaning, and any other incidental costs. This was in the amount of 2000 Kenya shillings ($20.00US) for every 10 EIMC procedures performed on-site.The only difference between the SDP division and the SDPplus division was the addition of Domiciliary Midwives (DMs) in the latter. DMs were recruited by identifying retired or unemployed health workers living in the community. This is a cadre of health workers that have been targeted by the Kenyan MOH to be used by health facilities to augment their community programs, including skilled deliveries outside health facilities, because of their high level of training, under-utilization, and close connection to the community. Beyond providing EIMC services, DMs were trained to deliver a comprehensive package of MNCH services consistent with Kenya Essential Package for Health. DMs were paid a low base salary of 22000 KSH ($220US) per month and provided modest monetary compensation  for conducting EIMC services in the home or, similar to a CHW, 200 KSH for referring parents to the health facility for EIMC services.Circumcisions were performed by providers who had completed a minimum of 10 procedures under supervision with additional training as needed. Circumcisions were performed employing the Mogen clamp as described in the WHO “Manual for Early Infant Male Circumcision under Local Anaesthesia” . At leasAll providers were trained on correct management, recording and reporting of AEs. Emergency procedures were in place, including a parental hotline, a fully stocked emergency kit at each facility, a project vehicle and driver at the ready, a standby pediatric surgeon within a maximum two-hour drive. All emergency first-responders were trained in European pediatric life support. The system for ascertaining and treating AEs was consistent with the WHO “Manual for Early Infant Male Circumcision under Local Anaesthesia” . All intParents were asked to return to the facility 3–4 days post-operatively to have the infant’s wound assessed. Those not returning for review were contacted, usually by cell phone, and encouraged to come to a facility, or they were asked about the progress of the wound over the phone. The number and proportion of those coming for their post-operative review were recorded.To evaluate uptake of EIMC, as well as demographic variables and levels of knowledge associated with uptake, survey questionnaires were administered to mothers coming to facilities with their baby son for the first Oral Polio Vaccine (OPV-1). Women aged 16 years and above were eligible for participation. Because 92% of infants receive the OPV-1 , a randoAfter undergoing informed written consent procedures, mothers were interviewed in a private location at the health facility in her language of choice  by Research Assistants (RAs) fluent in all three languages using netbook computers. Mothers were asked for consent to contact the father of the baby for an interview and, if she agreed, provided locator information for the father. RAs traced the father and attempted to interview him in the location of his choice. All participants were given 200 KSH in compensation for their time. We used publicly available data from the Kenya Health Information System  to deterThe main outcome variable of interest was whether the baby was circumcised or uncircumcised. This was assessed by inspection by the interviewer with approval from the mother. Independent variables of interest included whether in the SDP or SDPplus division, demographic variables, circumcision status of the father, and variables associated with being informed about EIMC, decision-making, and general endorsement of EIMC. We estimated bivariate and multivariate Poisson regression models with robust standard errors to compute prevalence ratios (PRs) and confidence intervals to assess differences between parents whose son was circumcised and those whose son was uncircumcised.All variables significant at the p<0.05 level in bivariate regression were considered for inclusion in multivariate regression models. Variables associated with treatment group were investigated for potential confounding effects. Due to collinearity between mother and father responses , we selected one or the other based on Wald tests. In addition, since not all fathers completed an interview, we created variables that supplemented the father’s information with information provided by the mother for this analysis . We first estimated a model including treatment group and sociodemographic variables (Model 1). Next, we added variables associated with knowledge and decision-making (Model 2). Model fit was assessed by examining the Hosmer and Lemeshow Goodness-of-fit statistic from the final models. Unless otherwise specified, a predetermined significance level of p ≤0.05 was used to assess significance for all tests. Stata v13  was usedThe Kenyatta National Hospital/University of Nairobi Ethics and Research Committee and the University of Illinois at Chicago Office for the Protection of Research Subjects provided ethical approval for this study.We do not have estimates of how many parents and guardians were informed about and offered EIMC for their babies, since mobilization and demand creation occurred throughout the community among the general population and in multiple venues in health facilities. A total of 2233 mothers consented to have their baby boy circumcised. One hundred thirteen babies (5.3%) were ineligible for circumcision: 2 were older than 60 days; 43 were low weight-for-age; 16 presented with fever; 16 had penile or scrotal abnormalities; 13 had jaundice; and 23 were excluded for other reasons . Three mothers consented, but then did not have their baby circumcised. Therefore, the final sample of early infants circumcised was 2117.There were 