The aim of this study was to investigate the association of perceived stress, depressive symptoms and religiosity with frequent alcohol consumption and problem drinking among freshmen university students from five European countries.2529 university freshmen  from Germany (n = 654), Poland (n = 561), Bulgaria (n = 688), the UK (n = 311) and Slovakia (n = 315) completed a questionnaire containing the modified Beck Depression Inventory for measuring depressive symptoms, the Cohen’s perceived stress scale for measuring perceived stress, the CAGE-questionnaire for measuring problem drinking and questions concerning frequency of alcohol use and the personal importance of religious faith.Neither perceived stress nor depressive symptoms were associated with a high frequency of drinking , but were associated with problem drinking. Religiosity  was associated with a lower risk for both alcohol-related variables among females. There were also country differences in the relationship between perceived stress and problem drinking.The association between perceived stress and depressive symptoms on the one side and problem drinking on the other demonstrates the importance of intervention programs to improve the coping with stress. Alcohol use during early adulthood presents a serious public health problem in many countries ,2. StudiGenerally, alcohol consumption has been linked to mental health problems e.g. perceived stress or depressive symptoms -15. DeprReligiosity is involved in the coping processes against stress and depressive symptoms ,24. ReliUniversity students in various Eastern and Western European countries differ in terms of the reported levels of perceived stress and depressive symptoms , alcoholAlthough the problem of alcohol use among university students is evident almost globally -38, compThe aim of the current study was to assess the associations of perceived stress and depressive symptoms with frequency of alcohol use and problem drinking among university students from five European countries, as well as to examine the role of religiosity for these associations. The specific objectives of the study were to:· Assess whether perceived stress is associated with a high alcohol use frequency and problem drinking and whether this association differs by country and/or by sex. It was hypothesized that a higher level of perceived stress would be associated with more frequent alcohol use and problem drinking.· Assess whether depressive symptoms are associated with high alcohol use frequency and problem drinking. It was hypothesized that a higher level of depressive symptoms will be associated with more frequent alcohol use and problem drinking.· For both the above objectives, the role of religiosity was examined. It was hypothesized that religiosity modifies the associations between perceived stress or depressive symptoms on the one hand, and the frequency of alcohol use and problem drinking on the other.The analysis described in this paper is based on data collected among university students in five countries from Western and Eastern Europe as part of the Cross-National Student Health Study (CNSHS) . The parA self-administered questionnaire was distributed to first-year students during regular classes of courses which were selected in order to obtain about one third of the sample each from the natural sciences, the social sciences, and business and law. In the UK and Slovakia, students cross all years were sampled, but only first year students were included in the current analysis. The overall response rate was 74% and the final sample included 2529 students. In order to increase the accuracy of self-reports, students were assured that their answers would remain confidential, and data protection was observed at all times.Participation in the study was voluntary and anonymous. Students were informed that by completing the questionnaire they were providing their informed consent to participate. They were also informed that they could terminate the participation at any point while filling out the questionnaire. The permission to conduct the study was granted by the participating institutions: Bielefeld University in Bielefeld, the Catholic University of Lublin, Lublin, the University of Sofia, the University of Gloucestershire, the University of PJ Safarik, the University of Veterinary Medicine and Pharmacy in Kosice and the Technical University of Kosice.The questionnaire was developed in German and then translated into Polish, Bulgarian, English and Slovak using two independent forward translations for each language. The research team reviewed any cases of disagreement and the authors familiar with the respective languages  made final decisions. The translations focused on and ensured the equivalence of meaning , and theFrequency of alcohol consumption was measured using the question: “Over the past three months how often have you drunk alcohol, for example, beer?” The response options were: “never,” “once a week or less,” “once a week,” “a few times each week,” “every day,” “a few times each day”. Abstainers were excluded from the analyses. For the purpose of analysis, this variable was dichotomised into “Low” (drinking once a week or less) versus “High” .guilty about your drinking?”; and, “Have you ever had a drink in the morning to get rid of a hangover?” Each question is answered with either “yes” or “no.” Two or three affirmative answers suggest problem drinking, while four positive responses indicate serious suspicion of alcohol dependence [In order to gather data on problem drinking we included an alcoholism-screening test, the CAGE test . CAGE ispendence . RespondStudents’ sex and age were based on individuals’ self-reports in the survey. Respondents’ subjective financial situation was measured by a single item: “How sufficient is your income?”, with a 4-point response scale ranging from 1 = ‘totally sufficient’ to 4 = ‘not sufficient at all’). To assess religion, the students were asked “What is your religion?”. They could chose among Christian, Islamic, other and none and in a second step specify the denomination of Christianity or Islam. In Slovakia, there was just one question with the three major Christian denominations, other religions and none as response options.This concept was measured with the four-item version of the Cohen’s perceived stress scale (PSS). PSS-4 is an economical and simple psychological instrument that measures the degree to which situations in one’s life over the past month are appraised as stressful . The queThese were measured using a modified version of the Beck Depression Inventory (M-BDI) ,47. StudFrom the many options available to measure formal and informal religiosity , we prioListwise deletion was performed for handling missing data. Descriptive analysis of alcohol consumption, problem drinking and other studied variables was undertaken separately for each country. In the next step, the association between stress or depressive symptoms on the one side and frequency of drinking or problem drinking on the other was analysed in four separate multivariable logistic regression models. All models included sex, country, perceived sufficiency of income and personal religiosity. Additionally, all two-way interactions and three-way interactions were assessed. Only significant interactions were reported and included in final tables. All analyses were conducted using SPSS 16, findings were reported as odds ratios (OR) with 95% confidence intervals (CI). Significance level was set at p <0.05.The main characteristics of the study population are presented in Table Subjective perception of sufficiency of income was similar across the countries, with highest scores in the UK and Bulgaria and lowest in Slovakia and Germany. Mean PSS scores were highest in Slovakia followed by Bulgaria, Poland, Germany and the UK. The M-BDI scores were highest for the Bulgarians followed by Poles, Slovaks, Germans and finally the UK students.Perceived stress was not associated with high frequency of drinking, but was associated with problem drinking after adjusting for sex, country, perceived sufficiency of income and importance of religious faith Table . There wDepressive symptoms were not associated with high frequency of drinking, but were associated with problem drinking after adjusting for sex, country, perceived sufficiency of income and importance of religious faith Table . SimilarThis study analysed the relationship between perceived stress and depressive symptoms and alcohol use and the modifying role of religious faith. We used two variables describing distinct patterns of alcohol use. Alcohol-related health and social problems tend to increase as the frequency of alcohol consumption rises , hence tOverall, the study found more high frequency drinking in Western (UK and Germany) and Southern (Bulgaria) European countries than in Central European countries (Slovakia and Poland). Problem drinking was most common in the UK and in Slovakia and least common in Bulgaria and Poland. Our results agree with WHO statistics of per-capita consumption of alcohol in these countries .In relation to perceived stress, several studies of stress and substance use among college student populations provide evidence that stress motivates alcohol consumption -56. StudProblem drinking among college students may be a means of coping with perceived stress and may also vary in relation to coping abilities e.g. religious coping. Results from current study are partly consistent with previous research demonstrating that religious faith was inversely related to the quantity and frequency of alcohol use and problem drinking in samples of college students ,34,58. IThere are several limitations to our study. Despite relatively low Cronbach’s alphas off PSS4 for the UK and Slovakia, we decided to keep these countries in the analyses. The alpha coefficient increases with the instrument's length ; and it We used a single measure of religiosity. Religiosity is a multi-dimensional construct  , and resRegarding the time window of three months for the question on the frequency of alcohol consumption, recall bias also needs to be considered. In addition, each of the applied measures included a different recall period . This further complicates the already difficult task of interpreting the findings from cross-sectional data in terms of temporality. For example, although problem drinking was regressed on depressive symptoms in the logistic regressions, the experience of alcohol problems may have occurred earlier in a student’s life (e.g. in adolescence) than the recent experience of depressive symptoms. We also did not address the issue of other potential variables associated with alcohol consumption and mental health. For example, it has been suggested in previous studies that when controlling for the effects of anger, depressed mood has little, or no independent effects on alcohol use . UnfortuThe sample comprised first-year students. Thus, any generalisations of the findings for all students should be undertaken cautiously. We included only one university per country (except for Slovakia), so the observed differences might be specific site characteristics rather than true differences between countries. Future research should address these limitations.We confirmed the previously proposed association between perceived stress and depressive symptoms and problem drinking in a culturally different sample of European students from five countries. At the same time, we demonstrated that the association does not exist for the frequency of alcohol consumption. We also showed that religiosity plays a role within this association, but the interaction effect is restricted to females.These findings should be taken into account when developing prevention programs for problem drinking among students. The policy recommendation for addressing problem drinking should include improvement of mental health and development of coping mechanisms. We studied the effects of religiosity and found out that its role was limited to females, but other coping strategies can be more universal. Many students can ‘feel down’ sometimes. For adolescents and young adults, maladaptive coping mechanisms e.g. drug or alcohol use are common when dealing with social and emotional problems. Such coping strategies are ineffective and provide only immediate relief from stressful situations, and may even exacerbate the problems that the person is currently experiencing. Talking openly, having appropriate social support and adequate coping skills can help prevent the transformation of periods of sadness to more severe depression.Prevention programs should directly target specific risk factors  that impact on adolescent well-being and focus on implementation programs that teach adaptive coping responses and problem solving skills so that they can effectively handle problems and stressors that typically characterise university students’ lives.The authors declare no conflict of interest.RS developed the research question, performed the statistical analyses and interpretation of the data, and drafted the manuscript. WEA wrote considerable parts of the manuscript and together with CS and OO commented extensively on the manuscript. RTM developed the study design, supervised the analysis, contributed to the interpretation and writing. All the authors read and approved the final version of the manuscript.


Video teaching modules are proven effective tools for enhancing student competencies and technical skills in the operating room. Integration into post-graduate surgical curricula, however, continues to pose a challenge in modern surgical education. To date, video teaching modules for neck dissection have yet to be described in the literature.To develop and validate an HD video-based teaching module (HDVM) to help instruct post-graduate otolaryngology trainees in performing neck dissection.This prospective study included 6 intermediate to senior otolaryngology residents. All consented subjects first performed a control selective neck dissection. Subjects were then exposed to the video teaching module. Following a washout period, a repeat procedure was performed. Recordings of the both sets of neck dissections were de-identified and reviewed by an independent evaluator and scored using the Observational Clinical Human Reliability Assessment (OCHRA) system.In total 91 surgical errors were made prior to the HDVM and 41 after exposure, representing a 55% decrease in error occurrence. The two groups were found to be significantly different. Similarly, 66 and 24 staff takeover events occurred pre and post HDVM exposure, respectively, representing a statistically significant 64% decrease.HDVM is a useful adjunct to classical surgical training. Residents performed significantly less errors following exposure to the HD-video module. Similarly, significantly less staff takeover events occurred following exposure to the HDVM. Many of these types of surgical learning modules have been validated for effectiveness in randomized controlled trials as well as systematic reviews.The high definition video module (HDVM) was created using three camera angles all shot in High Definition: a handheld camera, an overhead surgical camera, and a surgical headlight camera . The video captured a head and neck surgical attending at the University of Alberta performing a level II-IV selective neck dissection. The edited video module is 14 minutes in length. The video includes added text clearly outlining the surgical steps in sequence with the video. Participants also received a more detailed document of the consecutive surgical steps performed, which were numbered to match those of the video. The content validity of the teaching materials was ensured through a peer review process with five head and neck surgeons and using historically published technical protocols. Understandability was confirmed using a focus group of first and second year Otolaryngology-Head and Neck Surgery residents at the University of Alberta.Inclusion criteria for the study were Otolaryngology-Head and Neck Surgery residents in post-graduate year 3 through 5 at the University of Alberta. Participants were recruited by e-mail and participation was voluntary. Informed consent was obtained, ensuring that the study would have no impact on their formative and summative assessments for promotion or advancement in their residency training. Of those approached 100% enrollment was seen and all subjects completed the study.After enrollment into the study, participants were given a date for their initial assessment. They were instructed to perform a unilateral selective neck dissection (levels II-IV) on a radiographic N0 neck. While performing the neck dissection, participants wore an Integra® DLX Ultralite® Pro Camera in order to video record the procedure. All participants were de-identified and wore white surgical gloves and the attending staff surgeon wore brown surgical gloves to aid with evaluation of the video by a separate blinded reviewer. The video included no audio. A member of the study team was also present at all times during the procedures to facilitate recording and to document any ‘take over’ events by the staff surgeon.Following a washout period of at least 2 weeks after the initial assessment to eliminate carry-over effect, participants were given the HDVM the day prior to their final assessment. The following day, participants again performed a unilateral selective neck dissection (levels II-IV) on a radiographic N0 neck. The procedure was video recorded using the Integra® DLX Ultralite® Pro Camera.dexterity-based and video-analysis systems[formative and summative assessment[task analysis, which is an amalgamation of tasks and subtasks. Dexterity analysis is generic but video-based analysis can be used in this procedure-specific manner.Assessment of technical skill must be objective, reliable, and easy to perform. Current systems for this type of assessment can be divided into  systems. Dexterisessment. This enProcedural Errors. Errors 7 through 10 reflect manipulation of instruments in performing a specific task and are referred to as Execution Errors.For this study, we used the Observational Clinical Human Reliability Assessment (OCHRA) system to assess surgical performance, a system previously validated to assess the quality of surgical operative performance by documenting the errors and the stage of the operation in which errors are enacted most frequently. Error igeneric’ tasks, which could be found within most selective neck dissection procedures. This allowed the comparison of error rates between tasks within the procedure as well as making it possible to expand the utilization of the task analysis more widely to other forms of selective neck dissections performed at other surgical centers.A task analysis of a selective neck dissection used at the University of Alberta was undertaken, using a videotaped procedure, the historical technical protocol of the procedure, as wellProcedural or Execution Error. If it was possible to attribute a single error event to more than one pattern of failure  and the underlying causative mechanism[industrial human reliability assessment and has been shown by Tang et al. to be able to be adapted for clinical use to provide a comprehensive objective assessment of performance of a specific operative (open or endoscopic) procedure[Surgical error analysis allows identification of not only the quantity of errors being committed but also during what portion of the procedure they are occurring  were being more commonly committed by surgical residents and we found that overall, similar numbers of each type of errors were being committed. Procedural Errors refer to cognitive type errors  while Execution Errors refer to technical type errors . Interestingly, this is in contrast to recent literature, which indicates that surgical residents primarily commit cognitive type errors[This study also sought to identify what types of errors , reduced operating room time and cost, and reduction in patient morbidity and mortality. In addition, as our learners were only evaluated 24 hours after our intervention, we cannot gage long-term retention. There may be value in repeating evaluation 6 months post-intervention to determine if surgical error reduction was sustained.HDVM is a useful adjunct to classical surgical training. Otolaryngology-Head and Neck Surgery trainees at the University of Alberta show reduction of the number of errors committed and reduction of staff takeover events during neck dissection following exposure to the HDVM.The authors declare that they have no competing interests.AM participated in the design of the study, performed statistically calculations, and drafted the manuscript. HS participated in the design of the study, participated in all surgical procedures in the study. KA participated in the design of the study, and evaluated all surgical videos in the study. RM participated in the surgical procedures in the study as well as coordination of the study. DC conceived the study and participated in the design of the study. All authors read and approved the manuscript.


This study compared the effectiveness of a brief theory-based, youth-friendly HIV counseling video series with the standard practice (an HIV counselor) in improving risk reduction behavior among teens recruited in an urban Emergency Department (ED).A two-armed randomized controlled trial was conducted on a convenience sample of 203 non-critically ill, sexually active individuals aged 15-21 in an urban emergency department. Participants in the control (counselor) group received HIV information and counseling from a counselor while those in the intervention (video) group watched a series of youth-friendly counseling videos tailored to patients’ stages of change. All participants completed pre- and post-intervention measures on three mediating variables hypothesized to reduce unsafe sexual behavior: condom intention, condom outcome expectancy, and condom self-efficacy. HIV testing was optional for both arms.203 patients were enrolled and randomized, 102 in the video group and 101 in the counselor group. The groups were similar with respect to age, gender, race, ethnicity, and sexual history. The video intervention performed as well as in-person counseling at improving several condom use measures. The mean difference between groups (video-counselor) in improvement over time (from pre- to post-counseling) in condom self-efficacy was 0.26, CI, in male outcome expectancy was 0.15, CI, and in female outcome expectancy was 0.20, CI. Participants in the video group improved their condom use intention score significantly more than those in the counselor group, with a mean difference between arms for change over time of 1.02, p-value= 0.01, CI. The intervention effect on condom intention score did not differ by gender or ethnicity.The use of theory-based, youth-friendly video can be a valid means to provide post-test counseling education and prevention messages within an urban ED. The theory-based prevention messages can improve specific mediators representing risk reduction behavior among teenagers immediately following the intervention.