766 infant boys circumcised in the SDP division and 1351 in the SDPplus division. The distribution of the infants by age in days is shown in Regarding the EIMC procedure, nearly all took 15 minutes or less with those performed in the SDP division taking less time than those in the SDPplus division. In the SDPplus division, nearly 40% of procedures were performed by DMs and about half (51.2%) by Direct Hires ; whereas, in the SDP division nearly all (94.9%) were performed by the Direct Hire staff, with very few procedures (7.4%) performed by regular MOH staff in either division. As expected, all the circumcisions performed in homes were in the SDPplus division where the DMs operated, with 365 circumcisions representing 27% of all procedures perfomed in the SDPplus division. All mothers were urged to bring their babies back to the facility or to the DM 3–4 days after the procedure. Follow-up rates overall were 73.8%—higher in the SDP division (77.5%) than in the SDPplus division (71.7%) (p = 0.003)Out of 2117 circumcisions, there were 6 moderate AEs (0.28%); all were related to EIMC and all occurred post-operatively. Two were cases of the baby returning with bleeding from the wound, which required a suture, and four were infections which resolved with administration of an antibiotic (ampicillin/cloxacillin syrup). Three of the six cases of moderate AEs were in the SDPplus Division (AE rate 0.22%) and three were in the SDP Division (AE rate 0.39%). There were five severe AEs (0.24%), all of them entailing an injury to the glans penis and requiring hospitalization and corrective surgery by the consultant pediatric surgeon. Three were in the SDP division, one was in the SDPplus division and one was at the UNIM Research and Training Center in Kisumu and occurred in the context of training. Four of the five injuries to the glans occurred either during training (n = 1) or within two weeks after the provider had been trained and had started practicing (n = 3). These cases required emergency transport from the health facility where the injury occurred to a referral center 10 to 150 minutes away by road. The babies were hospitalized for two to seven days and were followed-up for weeks thereafter to ensure full function of the penis. The cases healed fully with pieces of tissue of varying sizes missing from the glans penis. Notably, there were no AEs, either moderate or severe, that occurred in the context of the 365 procedures performed outside health facilities.There were 3 deaths, two unrelated to the surgery. One baby suffered a severe fracture of his skull in the home and the other unrelated case was a baby initially diagnosed with neonatal sepsis and later found to have a heart defect upon autopsy. The third death was one of the cases of injury to the glans. The baby was put under general anesthesia for corrective surgery, came out of anesthesia, seemed well-recovered three hours after surgery, was placed in a bed with his mother and was sleeping with his mother, but was discovered deceased when she awoke one hour later. This death was determined to be “probably related” to EIMC since it would most likely not have occurred had the baby not been circumcised, but the proximal cause of the death was not clearly established.Of 22678 mothers who came to the facilities with a baby, 1841 (8.1%) came with a baby boy for OPV-1 services and 1768 (96%) were approached by a RA. Seventy-three mothers (4.1%) declined to participate, most citing inadequate time for the interview; 16 mothers (1.0%) were below 16 years of age; and 1679 were interviewed. There was insufficient or ambiguous location information collected on 19 (1.1%) of these women. Therefore, a total of 1660 consented mothers are included in this analysis.Of the 1679 mothers who agreed to be interviewed, 1501 (89.3%) gave approval to contact the father of the baby and 1288 (85.8%) of these fathers were contacted. Fourteen men refused to participate; 1274 (98.9%) consented and were interviewed, but 15 (1.2%) men could either not be matched in the dataset to a mother or there was ambiguous location information on the mother. Therefore, the final sample of fathers included in this analysis is 1259 men or 76% of fathers of babies whose mothers were interviewed.Overall, 425 mothers (25.6%) had babies who were circumcised : 189/799Circumcision of the infant was associated with mothers’ beliefs about their own likelihood of HIV infection, with the information that they had received about circumcision, and with whom they had consulted about the decision. Those mothers who perceived themselves to be HIV positive were more likely to have their son circumcised . If the mother had received information about EIMC, she was over ten times more likely to have her son circumcised than if she had not received information . If she received the information from a CHW, she was no more likely to have the baby circumcised  than if she had received no information, but if information came during a hospital consultation , the baby was more likely to be circumcised. There was a greater effect when information was received earlier–before pregnancy compared to after delivery–and information received during pregnancy or delivery had intermediate effects. Very importantly, discussing EIMC with the father of the baby influenced EIMC uptake significantly. The prevalence of the baby being circumcised—whether the discussion occurred before birth, around time of delivery or after delivery—at least two and a half times greater when the father was consulted than when he was not. The effect was greater when discussion occurred before birth (PR = 3.73) vs. at delivery (PR = 2.49) or after delivery (PR = 2.55). Mothers of circumcised babies believed their son was less likely to be “somewhat”  or “very much”  at risk of acquiring HIV.Of the 1259 fathers who were contacted, consented and interviewed, 333 (26.5%) were fathers of babies who were circumcised and 925 (73.5%) were fathers of babies who were uncircumcised at the time that the mother was interviewed at the health facility . The fatThe predictors of uptake of EIMC included in the first multivariable model in addition to treatment group were mother’s education level, her marital status, her self-perceived HIV status, and father’s ethnicity, religion, and circumcision status . AdjustiIn the second model we added variables related to levels and sources of information about EIMC, including the timing of mother receiving information about EIMC, her receiving information during a hospital consultation, and discussion of EIMC with the father. We also included the interaction effect of discussion with the father and marital status. Adjusting for these variables did not change the effect of treatment group; . The strongest effects were the mother having received information about EIMC at any time (Chi2(4) = 18.23, p = .001), with earlier information having larger effects, and the mother having discussed circumcision with the father if they were married or cohabiting; ,. Most unmarried women (67%) did not discuss infant circumcision with the father, and discussion of EIMC with the father among single mothers had no significant effect on prevalence of circumcision of the baby.To address the lack of evidence regarding introduction of EIMC services in sub-Saharan African settings, we conducted a simultaneous, prospective comparison of two models of EIMC service delivery: a standard delivery package (SDP) that included health facility-based provision of EIMC services with community engagement for client referral versus a standard package plus (SDPplus) that included community-delivered IMC services. We found that uptake of EIMC by parents for baby boys up to 60 days of age was 25.6% with a moderate increase in uptake in the SDPplus division. Babies were more likely to be circumcised if the mother had greater than a secondary education, if she knew or perceived herself to be HIV-positive, if she were single, if the father was circumcised and if the father was a Muslim. Also important was the mother’s and father’s exposure to information. Circumcision of the baby was much more likely if the mother had received information about EIMC and if the father and mother had discussed the EIMC decision together.The study was designed to test the difference between a primarily facility-based model versus a facility plus community-based model of integrating EIMC with MNCH services because in a previous study we found that approximately 45% of mothers do not deliver at health facilities and that fathers’ involvement has a significant impact on the EIMC decision . We expeThis study aimed to attain a level of 30% uptake of EIMC. Our weighted random sample of mothers coming to facilities with their babies for OPV-1 showed that uptake was approximately 26% in the catchment area. While lower than our original 30% target, it nevertheless represents a significant achievement given 0 babies were found to be circumcised at baseline , and appThe significant effect of knowledge on acceptability of EIMC has been documented in other studies of EIMC uptake ,31. In tBoth the mother and father are clearly important in the EIMC decision. In our baseline survey for this study, three quarters of women and men felt that the EIMC decision should be made equally between parents , and ourOne of the often cited advantages of EIMC over adult VMMC its greater safety ,9,33,34.The ages of babies circumcised in this study were restricted to between 24 hours to 60 days after birth, consistent with Kenya MOH guidelines. We are aware of one other EIMC program that extends the age window to 78 days , resultiOur study has several limitations. It was conducted in only one county in Kenya. The county is primarily rural with just two large towns. Our results may not be generalizable to other parts of Kenya or to other countries in East and southern Africa where introduction of EIMC is being considered for sustained coverage of male circumcision for HIV prevention. The providers who participated in this study were all either clinical officers or nurses with back-up support from Medical Officers and a surgeon. Other countries may not have the cadre of Clinical Officer, and may not permit nurses to perform procedures. This could result in different outcomes, although several studies have shown equivalent safety profiles of EIMC performed by nurses and doctors . We wereStrengths of our study include: large sample size, enrolling both mothers and fathers of infant males, a sampling strategy designed to be representative of the general population of parents in the study area and an innovative attempt to integrate EIMC information and services with both facility and community-based MNCH services.The addition of community-based domiciliary midwives to a facility based model of integrating EIMC services with MNCH services was safe, but resulted in only moderate increases in uptake of EIMC and is unlikely to be cost effective. Information and education campaigns will be crucial to improving uptake of EIMC and must be extended outside health facilities to reach members of the general population, especially men and fathers, who are crucial to the EIMC decision. AEs are rare, but when they occur they can be serious and require efficient, reliable emergency back-up. Achieving a goal of 40% of baby boys being circumcised before age 60 days will face many challenges.Kenya has a well-developed adult and adolescent VMMC program which is approaching saturation ,32. BeliS1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.S3 File(PDF)Click here for additional data file.