AbstractMonomorium dryhimi, is described based on workers from a single colony collected in Al Bahah, Asir Province, Saudi Arabia. This is the fourth species of the Monomorium monomorium-group collected from Arabian Peninsula, and appears to be closely related to Monomorium holothir Bolton, 1987, from Kenya. It can be distinguished by the following characters: head in profile with a weakly convex dorsal surface and a clearly convex ventral surface; eyes of moderate size with maximum diameter EL 0.19–0.25 × HW and with 6 ommatidia in the longest row; body colour yellow to light brownish yellow. In some individuals, head and gaster slightly but conspicuously darker than rest of body. Second halves of first and second gastral tergites with two characteristic brownish transverse bands. An identification key to the workers of the Arabian species of the Monomorium monomorium-group is presented. Scanning electron micrographs are given to illustrate the new species.A new ant species,  Monomorium was established by Monomorium minutum Mayr (which was given the new name Monomorium monomorium Bolton (1987:287)). This genus includes more than 300 species and subspecies , usually with a conspicuous 3-segmented club; mandibles with 3–5 teeth, median clypeal seta conspicuous; median portion of clypeus raised, the raised section longitudinally bicarinate; the carinae usually distinct; metanotal groove present, commonly impressed; propodeal dorsum usually unarmed and rounding into the declivity; propodeal spiracle usually circular, located at about the midlength of the sclerite (Members of the genus sclerite .Monomorium monomorium-group (The um-group  can be dMonomorium fauna was Collingwood’s (1985) study of the genus in Saudi Arabia where 20 species were recorded, of which a single species was of the monomorium-group, Monomorium clavicorne Andre, 1881. The second and more comprehensive contribution was that of Monomorium in the Arabian Peninsula. In that study, 53 species were recorded, 17 of which were described from Saudi Arabia including two species belonging to the Monomorium monomorium-group, Monomorium montanum and Monomorium qarahe. Since that time the contributions to the Arabian Monomorium fauna were descriptions of only two new species, Monomorium nimihil Collingwood from Socotra Archipelago .CI	Scape Length, excluding basal neck.SL	Scape Index (SL × 100/HW).SI	Eye Length; the maximum diameter of the eye.EL	Mesosoma Length; the length of the mesosoma in lateral view, from the point at which the pronotum meets the cervical shield to the posterior base of the propodeal lobes or teeth.ML	Pronotal width, maximum width in dorsal view.PRW	Petiole Length; the maximum length measured in dorsal view, from the anterior margin to the posterior margin.PL	Petiole Width; maximum width measured in dorsal view.PW	Postpetiole Length; maximum length measured in dorsal view.PPL	Postpetiole Width; maximum width measured in dorsal view.PPWImages taken under the scanning electron microscope ((SEM) JSM-6380 LA) were used to record morphological details of the new species .Aldawood & Sharaf sp. n.urn:lsid:zoobank.org:act:4C171A6D-B1F5-4D4D-BBAD-CE2250167E5Bhttp://species-id.net/wiki/Monomorium_dryhimiTL1.84, HL 0.48, HW 0.34, SL 0.31, ML 0.46, EL 0.08, PRW 0.22, PL 0.14, PW 0.11, PPL 0.08, PPW 0.11, SI 91, CI 71.TL 1.42–1.84, HL 0.42–0.49, HW 0.32–0.36, SL 0.26–0.32, ML 0.39–0.46, EL 0.07–0.08, PRW 0.19–0.24, PL 0.09–0.14, PW 0.08–0.11, PPL 0.05–0.09, PPW 0.09–0.12, SI 74–91, CI 73–83.(N=13).20°12'N, 41°13'E, 1881 m.a.s.l. 19.V.2010 (M. R. Sharaf & A. S. Aldawood Leg.); King Saud Museum of Arthropods (KSMA), College of Food and Agriculture Sciences, King Saud University, Riyadh, Kingdom of Saudi Arabia.SAUDI ARABIA, Al Bahah province, Amadan forest, Al Mandaq governorate, (M. R. Sharaf & A. S. Aldawood Leg.) These paratypes are in the King Saud Museum of Arthropods, King Saud University, Riyadh, Saudi Arabia.27 workers, same locality and data as holotype; 1 deposited in the Muséum ďHistoire Naturelle, Geneva, Switzerland (Dr Bernhard Merz); 1 in Naturhistorisches Museum, Basel, Switzerland (Mrs. Isabelle Zürcher-Pfander); 1 in California Academy of Science (Dr Brian Fisher); 1 in World Museum Liverpool, Liverpool, U.K (Dr Guy Knight), 1 in The Natural History Museum, London (Mr. Barry Bolton); 15 workers, SAUDI ARABIA, Elqamh park, Belgershi, Al Bahah, 17.V.2010 Headdistinctly much longer than broad with weakly convex sides and straight or feebly concave posterior margin . UndersiThis species is named in honor of Prof. Yousif N. Aldryhim, economic entomologist, Department of Plant Protection, College of Food and Agriculture Sciences, King Saud University, Kingdom of Saudi Arabia.Monomorium monomorium group with closest resemblance to Monomorium holothir Bolton, 1987, which was described from KenyaPageBreak. Both species sharing the following characters: clypeal carinae sharply developed and distinctly elevated; head sides behind eyes weakly convex; posterior margin feebly concave; in lateral view the maximum diameter of eyes clearly greater than the distance between anteriormost point of the eye and the nearest point of the mandibular articulation; body colour yellow to light brownish yellow; relatively similar body dimensions e.g. HL, HW, SI, and CI.This new species is a member of the Monomoroium dryhimi can be easily separated from Monomorium holothir by the following characters: eyes relatively small, their maximum diameter EL 0.19–0.25 × HW and with 6 ommatidia in the longest row, while in holothir eyes larger, their maximum diameter EL 0.30 × HW and with 8–9 ommatidia in the longest row. In Monomorium dryhimi, the median portion of anterior clypeal margin is clearly concave, whereas it is transverse to feebly concave in holothir. Moreover, in Monomorium dryhimi head in profile with a weakly convex dorsal surface and a clearly convex ventral surface, whereas in Monomorium holothir, head in profile dorsoventrally flattened. Furthermore, the promesonotum in Monomorium dryhimi has 3–4 pairs of hairs whereas in holothir the promesonotum have 8 pairs of hairs.Erica arborea L, Juniperus procera Hochst. Ex Endle.and Acacia gerrardii Benth (Monomorium dryhimi type was taken from a nest under a stone on hard-packed soil which contained tens of workers and was found in relatively elevated area of a valley which is high enough to avoid direct impacts of flooding. No additional nests were found despite extensive surveys. In addition, we were not able to collect foraging workers near the nest. It appears that members of the Monomorium monomorium group may prefer inhabiting areas of high elevations. All the four Arabian species were found inhabiting elevated localities with more than 1800 m asl., except Monomorium clavicorne which was also recorded from both relatively lower elevated areas including Riyadh and Al Qatif, in Central and Eastern regions of Saudi Arabia, respectively, and also from a much elevated area, Fayfa, Asir province (The type locality is a forest called Amadan, Al Mandaq governorate, Al Bahah province, Kingdom of Saudi Arabia, with much wild vegetation including ii Benth . Monomorprovince . Apparen


Nonmelanoma skin cancer (NMSC) is the most commonly diagnosed cancer in Australia and has a significant impact on the cost of and use of healthcare resources. Current estimates of NMSC in the USA are 3.5 million cases in 2010 compared to 1.63 million cases of all other cancers combined.  However, we believe that this figure significantly underestimates the prevalence of NMSC in the USA.  We calculated that melanoma is diagnosed 5.7 times more in the USA than in Australia.  In Australia, in 2010, there were 767,000 NMSC diagnoses.  If the ratio of melanoma: NMSC is constant in both Australia and the USA, then there should be 5.7 times the number of NMSC in the USA or 4.3 million cases.  The assumptions that underlie this calculation are discussed. NMSCs are predominately managed privately in an outpatient setting. NMSC is not a reportable cancer and NMSC data are not recorded on national cancer registries in either Australia or the USA.Nonmelanoma skin cancer (NMSC) includes basal cell carcinoma and squamous cell carcinoma of the skin, and is common in both Australia and the USA. In fact, in both Australia and the USA, NMSC is more common than all other forms of cancer combinedEstimates of the incidence of NMSC in both Australia and the USA are obtained by periodic surveys. Incidence data record an individual’s first episode of skin cancer within a calendar year. As NMSC patients commonly develop multiple primary cancers, incidence data are likely to significantly underestimate the burden of disease.4 were evaluated by Fransenet al. Data from the study were obtained from Medicare Australia. The population of Australia grew 23% from 18.3 million in 1997 to 22.6 million in 20105. Roughly 95% of the population or 21,470000 people are of European or Anglo-Saxon descent. Medicare Australia is a Commonwealth Government-funded universal health insurance scheme. Medicare Australia data captures 98% of all skin cancer treatments in Australia. Fewer than 2% of NMSC lesions are treated in public hospitals that record data independently6. All skin cancer treatments in Australia, except those provided in a public hospital, are individually itemized and recorded by Medicare Australia for the purpose of patient reimbursement. Item numbers for the excision, cryotherapy, curettage or laser treatment of skin cancers require histological confirmation of the diagnosis or clinical diagnosis by a registered dermatologist prior to Medicare coding.In order to calculate NMSC prevalence in Australia, data from more than 8 million skin cancers treated between 1 January 1997 and 31 December 20104. The number of treatments are estimated to increase to 938,991  by 20154.The total number of NMSC treatments increased by 186% from 412,493 in 1997 to 767,347 in 2010et al. estimated that in 2010 more than 3.5 million skin cancers were diagnosed in over 2 million people2. The number of practicing dermatologists in USA in 2010 was 95987. This figure suggests on average that each dermatologist treats 364 NMSCs a year, or one a day. Anecdotally, this figure seems low, even accounting for differences of skin cancer prevalence in each state.So, what is the prevalence of NMSC in the USA? RogersAnother way to estimate the burden of NMSC in USA is to compare the incidence of melanoma in the USA to that in Australia. Melanoma is a cancer that is reportable in both the USA and Australia. Reporting is mandatory and data on melanoma prevalence are likely to be more complete compared to data on NMSC.3 and 11,900 were predicted for the national cancer registry in Australia in 20101. This amounts to 7.1 melanomas per dermatologist per year in the USA and 21.6 melanomas per dermatologist in Australia in 2010.In 2010, it was predicted that 68,130 melanomas would be recorded on the cancer registry in the USA6 assumes that the climate, ethnicity, sun exposure behaviour and population differences that lead to the higher incidence of melanoma in Australia do not affect the ratio of melanoma to NMSC. We also assume that melanoma is recorded with equal accuracy and completeness in both the USA and Australia. Based on these assumptions, the number of NMSCs treated in the USA in 2010 would also be 5.7 times the number of NMSCs treated in Australia. As 767,000 NMSCs were treated in Australia in 2010, we estimate that 4.3 million NMSC were treated in USA.National registries data indicate that 5.7 times the number of melanomas were diagnosed in the USA among a population that is 14 times larger than Australia. One model8, 12.6% were black or African American8. The remaining 15% comprised people of different ethnicities including Hispanic or Latino, Asian, Native American, Hawaiian and Pacific Islanders8. The skin cancer with the least ethnic variation in incidence is acral lentiginous melanoma (ALM). ALM only represents 2–3% of all melanoma diagnosed in the USA9. If ALM were excluded from the total number of melanomas diagnosed in the USA in 2010, that reduces our estimate of NMSC in USA from 4.3 to 4.21 million cases.The population of the USA was 308.7 million in 2010 and 72.4% were White or European Americanet al2. This now equates to approximately 1.2 NMSCs per US dermatologist per day. Anecdotal experience would suggest this figure still underestimates the true burden of NMSC in USA. A prospective registry may be required to better estimate the full burden of NMSC and to ensure that there are adequate physical resources and manpower to treat NMSC patients in the USA.This is roughly an extra 700,000 cases on top of the current estimations of NMSC by Rogers The findings of this commentary are based on the estimations and calculations made by the authors of the work. The commentary itself is interesting, and helps provoke the idea that there is a higher prevalence of non-melanoma skin cancer (NMSC) in the US. However, the authors quite rightly demonstrate the potential weaknesses in the epidemiology of the disease; it is still difficult to collect data on the epidemiology of skin cancer even in Western countries. The authors do encourage prospective registries to help estimate NMSC, however as discussed, sun exposure and other factors have to be considered too in order to provide a more definitive answer for the prevalence of NMSC in the US.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This study can be considered very interesting for the new epidemiological insights that it provides. The study is interesting for the evaluation of relationship between melanoma and non-melanoma skin cancers (NMSC) in Australia and in USA; it highlights the underestimation of NMSC prevalence in USA, so it opens new inputs for a better demographic evaluation of these tumors.The title is simple and appropriate for the content of the article and the abstract can be considered a good summary of the work. The design of the study, and relative materials and methods are clearly explained and appropriate for this study. All data are clearly specified, clearly exposed and well schematized. The conclusions respect the basis of the study results.I have read this submission. I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Objective. Assess the relationship between body mass index (BMI) and drinking in college freshman. Method. College freshman (N = 199) at a university completed the drinking questionnaires. Drinking amount and the alcohol problem index (RAPI) served as outcomes, and BMI was the independent variable. Results. RAPI scores were associated with gender, amount of drinking, and BMI . Increase of RAPI with drinking amount was larger for females (slope = 0.06) than for males (slope = 0.03). Conclusion. This information can be helpful when providing health promotion strategies to college students regarding nutrition modifications that would be most beneficial for their health. This study investigated the relationship among body mass index (BMI), stages of change, number of drinks, and consequences of drinking in college freshmen. Consumption of alcohol is high among college students. According to Lloyd-Richardson et al. , 63% of  The amount and frequency of alcohol consumed have been found to correlate with BMI. In a large cross-sectional survey, noninstitutionalized individuals were administered a questionnaire to determine their history of drinking, quantity of drinking, frequency of drinking, average volume of drinking, and binge drinking . The binFrequency of drinking has sometimes been found to have an inverse relationship with BMI. Studies have suggested that people who drink a small amount daily have a lower BMI. Arif and Rohrer  and Bres Data on the relationship of BMI to alcohol consumption in the college-age population have been limited. The role of BMI as an independent variable on college student drinking as an outcome variable remains unclear. Additional studies are needed to explore the relationship of BMI to the number of drinks and gender in this population. This study attempted to help fill this gap in the literature by assessing the relationship among BMI, stages of change, number of drinks, and consequences of drinking in college freshmen. Drinking amount and related negative consequences served as outcomes; BMI was the independent variable.This descriptive, correlational study used a convenience sample of 199 college freshman males and females ages 18 to 20 at a large southern university who indicated that they had more than zero drinks for a typical week. Institutional Review Board was approved, and following completion of the informed consent, the participants completed the questionnaires in a private room. The following measures were completed: daily drinking questionnaire (DDQ) ; the bri2. A BMI of 18.5 to 25 may indicate optimal weight, a BMI lower than 18.5 suggests underweight, and a BMI above 25 may indicate overweight. A BMI below 17.5 may indicate anorexia nervosa or a related disorder, and a BMI above 30 suggests obesity, with a BMI above 40 indicative of morbid obesity [BMI is a measurement that combines a person's weight and height. BMI is used to estimate a healthy body weight based on the height. It is widely used to diagnose whether individuals are underweight, overweight, or obese. BMI is defined as body weight divided by the square of one's weight. The formula used is a unit of measure of kg/m obesity .All of the participants completed the DDQ. They reported the number of drinks consumed on that day of a typical week during the past month. The number of drinks was calculated by summation, that is, by the total number of drinks consumed weekly. A drink is equal to a 12oz beer or a 1oz shot, or a 4oz glass of wine.The BRCQ is a 12-item questionnaire. It is a brief measure of motivation to change alcohol use developed to be consistent with the transtheoretical stages of change model . The BRCnone, 1: 1-2 times, 2: 3–5 times, and 3: more than 5 times). The final RAPI score is the sum of the responses. The range for the RAPI score is 0 to 69. High scores indicate several alcohol problems. In a clinical sample of adolescents ages 14 to 18, the means ranged from 21 to 25; in a nonclinical sample ages 15 to 18, means ranged from 4 to 8, depending upon age and sex.The RAPI is a brief 23-item measure with good psychometric properties designed to assess the frequency of the occurrence of negative drinking consequences . The RAP2. Participants consumed an average of approximately 13.5 drinks per week; the mean RAPI score was 11 , the RAPI score, and BMI, with adjustment for gender and readiness to change stage. Residual diagnostics were performed for the final models used in the analysis.P < 0.0001 for the whole model). For males precontemplating change, the relationship between BMI and amount of drinking was nonlinear. Participants with average BMIs drank the least , and those with the highest BMIs drank the most . Participants with the lowest BMIs fell in between the range   see .P < .001, for the whole model). Increase of RAPI with drinking amount was larger for females (slope = 0.06) than for males (slope = 0.03). Participants with high BMIs had lower RAPI scores (see Figures RAPI scores were associated with gender, amount of drinking, and BMI ( The relationship between BMI and number of drinks was significant only for the male participants in the P stage, that is, the male participants in the P stage with high BMIs drank more. These male participants were not taking any action to change. The male and female participants who were obese had fewer alcohol consequences; however, drinking was still harmful to their health. Given the number of drinks consumed, the male participants experienced fewer consequences than the female participants did. The male participants in the P stage were not thinking about making any changes, so those with the highest BMIs may have felt comfortable consuming more alcohol. Even though they had high BMIs, the male participants in the C and A stages did not consume more alcohol because they were trying to make changes to their drinking behaviors. For the female participants, the stages of change did not have a significant effect. The more alcohol that the students, male and female, drank, the more alcohol-related consequences they encountered; however, the male participants had a greater ability to handle the consequences perhaps because males have more muscle tissue and can absorb alcohol more efficiently than females can. Thus, it is important to focus on developing interventions for females. This information can be helpful to clinicians who are striving to provide health promotion strategies to college students regarding nutrition modifications that would be the most beneficial to their health. Alcohol is high in calories, so drinking alcohol may contribute to higher BMIs and the poor health choices of college-age students who are already overweight, particularly freshmen female students who drink four or more drinks per day and male students who consume five or more drinks per day. College students should be cautioned about the high carbohydrate content of alcohol, especially if they drink large amounts. Elevated triglycerides and low high-density lipoprotein cholesterol levels are the result of continued high carbohydrate intake, especially if students are already overweight when they first start to drink . Moderat


Using an allelic series of the thymic epithelial cell (TEC) specific transcription factor Foxn1, we showed that these events are delayed by 1–2 days in Foxn1/ΔΔ mice, and this phenotype was exacerbated with reduced Foxn1 dosage. At subsequent stages there were fewer capillaries, leaky blood vessels, disrupted endothelium - perivascular cell interactions, endothelial cell vacuolization, and an overall failure of vascular organization. The expression of both VEGF-A and PDGF-B, which are both primarily expressed in vasculature-associated mesenchyme or endothelium in the thymus, were reduced at E13.5 and E15.5 in Foxn1/ΔΔ mice compared with controls. These data suggest that Foxn1 is required in TECs both to recruit endothelial cells and for endothelial cells to communicate with thymic mesenchyme, and for the differentiation of vascular-associated mesenchymal cells. These data show that Foxn1 function in TECs is required for normal thymus size and to generate the cellular and molecular environment needed for normal thymic vascularization. These data further demonstrate a novel TEC-mesenchyme-endothelial interaction required for proper fetal thymus organogenesis.The thymus is composed of multiple stromal elements comprising specialized stromal microenvironments responsible for the development of self-tolerant and self-restricted T cells. Here, we investigated the ontogeny and maturation of the thymic vasculature. We show that endothelial cells initially enter the thymus at E13.5, with PDGFR-β Organ vascularization is essential for the delivery of oxygen and nutrients to developing tissues and is required for normal tissue growth and homeostasis. Vasculature is primarily comprised of endothelial and perivascular support cells + and CD8+ single positive T cells exit to the periphery in a highly regulated fashion via specialized blood vessels at spatially defined regions of the organ In the thymus, the vascular network plays a critical role in organ function, and has also been implicated in organ development. The thymus provides a specialized microenvironment that supports the development of self-MHC restricted and self-tolerant T cells. Lymphoid progenitor cells (LPCs) enter the thymus and CD4The predominant functional stromal cell population is the thymic epithelial cell (TEC) compartment. TECs are broadly subdivided into cortical (cTEC) and medullary (mTEC) subsets, which have specific roles promoting the development of T cells As in all organs, initial thymic vascularization takes place during fetal organ development. The fetal thymus and parathyroid glands develop from an outgrowth of the third pharyngeal pouch endoderm Two recent studies have reported on the role of VEGF in the thymus of neonatal and adult mice Foxn1, referred to as Foxn1ΔFoxn1/ΔΔ homozygotes, TEC differentiation is largely arrested at an immature stage, and organization of defined cortical and medullary epithelial cell compartments fails. These mice therefore provide a model for investigating the roles of Foxn1 in later stages of fetal thymus organogenesis Thymic epithelial cells express the forkhead box transcription factor Foxn1 at E11.25, just before colonization of the thymus by the first wave of thymocytes +/Foxn1Δ, Foxn1/ΔΔ, Foxn1/nuΔ and nu/nuFoxn1 embryos. Initial attraction of the embryonic vasculature and neural crest cells (NCCs) to the vicinity of the thymus rudiment and initial immigration of lymphoid progenitor cells (LPCs) into the thymus are normal until E12.5 in +/Foxn1Δ and Foxn1/ΔΔ mice. However, there was a specific delay in endothelial and neural crest-derived perivascular cell recruitment into the thymus in Foxn1/ΔΔ mice. Progressive exacerbation of this vascular phenotype in Foxn1/nuΔ and nu/nuFoxn1 mice demonstrated that the process of thymus vascularization is sensitive to changes in Foxn1 function and dosage. We further demonstrated that the thymic blood vessel network is connected to the fetal vascular network at E14.5 in both control and Foxn1/ΔΔ mice. However, blood vessel patterning was compromised in Foxn1/ΔΔ thymi, as indicated by “leaky” vessels, an apparent decrease in capillaries, loss of tight association between the endothelium and perivascular cells, indistinct vessel walls, vacuolated endothelium, and an overall failure of vessels to model into a stereotypical thymus vascular network. These results demonstrate that Foxn1-expressing thymic epithelial cells are required for normal epithelial-endothelial-mesenchymal cell interactions that are necessary for the formation of a functional vascular network in the thymus.To test whether proper TEC differentiation is required for vascular development during thymus organogenesis, we analyzed an allelic series including Foxn1Δ mice were previously described Foxn1Δ mice are on a mixed 129v/C57BL/6J background that has been backcrossed to C57BL/6J for 5 to 7 generations. nuFoxn1 mice on a C57BL/6J background were purchased from The Jackson Laboratories . Foxn1/nuΔ mice were generated from Foxn1/ΔΔ X +/nuFoxn1 crosses. All experiments were performed with approval from the UGA Institutional Animal Care and Use Committee .Embryos were isolated at E11.5–E18.5, flash frozen in liquid nitrogen and cryosectioned at 10 µm. The following primary antibodies were used for the embryonic thymus immunofluorescence analysis + cells were depleted using Dynabeads® sheep anti-mouse and following manufacture’s protocol for magnetic bead depletion . CD45 purity and EpCAM expression was determined by real-time quantitative polymerase chain reaction (qRT-PCR)  for 30 min and washed three times with PBS. CD45qRT-PCR) .T method.RNA was isolated from embryonic thymi using the RNeasy Micro kit (QIAGEN). In each litter, mutant thymi were pooled, as well as control thymi. First-strand cDNA was synthesized using a cDNA synthesis kit . qRT-PCR was performed using TaqMan Universal Master Mix and TaqMan probes for VEGF-A, PDGF-B, EpCAM, CD45 and 18S rRNA (endogenous control) on an ABI 7500 thermocycler. Controls are set to a value of 1 in each experiment relative to mutants. All experiments were performed in duplicate and analyzed using the ΔCFetal vascular labeling was performed as previously described Thymi were fixed and processed for electron microscopy as previously described + Area/Thymus Area was calculated using CellProfiler cell image analysis software Average mean fluorescence intensity was calculated using Zeiss LSM 510 software. CD31Values are expressed as means plus or minus Standard Deviation (SD). Student’s t test was performed to determine whether the difference between the means of mutants compared to control groups were statistically significant.