Content analysis of UK newspaper and online news representations of women's and men's ‘binge’ drinking: a challenge for communicating evidence-based messages about single-episodic drinking? BMJ Open 2016;6:e013124. doi: 10.1136/bmjopen-2016-013124Patterson C, Emslie C, Mason O, In


Cryptocercus, the sister group of termites, retain their symbiotic gut flagellates during the host molting cycle, but in lower termites, closely related flagellates die prior to host ecdysis. Although the prevalent view is that termite flagellates die because of conditions of starvation and desiccation in the gut during the host molting cycle, the work of L.R. Cleveland in the 1930s through the 1960s provides a strong alternate hypothesis: it was the changed hormonal environment associated with the origin of eusociality and its concomitant shift in termite developmental ontogeny that instigates the death of the flagellates in termites. Although the research on termite gut microbial communities has exploded since the advent of modern molecular techniques, the role of the host hormonal environment on the life cycle of its gut flagellates has been neglected. Here Cleveland’s studies are revisited to provide a basis for re-examination of the problem, and the results framed in the context of two alternate hypotheses: the flagellate symbionts are victims of the change in host social status, or the flagellates have become incorporated into the life cycle of the eusocial termite colony. Recent work on parasitic protists suggests clear paths for exploring these hypotheses and for resolving long standing issues regarding sexual-encystment cycles in flagellates of the Cryptocercus-termite lineage using molecular methodologies, bringing the problem into the modern era.Subsocial wood feeding cockroaches in the genus  These gut protists fall into two main groups traditionally known as flagellates—the Phylum Parabasalia and the Order Oxymonadida (Phylum Preaxostyla) [Cryptocercus hosts that have been investigated  , with thted  or colony (termites), which is lodged within the buffered environment of a nest. They are supplied with a steady stream of food, in a liquid, temperature-controlled, safe haven. Their world, then, is fairly constant, with one notable exception: the molting cycle of their insect host.The environment in which the flagellates live is unusually homeostatic and closely comparable from host to host . The proCryptocercus and lower termites, neonates acquire the flagellates from a parent or a sibling (the latter in established colonies of termites); the symbiosis is established at about the third instar in both taxa. The big difference lies in what subsequently occurs during the molting cycles of the developing juvenile host. After the symbiosis is established in Cryptocercus, it is retained through all subsequent ecdyses; it is never lost under natural conditions [Cryptocercus are used as a model of the termite ancestral state, that shift in the host-symbiont relationship can be pinned to a specific node of the Dictyopteran phylogenetic tree. This paper is an attempt to explore the foundations of that evolutionary transition.If the relationship of these two insect taxa to their gut fauna during developmental ontogeny is compared, it is obvious that there has been an evolutionary change during the host molting cycle. In both nditions ,44,45. Dnditions  then, deCryptocercus-termite lineage. Historically, the death of these flagellates at molt was thought to be a key factor associated with termite eusocial origins, e.g., [Among eusocial insects, the symbiosis with these gut flagellates is a feature unique to the s, e.g., ,48 but ms, e.g., ,50. A reCryptocercus and lower termites there are two levels of dependence. First, individuals rely on gut flagellates to metabolize and supplement their wood diet; and second, neonates in both taxa rely on their parents (in incipient colonies of termites) for vertical transfer of the symbionts. In termites alone, there is a third level of dependence: because the flagellates die at molt, developing termite individuals do not survive unless they have access to the hindgut fluids of a relative [Cryptocercus is used as a model of the termite ancestral state, previously independent insects evolved interdependency. Up to the threshold when the protistans began dying during the termite molting cycle, eusociality in termites may have been reversible, but in interdependent organisms the fitness of one depends on the fitness of another, making cooperation the best strategy [In both relative . The depstrategy . The deastrategy , in thatstrategy .Cryptocercus and lower termites, and how the symbiotic bond between the host and its gut flagellates is either maintained, or broken and subsequently re-established during the host molting period are consistently misunderstood in current literature [Cryptocercus; rather, these authors assumed two things about the natural history of the cockroach based on their observations of gut flagellates during Cryptocercus molting cycles. The first assumption was that neonates of Cryptocercus acquired their gut symbionts by feeding on the fecal pellets of recently molted older siblings, because these pellets contained resistant stages of the gut protists. The second assumption was that, because adults do not molt (and therefore their feces would not contain resistant stages of the symbionts), an adult pair of these cockroaches could not found a colony independently. These authors speculated that new colonies were formed by a ‘combined creeping migration’ of adults and older nymphs to a new log. Cleveland et al.  