+/Foxn1Δ thymus  and VE-Cadherin (CD144). We also confirmed that the timing of vascularization events was similar between wild-type and +/Foxn1Δ embryos  subset of thymic epithelial cells  in the rudiment . VesselsΔ thymus , but wertermates . RBCs we/Δ thymi . We next embryos , confirmby E12.5 , and 3A,al cells  and 3A. senchyme  [14]. Ate thymus  and 3B–D network . PGDFR-βat E14.5  and 3C–DFoxn1Δ allele. At E12.5, the Foxn1/ΔΔ thymic rudiment resembled the stage-matched +/Foxn1Δ control littermate thymus , and assayed for vascular markers in Foxn1/ΔΔ, Foxn1/nuΔ, and nu/nuFoxn1 mice (Foxn1/ΔΔ thymus was more pronounced in Foxn1/nuΔ (nu/nuFoxn1 mice (nu/nu), CD144+ endothelium was not present inside the thymic epithelial rudiment at least until E17.5 (data not shown). We also noted that although initial capsule formation as assayed by PDGFR-β expression appeared normal , bone marrow derived-hematopoietic precursor cells (HPC) migrate to, but fail to colonize the thymus rudiment Foxn1Δ mutation affected the timing of initial HPC infiltration of the thymus, which might contribute to these early vascular defects in Foxn1/ΔΔ mice. At E11.5, when thymocytes initially infiltrate the thymus + cells were present in the thymus rudiment in both Foxn1/ΔΔ and control littermates at similar frequencies . As mutation of the CCL25 receptor, CCR9, exhibits a ∼40% reduction in the number of initially immigrating thymocytes, but does not affect timing of initial immigration Foxn1/ΔΔ mice. After this initial immigration, subsequent proliferation and differentiation of thymocytes is strongly suppressed, presumably by delayed and defective TEC differentiation, as we previously published We further tested whether CCL21 and CCL25, two key chemokines required for initial HPC recruitment to the shared thymus/parathyroid primordia, were reduced in /Δ thymi . In cont/Δ thymi , E13.5 a+/Foxn1Δ thymi tightly associated with CD31+ vasculature , as shown by comparing the average mean fluorescence intensity measurements (+/Foxn1Δ (n = 8) and Foxn1/ΔΔ (n = 6) mutants.Thymic vascular patterning requires the formation of a primary blood vessel network and subsequent vascular pruning. This process culminates with the establishment of a capillary-rich cortex that connects to PCVs at the CMJ and within the medulla . However mutants , which durements  from FoxFoxn1/ΔΔ thymus, based on a morphological analysis of endothelial cell-pericyte interactions. We observed pericytes associated with most vascular structures in the thymus  is a potent inducer of vascular development during embryogenesis and in adults . VEGF-A  expressiand TECs . In E13. in TECs . By E15. in TECs  but not /Δ thymi , indicatFoxn1/ΔΔ and at E15.5 in Foxn1/nuΔ thymic stromal cells by qRT-PCR  and is critical for cell migration, adhesion, proliferation, and differentiation r region . FollowiIV+ beds . In newb medulla . There wol thymi –F. In coΔ thymus , with CDcontrols , further+ mesenchyme; these immigration events were specifically delayed by one day in Foxn1/ΔΔ mice. Further, we demonstrated that once formed, the organization and structure of the thymic vasculature in Foxn1Δ/Δ mice is abnormal, with changes in both vessel size and structural integrity that indicate defective maturation of and interactions between endothelial and mesenchymal cells. In contrast, the timing of initial LPC immigration into the Foxn1/ΔΔ fetal thymus was normal, although as reported previously, the number of thymocytes was significantly reduced due to delayed and reduced proliferation and differentiation Foxn1/ΔΔ mutants. Since not all events during early thymus organogenesis are delayed, these defects may reflect specific functions for TECs in regulating vascularization, rather than a general delay in thymus development. The overall reduction in thymus size in Foxn1/ΔΔ mice may also contribute to the observed defects in thymus vascularization. TEC specific deletions of pro-angiogenic molecules will be needed to establish specific roles for TECs in driving the formation of the thymus vasculature. The non-cell-autonomous nature of the vasculature-associated defects in the Foxn1/ΔΔ mutants provides evidence for a TEC-endothelium-mesenchyme interaction that plays a key role in thymus organogenesis and the organization of the thymic architecture.In this study, we have defined the early stages of thymic vascularization during organogenesis in the mouse, and established that Foxn1-dependent TEC differentiation is required for this process. Specifically, our data demonstrate that Foxn1 function in TECs is required to regulate the initial formation of the thymic vasculature, and that this function is sensitive to Foxn1 function and dosage. Effects on vascular development are non-cell-autonomous, and may be due to either direct production of angiogenic factors by TECs, or to more indirect effects of reduced thymus size. Vasculature initially infiltrates the thymus at E13.5, followed closely by PDGFR-βTaken together, our current results and those of previous studies suggest the following model for initial thymic vascularization. Neural crest cells are first recruited to the periphery of the thymus at E10.5–E11.5 Foxn1/ΔΔ phenotype, and the expression and function of PDGF and VEGF further suggest a molecular model for the mechanisms controlling this process. Both NCCs Foxn1/ΔΔ mutants, this process may be regulated either by NCC-derived signals, or by Foxn1-independent TEC-based signals, while immigration into the rudiment itself may require TEC-derived signals downstream of Foxn1. Once inside the rudiment, branching vasculature structures and possibly angioblasts form the intrathymic vasculature via vasculogenesis. The structure of this network is patterned by the level of intrathymic proangiogenic molecules This cellular order of vascular development, the Foxn1/ΔΔ mice. Interestingly, E15.5 Foxn1/nuΔ mice had a similar level of VEGF-A as Foxn1/ΔΔ mice, but show more severe vascular defects. The loss of other TEC-derived pro-angiogenic factors in TECs might account for this difference. Alternatively, the more severe phenotype may reflect other changes in TEC differentiation that could affect the accessibility of the thymic epithelial rudiment to invasion by the vasculature.Although reports suggest VEGF-A mRNA is expressed in TECs Foxn1/ΔΔ mutants, both the delay in mesenchymal cell immigration and the reduced intrathymic PDGF-B expression are likely secondary to the delayed and reduced number of intrathymic endothelium. Endothelial cell-mural cell contact is predominantly mediated by PDGFR-β/PDGF-B ligand/receptor signaling Foxn1/ΔΔ mutants were also reduced , where mature T-cells accumulate prior to immigration into the thymus and egress to the periphery Foxn1/ΔΔ mice The TEC differentiation and mTEC organization phenotypes in The paradigm of TEC-thymocyte crosstalk informs much of our understanding of the mechanisms underlying the organization and function of the thymus. The identification of further interactions between TECs, endothelial cells, and mesenchymal cells expands the network of intercellular interactions required for the proper formation of the complex thymic architecture. Our current and previous data suggest that Foxn1 plays a central role in TECs to orchestrate these diverse crosstalk pathways during fetal thymus organogenesis. This novel TEC-endothelium-NCC interaction may also be required for the cortico-medullary organization, and for formation of blood vessels at spatially defined regions of the thymus that facilitates the immigration of LPCs into the thymus and egress of LPCs to the periphery.Figure S1EpCAM and CD45 expression in depleted stroma from Δ/ΔFoxn1 thymus. (A) EpCAM expression is normal in pooled E13.5 ΔFoxn1Δ/ and control thymi before and after CD45+ cell depletion. (B) CD45 expression before and after CD45+ cell depletion in pooled E13.5 ΔFoxn1Δ/ and control thymi.(TIF)Click here for additional data file.Figure S2Initial thymic vascularization is similar in E13.5 +/+Foxn1 and +/ΔFoxn1 mice. Immunofluorescence analysis of CD144 (VE-Cadherin) and Keratin 5 (K5) in the wild-type thymus from frozen sections of whole embryos  and dissected thymi . Timing of vascularization of overall vessel patterning is similar to that seen in +Foxn1Δ/ mice, as shown in (TIF)Click here for additional data file.Figure S3Collagen IV is broadly expressed throughout NB Δ/ΔFoxn1 thymus. Immunofluorescence analysis of embryonic (A–F) and newborn transverse sections (G–H) of thymus for CD31+ (blue) and Collagen IV (green). Collagen IV deposits adjacent to CD31+ cells in E12.5 (A) +Foxn1Δ/ and (B) ΔFoxn1Δ/, E13.5 (C) +Foxn1Δ/ and (D) ΔFoxn1Δ/, E15.5 (E) +Foxn1Δ/ and (F) ΔFoxn1Δ/, Collagen IV expression in newborn (G) +Foxn1Δ/ and (H) ΔFoxn1Δ/ thymus. Cortex (c) and medulla (m) Scale bar, 100 µm; n ≥ 3.(TIF)Click here for additional data file.


To evaluate the performance of the WHO criteria for defining maternal near miss and identifying deaths among cases of severe maternal morbidity (SMM) admitted for intensive care.Between October 2002 and September 2007, 673 women with SMM were admitted, and among them 18 died. Variables used for the definition of maternal near miss according to WHO criteria and for the SOFA score were retrospectively evaluated. The identification of at least one of the WHO criteria in women who did not die defined the case as a near miss. Organ failure was evaluated through the maximum SOFA score above 2 for each one of the six components of the score, being considered the gold standard for the diagnosis of maternal near miss. The aggregated score  was calculated using the worst result of the maximum SOFA score. Sensitivity, specificity, positive and negative predictive values of these WHO criteria for predicting maternal death and also for identifying cases of organ failure were estimated.The WHO criteria identified 194 cases of maternal near miss and all the 18 deaths. The most prevalent criteria among cases of maternal deaths were the use of vasoactive drug and the use of mechanical ventilation (≥1 h). For the prediction of maternal deaths, sensitivity was 100% and specificity 70.4%. These criteria identified 119 of the 120 cases of organ failure by the maximum SOFA score (Sensitivity 99.2%) among 194 case of maternal near miss (61.34%). There was disagreement in 76 cases, one organ failure without any WHO criteria and 75 cases with no failure but with WHO criteria. The Total Maximum SOFA score had a good performance (area under the curve of 0.897) for prediction of cases of maternal near miss according to the WHO criteria.The WHO criteria for maternal near miss showed to be able to identify all cases of death and almost all cases of organ failure. Therefore they allow evaluation of the severity of the complication and consequently enable clinicians to build a plan of care or to provide an early transfer for appropriate reference centers. During the last two decades the reduction in the number of maternal deaths in developed countries and their under estimation in developing countries stimulated the interest for studying and reporting severe maternal morbidity (SMM) or maternal near miss -6. Concend day postpartum [In this continuum, among the potentially life threatening conditions, there is a specific extreme degree of severe morbidity compatible with the concept of maternal near miss ,8. The Wstpartum . There hstpartum ,12,13, bstpartum . A definstpartum .There are practical difficulties for determining the criteria for a strictly organ dysfunction based definition for international use due to widely varying resources available. There are however tools already validated for recognizing organ dysfunction and failure. The SOFA score, for instance, was extensively validated in general populations for quantifying organ dysfunction ,17. For In order to achieve a situation where the maternal death can be avoided, the cases of SMM and/or maternal near miss must be identified early, feasibly, consistently and uniformly ,5,19. ThThe professionals participating in this WHO Working Group were challenged to test the proposed set of criteria for maternal near miss in their datasets. Therefore the objective of the present study was to retrospectively evaluate the performance of these WHO criteria against markers of organ dysfunction and failure using the maximum SOFA  score  as a golThis study is a pre-validation of the WHO proposed criteria for identifying maternal near miss. It was performed at the Center for Integral Care to Woman's Health (CAISM), in Campinas, Brazil. It is a public university hospital, which is part of the hospital complex from the University of Campinas (UNICAMP), where around 2,900 deliveries take place annually. This facility serves as a tertiary reference center for the regional population of around three million inhabitants and has an intensive care unit conceived specifically for giving appropriate care for women with life threatening conditions during pregnancy and postpartum period.During the first five years of activity of this obstetric intensive care unit, between October 2002 and September 2007, there were 673 obstetric admissions that were retrospectively analyzed, and among them there were 18 maternal deaths. Women presenting any severe complication related to pregnancy were admitted to the unit as already described elsewhere . The datAlthough data were collected for a series of variables related to women and the care they received, for the current approach we used information on the presence of any criterion for maternal near miss as proposed by WHO , proceduThe reason for admission to the unit was classified as obstetric if the morbidity was due to a complication directly related to pregnancy or postpartum period, and as clinical-surgical if due to a complication that was previous condition or concomitant to the current pregnancy -25. The The concept of maternal near miss as proposed by WHO uses criteria based on the identification of clinical signals and symptoms, laboratory tests, and the use of some interventions and/or procedures for its clinical management during any pregnancy or postpartum period . The stu2) below 90% for 60 minutes or more, and the loss of consciousness and the presence of glucose and ketoacids in the urine, were not routinely registered during the admission of these 673 cases at the unit. The dosage of serum levels of lactate was not included in this analysis because it was also not routinely performed for all cases of SMM admitted. Generally speaking, when performed, its serum measurement was linked with the evaluation of the therapeutic effect following hemodynamic resuscitation in the first 24 h after shock.Among the eight laboratory criteria proposed by WHO, the oxygen saturation  can be observed in Table All the 18 maternal deaths occurring at the institution during the period of study were in the intensive care unit (ICU) and all were identified through at least one of the WHO criteria. There were 194 cases presenting life threatening conditions that were afterwards considered as maternal near misses. The remaining 461 cases, although having potentially life threatening conditions, had a good clinical course and did not become near miss cases. Among the women initially admitted to the ICU, the sensitivity of the criteria for identifying maternal deaths was 100%, while the specificity was 70% Table .Among the 194 cases of near miss according to WHO criteria, the evaluation of the organ function through the maximum SOFA score identified 120 women with one or more organ failures. From the 76 cases with discordant results between both methods, only one had organ failure and was not identified as maternal near miss by the WHO criteria Table . Figure In the remaining 75 cases with no organ failure, 74 women (98.6%) had one or more management criteria: one criterion in 59 cases, two in 10 cases, three in three cases, and four in two cases. Only one laboratory criterion was alone responsible for the discordance in the unique case (pH < 7.10). The respective values for their sensitivity, specificity, and predictive values are in Table When considering the cut off point for the identification of organ dysfunction (maximum SOFA score ≥ 1 and ≤ 2) among the 75 discordant cases, 74 were classified as maternal near miss due to management criteria, and 59 women (78.6%) presented one or more organs with dysfunction. Therefore, the combined criteria for organ dysfunction and failure would be able to define 178 women as cases of maternal near miss (91.75%). Among the 16 cases still discordant (without organ dysfunction and/or failure), in 15 women one management criterion was identified  in five cases, red blood cell transfusion and use of vasoactive drugs in one case each), and in one case two criteria were identified . The management criteria seem very valuable as they potentially indicate where intervention occurred early enough to prevent organ failure (data not presented in table).Table This was the first study to evaluate the performance of laboratory and management criteria proposed by WHO for defining cases of maternal near miss against the organ dysfunction and failure identified by the maximum SOFA score as the gold standard ,18. The The prevalence of cases of SMM and/or maternal near miss is variable depending on the criteria used ,3,13. InIn this study, the combined criteria of WHO identified 194 cases of maternal near miss among 673 women with severe maternal morbidity or with potentially life threatening complications. The use of vasoactive drugs and/or mechanical ventilation were more frequent (88.9%) in women who died and this agrees with the findings from other studies showing that the need for hemodynamic and ventilatory support are directly associated with a worse prognosis and higher maternal mortality. This reflects the dysfunction or failure of the cardiovascular and respiratory systems ,19,24,29The WHO laboratory and management criteria for maternal near miss were able to identify all cases of maternal deaths and had a specificity of 70.4%. In a previous publication, the organ failure of one or more organs was present in 17 of 18 maternal deaths (89.4%), and the total maximum SOFA score ≥ 6 had a sensitivity of 88.9% and specificity of 91.1% [When comparing the WHO criteria with the organ failure based ones, we identified 76 discordant cases. There was disagreement in only one case of organ failure without WHO criteria for near miss. This case was a pregnant diabetic woman in hypoglycemic coma after misuse of insulin, which was reverted after a short period of time. At admission she had five points in the Glasgow Coma Scale . Considering the criteria used by WHO for evaluation of consciousness is the lowering of its level (Glasgow <10) within a minimum period of time (≥ 12 h), this case, despite the severity and potential for damage, could not therefore be classified as a maternal near miss.In contrast, 74 women were defined as maternal near miss by management criteria alone, representing 98.6% of discordant cases and 38.1% of all cases of near miss in this study. This result may have been influenced mainly by two ways. First, the cutoff point for defining the laboratory variables of near miss by WHO consists of values compatible with already established organ failure ,18,20, w2/PaO2 <200 mmHg) and a case with tachypnea (RR > 40 rpm) secondary to pulmonary congestion immediately after delivery, are equally defined as maternal near miss by WHO, however they are in fact different in terms of severity and prognosis. Among the management criteria evaluated, the need for postpartum hysterectomy may be the only one with no parallel in the scores assessing organ function, being present in nine out of the 16 discordant cases of near miss with no organ dysfunction.However, as we consider the clinical events or management criteria alone for evaluation, there is a trend to include less severe cases . As an eThe results of the current study showed that the occurrence of maternal near miss in this population using this new definition and criteria was around 13.5 per a thousand live births, an acceptable figure considering the health facility is a tertiary referral university hospital from a middle income country like Brazil, to where the vast majority of real complicated obstetric situations from the whole region are referred to. Some concern may however arise from the fact that SOFA score was used for the first time as the gold standard for identifying organ dysfunction as the ideal way for defining maternal near miss.The general impression from all the team involved in such initiative was that this classification is relatively easy to use, making it possible to differentiate the most severe cases among all obstetric complications. Therefore the group fully supported the recommendation of its feasibility to be used worldwide, especially considering that this should imply a corresponding appropriate standard of quality care or alternatively a referral to an appropriate health facility with capacity of dealing with that specific clinical situation. However, additional studies should be recommended and welcome, including a specific validation of the clinical criteria, how feasible would be the implementation at primary level through community health care workers, TBA, and a prospective large scale validation of these criteria. This probably would help health systems to better deal with actions towards the reduction of maternal mortality and morbidity as a Millennium Development Goal to be reached soon, and to build a real surveillance system for maternal near miss.This study provided an important contribution to the strategies in the management of complications associated with pregnancy, childbirth and postpartum. The first concerns the need for a standard definition of maternal of near miss, already identified, in order to be consistently used and allow comparable results from different contexts. The second refers to the ability of the criteria recently adopted by WHO in predicting maternal deaths and identify the more severe cases who have organ dysfunction or failure. Early recognition of more severe cases is the first step in taking specific measures and, consequently, reduction of maternal mortality, especially in developing settings.AUC: area under the curve; ICU: intensive care unit; IMV: invasive mechanical ventilation; LB: live births; MD: maternal death; MMR: maternal mortality ratio; MNM: maternal near miss; PLTC: potentially life threatening condition; RDS: respiratory distress syndrome; SMM: severe maternal morbidity; SOFA: Sequential Organ Failure Assessment; TBA: traditional birth attendant; TM-SOFA: total maximum Sequential Organ Failure Assessment; WHO: World Health Organization.The authors declare that they have no competing interests.JGC and JPS had the original idea for the study. AON, JGC and MAP were responsible for data collection and the plan of analysis. MHS performed the statistical analysis. All authors saw the output of analysis, drew the tables and commented on their significance. AON wrote the first version of the manuscript, then reviewed, amended and corrected by JGC. All authors read the final version of the manuscript and agreed with its content before submission.