Cryptocercus. A subsequent study was done on adults collected in the field as mated pairs [Cryptocercus egg cases hatch; the typical family consists of a pair of adults with a single cohort of offspring. This social structure, together with the observation of parent to offspring vertical transmission of gut symbionts via proctodeal trophallaxis, was subsequently supported by Nalepa [Cryptocercus, including parent to offspring vertical transmission of gut symbionts, is now well established, and it is generally accepted that extended parental care in an ancestral cockroach modeled after Cryptocercus was the key basal condition in the pre-eusocial termite ancestor [Nutting  was the ed pairs , suggested pairs  demonstry Nalepa  and Parky Nalepa . The subancestor . Misconcancestor ,59,60.Cryptocercus enters its molting period, rising titers of the molting hormone ecdysone trigger the sexual/encystment (SE) cycles (addressed below) of the flagellates in the gut. During the SE cycle, the protistans become more resistant by producing cysts, pseudocysts, or by employing other mechanisms. The lining of the cockroach hindgut is then shed whole, but retained within the host body. The resistant flagellates are then held within the old gut lining (intima) until formation of the new lining is completed. The old intima ruptures, and the protists escape into and repopulate the gut lumen. The old hindgut lining subsequently breaks into small pieces, and is voided in fecal pellets along with some resistant protists [The gut microbiota of insects have a unique challenge not faced by those in vertebrate taxa. Because the insect hindgut lining is ectoderm, it is shed along with the rest of the exoskeleton during the molting period throughout host development. Consequently, insect gut microbiota may require measures to cope with the conditions of the digestive tract during this time. As protists ,61. AlthCryptocercus in the 1980s, it was thought that SE cycles in flagellates of Cryptocercus were rooted in a fecal-oral mechanism of transmission between generations. The cysts were considered mandatory to withstand the stress of being subjected to the environment outside the insect host, i.e., in fecal pellets lying on the floor of the nest. We now know that flagellates are transferred to neonates via ingestion of the trophozoite stage in the hindgut fluids of parents. After their hindgut microbiota have become established at about the third instar, trophallactic behavior in young nymphs of Cryptocercus ceases. The fact that some cysts may be found in the fecal pellets of post-molt juveniles of Cryptocercus, however, suggests that contemporaneous members of the family may ingest some of these; trophozoites that subsequently emerge from these cysts are probably re-integrated into the existing gut microbiota of the coprophage. Feces are a part of the diet in most cockroaches, including Cryptocercus [Prior to the work on social structure of tocercus ,62. HoweKalotermes flavicollis [Coptotermes formosanus [Cryptocercus. The lining of the hindgut is shed but retained within the body for two or three days; it later breaks up and is voided. Consequently, the gut protists cannot be re-acquired by a post-molt termite via feeding on its own shed exuvium, that of a nestmate, or by feeding on feces. The hindgut lining is not attached to the remainder of the shed exuvia [Cryptocercus is used as a model of the termite ancestor, the host-symbiont relationship during molt changed from retention by the individual host via the behavioral and physiological responses of the flagellates (SE cycles), to retention by the colony via host behavioral interaction with other colony members [The most common error regarding the disappearance of the protistans in molting termites is that the hindgut lining is excreted whole with the protists still in it; prevalent fallacies regarding how the symbiosis is re-established after molt is that it is restored by coprophagy or by feeding on an intact, shed hindgut lining. With a few possible exceptions (discussed below), however, the flagellates are dead and gone from the hindgut prior to the molt of their termite host ,65,66,67vicollis  and six rmosanus . The phyd exuvia , and terd exuvia ,61,64,71d exuvia . If Cryp members .One explanation offered for the death of termite flagellates during host molt was that because termites exhibit colony-wide proctodeal trophallaxis, the SE cycle in their flagellates was superfluous and expendable, as the flagellates were never exposed to the outside environment ; this exCryptocercus protect them during this period. The flagellates are known to be extremely sensitive to changing conditions of temperature, food, and water [Cryptocercus and termites to heat, starvation or oxygen is a standard technique for rendering them aposymbiotic for experimental purposes, e.g., [Cryptocercus [Cryptocercus nymphs as well as in adults, both of which have normal, wood-and fluid-filled guts [Cryptocercus, but lead to disintegration of the flagellates in termites? To address this question, the host-symbiont relationship at molt displayed by Cryptocercus will be examined in detail.It is commonly assumed that abiotic factors in the gut environment are responsible for killing termite protistans during molt, and that encystment by the flagellates in nd water ; indeed,s, e.g., ,76. The s, e.g., ,77. Largs, e.g.,  Plate 7)s, e.g., ,79,80. Stocercus ,81. The tocercus . Furtherled guts . The relCryptocercus exhibit two morphologically distinct stages in the life cycle. Intermolt Cryptocercus typically harbor the trophozoite stage, which reproduces by mitosis. Flagellates change from asexual to sexual methods of reproduction  at the time their host enters its molting period. The molting period of Cryptocercus begins with the first appearance of ecdysone in the insect and ends with the disappearance of this hormone. Ecdysone can begin rising as much as 50 days prior to ecdysis, and persists until three days after [Cryptocercus molting cycle; likewise, the morphological indications of flagellate resistance vary, both in degree and in the timing of appearance.Protists in ys after ,83,84. ECryptocercus exhibited a variety of sexual forms as extensive as all other protistan groups known at his time. In general, his accounts of the SE cycles in the flagellates indicate little opportunity for genetic recombination. There are reports of remarkable abbreviations of, and variations on, standard sexual processes that are difficult to interpret .  meiosis . Haploid meiosis . Diploidy Raikov ). Even wlization .Although meiosis is highly conserved in eukaryotes, deviations from the norm are ubiquitous and the evolutionary significance of these deviations is largely unknown. In many protists meiosis is not tightly associated with reproduction ,92,93, aCryptocercus exhibit the entire spectrum of the morphological indications of resistance during host molt, ranging from those that produce a thick, double-walled cyst to those that undergo a differentiation cycle during host molt but display no physical evidence of a resistant outer wall. Individuals of more than one species can skip an SE cycle altogether but are nonetheless retained during host molt.The flagellates in Trichonympha and Macrospironympha; Cleveland [Barbulanympha, for example, he described the organism as losing water, taking on a hyaline appearance, discarding its flagella, becoming circular and immobile, and becoming capable of withstanding conditions outside the host body. He considered it a ‘clear cut case of protozoa becoming resistant without formation of an external, protective cyst membrane or wall’ but refrained from naming the condition [Barbulanympha forms a pseudocyst [Rhynchonympha was described as undergoing ‘partial or pseudoencystation’, but it was also noted as ‘sometimes’ forming a cyst [Oxymonas nana forms a cyst, but O. dorsalis forms a pseudocyst [Leptospironympha typically forms a cyst, but there is no encystment or pseudoencystment in L. wachula [L. wachula, Eucomonympha, Notila and Saccinobaculus apparently undergo sexual cycles with neither encystment nor pseudoencystment [True cysts are defined as having a thick hyaline wall formed from the outer layer of the cytoplasm, with an empty space between the inner margin of the cyst wall and the living cytoplasm . Exampleleveland  considerleveland . Clevelaondition . He lateeudocyst . Rhynchog a cyst ,99. Varieudocyst . Leptosp wachula ,96. As icystment ,101.Cryptocercus during molt. Although in most flagellates all individuals undergo an SE cycle when their host molts [Trichonympha, Leptospironympha and possibly others do not. These individuals are actively motile, free of wood particles, and location specific: they are always found in the very anterior part of the hindgut [Cryptocercus are currently of no functional consequence, but are vestiges from a distant gregarious ancestor when externally excreted cysts functioned in horizontal transmission [Giardia lamblia, for example, involves pulsed production, processing and secretion of cyst wall material, and neogenesis of encystment specific vesicles [Finally, Cleveland described instances of flagellates that do not undergo an SE cycle but are nonetheless retained by st molts , a small hindgut ,61,91. T hindgut  p. 262) smission . Fewer tsmission  Table 2)vesicles ,102, indCryptocercus and extant lower termites suggests a logical evolutionary sequence , which are functionally sterile, developmentally plastic, immature stages stalled in a small bodied, altricial morphotype  to one with alternate pathways. These alternate developmental tracks are rooted in the independent ontogeny of different organs relative to each other . TermiteIn sum, there was extensive remodeling of the nature and timing of endocrine signaling pathways associated with host molt when the subsocial cockroach ancestor became eusocial. Because the ultrastructure, metabolism and gene expression of the flagellates was deeply integrated into the ontogenetic rhythm of their subsocial cockroach host, it is reasonable to assume that, as suggested by Cleveland, a drastic change in host developmental ontogeny had fatal consequences for the flagellates. Support for this suggestion comes from Cleveland’s work on the flagellates over the entirety of his career.Cryptocercus, the timing of host hormonal ebb and flow for the flagellate SE cycle is critical to the outcome, just as it is for termite caste determination. From the beginning of the molting period until several hours after ecdysis, the host is constantly changing the hormonal environment in which the hindgut protists live [Barbulonympha, Saccinobaculus and Oxymonas begin gametogenesis 40–45 days before ecdysis of their host, while Trichonympha begins this phase of its life cycle 5–6 days before ecdysis [Cryptocercus or an intermolt nymph is injected in doses too low to trigger ecdysis in the host [In sts live . Each fl ecdysis . Timing  ecdysis ; it is r ecdysis . Althoug ecdysis ,84, the the host , and molthe host .Macrospironympha, all divisions, haploid gametogenesis as well as meiosis, are synchronized during encystation. If these same divisions occur when the cell is not encysted, synchronization is lacking and the division process speeds up [Ecdysone acts differently on each flagellate genus not only in terms of triggering the SE cycle, but also in orchestrating its details . In somepeeds up .Transfaunation experiments indicate that once the SE cycle has been initiated by host ecdysone, there is no turning back; the flagellates reach a ‘point of no return’ early in the process. Any hormonal change in titer or timing that interferes with the early stages of the SE cycle blocks or alters all downstream events. If there are more than a few hours difference in the molt cycles of a donor and recipient, a transfer of gut contents results in flagellate degeneration and death .Only those flagellates that have initiated the SE cycle are susceptible to hormonal disruption; the beginning and end of the host molting cycle bracket the period of vulnerability ,81. Key Cryptocercus flagellates is likely coordinated at multiple levels, and involves cascades of up- and down-regulated genes associated with metabolic adjustment, nuclear division, and protein synthesis and transport [Cryptocercus, before the SE cycle is visible but when it is already susceptible to host hormonal changes. If so, there is a strong possibility that SE cycles in flagellates may be initiated during juvenile molts of lower termites, but the cycle is aborted with consequent disintegration of the flagellates before there is visible evidence that the cycles were occurring. Cleveland provided evidence that such was the case.As in other one-celled eukaryotes that encyst, morphological differentiation during SE cycles of ransport ,130,131.ransport . These pMastotermes darwiniensis, where the cycles were found in the flagellates Deltotrichonympha, Koruga, and Mixotricha (Trichonympha), and always correlated with the termite molting cycle. Although these flagellates were sometimes successful in producing a zygote, it was nonetheless short-lived; the process was always abortive prior to host molt [Zootermopsis [Zootermopsis and observed both sexual stages and cysts in Trichonympha. The evidence suggests, then, that there was not a complete loss of the SE cycle during molt in juvenile stages of termites; there was loss of a functional SE cycle. The underlying machinery is still present and can be activated, even if morphological changes cannot be detected in flagellates examined under a microscope. It is notable that when Cryptocercus donor flagellates are transferred to recipient termites, they initiate an SE cycle during termite molt, but then degenerate, just as termite flagellates in the termite host usually do. The fact that these SE cycles abort, with resulting degeneration of the protists parallels precisely the behavior of the sexual protists after they are transferred to another cockroach host either more or less advanced in the molting cycle [Although as a rule, all the large protists die prior to ecdysis in termites, Cleveland documented that some flagellates undergo sexual or sex-like differentiation prior to their death. The phenomenon is especially well studied in the basal termite xotricha . The cycost molt . There iermopsis . Messer ermopsis , howeverng cycle .Coptotermes formosanus, while ecdysteroids peaked a day later. Sen et al. [Reticulitermes flavipes, possibly indicating flagellate susceptibility to host hormones.The aborted SE cycles of termites during molt are a ‘smoking gun’ that supports Cleveland’s hypothesis: whatever hormonal mechanisms suppress or alter progressive maturational development of the termites also disrupts the SE cycle of termite protists. Flagellate disappearance prior to molt is not a programmed cell death, nor the result of starvation, dehydration or oxygen levels; it stems from an evolutionary change in the host hormonal regulatory network at molt. Recent support for the hypothesis comes from studies of termite physiology. Raina et al.  found thn et al.  showed tTricercomitus, Hexamastix, and Streblomastix, persist through the molting cycle of their host, and undergo unusual morphological modifications during this time [There are two exceptions to the ‘rule’ of flagellate loss during molt in termites. The first is that in some  termites, the smaller and simpler protists, specifically those in the genera his time ,142,143.Mastotermes darwiniensis, for example, the hindgut paunch at flight it is just 3% of alate wet weight, while it is typically 22% in two-month-old colonies [More intriguing from an evolutionary standpoint is that there are several reports that the symbiotic association with large, wood-digesting flagellates is often retained by the termite host during its final molt to the alate  stage. The imaginal molt differs from those previous in more than one aspect. It is a molt in which the termites acquire adult structures and reproductive competence, thus entailing a different hormonal regulatory network ; physiolcolonies .Trichonympha magna in Porotermes), and others report complex morphological transformations that suggest sexual phenomena [Cleveland  reportedhenomena ,71,142. henomena ,71, but henomena ,74.Cryptotermes lamanianus), recently eclosed alates were found to be devoid of flagellates and therefore dependent on proctodeal feeding from nest mates to replenish their symbionts prior to flight from the nest [Reticulitermes lucifugus retains its flagellates during the imaginal molt in some geographic locations but not others [Cryptocercus that survive host molt, but for which there is no evidence of encystation.In one studied termite  in a single termite of unreported developmental status. The cysts were mixed in among normal swimming cells of the same flagellate species. No cell division was observed, and the photographed cyst did not exhibit a space between the cyst wall and the cytoplasm, typical in encysted gut flagellates of Cryptocercus [Cryptocercus, where nearly 100% of a given species in the host synchronously undergo an SE cycle during the host molting period [Cryptocercus-termite clade may have more than one type of resistant stage. A protist species can exhibit a variety of cysts: as a regular part of the life cycle (like the reproductive cysts in flagellates of Cryptocercus during molt), and those instigated by a variety of different environmental conditions  [Cryptocercus punctulatus can be collected from frozen logs during winter in their Appalachian mountain environment [Cryptocercus are maintained during winter, as protective cysts are a distinct possibility. Cleveland [Oxymonas encysted in the gut of Cryptocercus in winter, during the asexual phase of this flagellate’s life cycle.A sidetrack to the main arguments is in order here, because Dolan et al.  recentlytocercus  and sometocercus . Moreoveg period ,61,81. Ig cysts) ,148. Thog cysts)  may be aironment . During ironment . It woulleveland  indicateThe evidence to date suggests two evolutionary hypotheses regarding the death of termite flagellates during the host molting cycle, providing a basis for further studies. The fact that non-functional sexual cycles are still sometimes found in the flagellates of termite juveniles during molt  more thaCryptocercus, host ecdysone had been ‘captured by the protozoa’ and turned to their own ends. If so, perhaps it backfired on them when the hormonal regulation of host development changed.In general, the partners in a vertically transmitted, obligate symbiosis are not equal. A loss of autonomy on the part of the smaller partner, in this case the flagellates, gives the host full control of the alliance, limiting the evolutionary pathways available to the symbionts. They can neither enter the system from the outside environment, nor re-evolve to free-living status. Eventually the smaller partner progresses to oblivion or to partial incorporation into the host ,152,153.An alternative to the protist as victim hypothesis is that the life cycles of the termite colony and the flagellates became aligned when the host evolved eusociality. Instead of individual host-symbiont fitness, colony-symbiont fitness became coupled, with intermolt termites serving as flagellate reservoirs . An intrKey to distinguishing between these hypotheses will be to determine the behavior of flagellates during the final, imaginal molt of their termite hosts. Survival and sexual activity of the flagellates should be the primary foci, as encystment may not be a requirement to withstand the host molting period. The behavior of the host at this time is of equal interest. Are alates fed hindgut fluids prior to their dispersal flight to assure an inoculum of symbionts? Or do they abstain because they have retained a representative sample of protists during their final molt, and flight weight is critical? Alates in three termite species studied by Heath  are repoCryptocercus [Trichonympha (Trichonympha using phase contrast, which he considered essential to rule out artifacts in the stained material [There is plenty of opportunity to address several pivotal aspects of this host-symbiont system. A good foundation lies in linking the regulation of developmental pathways in the host to the fate of the flagellates in its gut, and can be examined at a variety of levels. Cleveland’s  meticulotocercus ,127. To honympha , he studhonympha . He addimaterial .Cryptocercus and lower termite workers during their respective molting cycles; such data would help determine how the precise endocrine cascade to which the flagellates were adapted shifted when their host developed eusociality. Recent studies are beginning to lay the groundwork. Genes related to the synthesis, degradation, sequestration and reception of juvenile hormone have been detected in Cryptocercus punctulatus [Zootermopsis nevadensis [The action of insect hormones and their precursors are considerably better known since Cleveland’s investigations, and molecular methods now allow a much deeper exploration of unseen underlying processes. Potentially productive directions for exploring the mechanistic basis of flagellate death at molt include characterizing the hormonal differences between young ctulatus  and a covadensis . A compaGiardia lamblia, for example, is well characterized, as cysts are a key virulence mechanism allowing it to survive in the environment and infect new hosts [Instead of relying on visual evaluation of whether a flagellate enters an SE cycle, molecular techniques now make it possible to detect both encystment and sexual processes. Every microbial cryptobiotic state is the direct result of the opening and closing of specific genes , and sigew hosts ,161,162.ew hosts ,165,166.Giardia [Trichomonas vaginalis [Cryptocercus and lower termites. The genome of flagellates in Cryptocercus can be inventoried and used to develop a SE cycle ‘detection toolkit’ [Although Cleveland detected sexual cycles in flagellates of naturally molting termites, it took extraordinary effort on his part . MoleculGiardia , amoebaeGiardia , and sigaginalis , which itoolkit’  to deterTrichonympha, which predates the Cryptocercus-termite divergence [Trichonympha in Cryptocercus, and the genus is found in at least 111 lower termite species [Cryptocercus, and all species in the cockroach go through precisely the same sexual cycle within the same time frame [Trichonympha species from termites, including instances of T. magna surviving the imaginal molt in Porotermes (Because of the variation in SE cycles of the flagellates, efforts might best be directed to a single, well-studied flagellate genus such as vergence . There a species ,20,175. me frame ,61 (Figurotermes .Cryptocercus-termite lineage. In 1949, Cleveland [Symbiosis has entered a new era, with high throughput sequencing making it possible to analyze the capacities, functions and metabolism of each partner; analysis of the expression of mRNA or proteins further allow comparison of how symbiotic systems react when exposed to different environments . These tleveland  wrote th