Although there are inequalities in child health and survival in the Democratic Republic of Congo (DRC), the influence of distal determinants such as geographic location on children's nutritional status is still unclear. We investigate the impact of geographic location on child nutritional status by mapping the residual net effect of malnutrition while accounting for important risk factors.We examine spatial variation in under-five malnutrition with flexible geo-additive semi-parametric mixed model while simultaneously controlling for spatial dependence and possibly nonlinear effects of covariates within a simultaneous, coherent regression framework based on Markov Chain Monte Carlo techniques. Individual data records were constructed for children. Each record represents a child and consists of nutritional status information and a list of covariates. For the 8,992 children born within the last five years before the survey, 3,663 children have information on anthropometric measures.Our novel empirical approach is able to flexibly determine to what extent the substantial spatial pattern of malnutrition is driven by detectable factors such as socioeconomic factors and can be attributable to unmeasured factors such as conflicts, political, environmental and cultural factors.Although childhood malnutrition was more pronounced in all provinces of the DRC, after accounting for the location's effects, geographic differences were significant: malnutrition was significantly higher in rural areas compared to urban centres and this difference persisted after multiple adjustments. The findings suggest that models of nutritional intervention must be carefully specified with regard to residential location.Childhood malnutrition is spatially structured and rates remain very high in the provinces that rely on the mining industry and comparable to the level seen in Eastern provinces under conflicts. Even in provinces such as Bas-Congo that produce foods, childhood malnutrition is higher probably because of the economic decision to sell more than the population consumes. Improving maternal and child nutritional status is a prerequisite for achieving MDG 4, to reduce child mortality rate in the DRC. Malnutrition prevents children from reaching their full physical and mental potential. Health and physical consequences of prolonged states of malnourishment among children are: delay in their physical growth and motor development; lower intellectual quotient (IQ), greater behavioural problems and deficient social skills; susceptibility to contracting diseases ,2. FurthThe majority of studies on child nutritional status have described prevalence of malnutrition among under-five children and analyzed socioeconomic, demographic and cultural factors associated with child malnutrition in SSA -7. HowevOur study aims to investigate the impact of geographic location as a proxy for distal factors and their influences on nutritional status of children. The province of residence is taken as a modifiable variable which can help explain the variation of malnutrition among children between different provinces.Four reasons justify the interest of this study: first, geographic location is an important modifier of known predictors of malnutrition and is associated with food security and accessibility, especially in the context of conflict affected country such as the DRC.Second, through the use of our empirical methods we can investigate inequalities in childhood malnutrition by mapping the residual net effect of spatial pattern of malnutrition more flexibly than most previous work.Third, the methods also allow us to investigate non-linear effects of some risk factors prior to and after controlling for the socioeconomic determinants. This enables us to determine to what extent the substantial spatial pattern of malnutrition is driven by socioeconomic factors or point to the influence of omitted variables with strong spatial structure or possibly conflicts, political or environmental and cultural factors or even epidemiological processes that account for this spatial structure.Fourth, the worsening socioeconomic, cultural and political context of the DRC needs to be investigated. The DRC is one of the SSA countries characterised by extreme poverty, high incidence of childhood diseases, high mortality and poor infrastructure: 75 percent of people are malnourished ; hundred2) in Africa and with immense natural resources distributed across its 11 provinces. It is, with the population of more than 68 million, the eighteenth most populous nation in the world, and the fourth most populous nation in Africa, 62 percent of which are under the age of fifteen.The DRC is the third largest country  in 1999 was 78 US Dollar. The GDP has since declined. External debt at the end of 2000 was 12.9 billion US$ which, according to the Word Bank, equals roughly 280 percent of the GDP and to 900 percent of the exports. The accumulated debt and severe economic decline are due to both recent war and decades of corruption and economic mismanagement  of the x-axis. Such a spline can be written in terms of a linear combination B-spline basis functions Bm(x), i.e.Several alternatives are available as smoothness priors for the unknown functions xj), see . We use These basis functions have finite support on four neighbouring intervals of the grid, and are zero elsewhere. A comparably small number of knots  is chosen to ensure enough flexibility in combination with a roughness penalty based on second order difference of adjacent B-spline coefficients to guarantee sufficient smoothness of the fitted curves. In our Bayesian approach this corresponds to second order random walksum ~ N. The variance parameter τ2 controls the amount of smoothness, and is also estimated from the data. More details on Bayesian P-Splines can be found in [with Gaussian errors found in . Note thstr fand unstrf. For the spatially correlated effect str f(s), s = 1, ... S, we choose Markov random field priors common in spatial statistics. These priors reflect spatial neighbourhood relationships. For geographical data one usually assumes that two sites or regions s and r are neighbours if they share a common boundary. Then a spatial extension of random walk models leads to the conditional, spatially autoregressive specificationWe now turn our attention to the spatial effects s Nis the number of adjacent regions, and r ∈ ∂s denotes that region r is a neighbour of region s. Thus the  mean of str(s) fis an average of function evaluations str(s) fof neighbouring regions. Again the variance 2τstr controls the degree of smoothness.where unstr fa common assumption is that the parameters unstr(s) fare i.i.d. GaussianFor a spatially uncorrelated (unstructured) effect 2τj, j = 1,...,p, str, unstr, are also considered as unknown and estimated simultaneously with corresponding unknown functions jf. Therefore, hyper-priors are assigned to them in a second stage of the hierarchy by highly dispersed inverse gamma distributions p(τ2j) ~ IG with known hyper-parameters j aand jb. For model choice, we routinely used the Deviance Information Criterion (DIC) developed in [Variance or smoothness parameters loped in , as a meThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/261/prepub


Throughout the past 50 years mental health services have aimed to provide and improve high quality inpatient care. It is not clear whether there has been improvement as service users and nursing staff have both expressed frustration at the lack of therapeutic activities. In particular, it may be that the changing levels of symptoms over the past 50 years may affect engagement with ward activities.Eight wards in a health care trust in London serving an inner city and urban populations participated. Data were collected on participation in activities and 116 service users’ perceptions of acute care as well as clinical factors.Less time was spent participating in activities today than 50 years ago, while one quarter of service users reported taking part in no activities at all. Uptake of activities was related to more positive service user perceptions of the wards. Symptom severity did not impact the frequency of participation in activities, although those who took part in no activities at all had higher negative symptoms scores.Service users’ uptake of activities was not related to the severity of their illness. This belies the belief that the acutely ill cannot take part in meaningful activities. This study supports the view that more therapeutic activities could be taken up by the acutely ill and are in fact appreciated. Growing concerns about the poor living conditions in asylums and changing attitudes toward mental illness and institutionalisation have led to the gradual transition from the long-term hospitalisation of those with mental health problems to an increase in community treatment. However, hospitalisation for acute episodes is still an indispensable feature of mental health care and service users continue to complain about the quality of inpatient care . Around Although much has changed in the nature of inpatient provision with the move away from the hospital asylum, the essential association between social interaction and better clinical outcome continued to be reported across the next two decades  as has tA Sainsbury Centre for Mental Health  report pWe investigate the hypothesis that levels of activity are associated with clinical functioning just as they were 50 years ago and that activity and one-to-one contact continue to be closely correlated with service users’ satisfaction with inpatient care.www.perceive.iop.kcl.ac.uk. Data for the current paper were collected over a 1-month period for each of eight acute inpatient wards.The present study is a cross-sectional exploration of the activities on inpatient wards that was gathered as baseline data preparatory to an inpatient activity intervention in a large Trust serving both inner city and suburban communities. A detailed description of the whole programme of research is given on All service users who were on the ward for at least 7 days, spoke English and were able to consent were eligible from wards providing all acute care for a defined geographical area involving both inner city and inner urban areas. Ward staff introduced the researchers to service users individually, or at ward community meetings. After gaining informed consent, assessments were carried out in ward offices or other private rooms on the ward with just the researcher and service user present, as approved by the Bromley Ethics Committee.Global assessment of functioning  is a 100Positive and negative syndrome scale: PANSS  a 30-iteNurses’ observational scale for inpatient evaluation: NOSIE , a 12-itClient services receipt inventory-inpatient; CITRINE  gathers n = 40) was high . An example of an item is ‘Staff give me medication instead of talking to me’.Views on inpatient care: VOICE  is a 19-Information regarding the number and grade of staff on duty, the time nurses spent in one-on-one observations with service users and the percentage service users under a section of the Mental Health Act constitutes the ward level data. The number of incidents of self-harm, suicide attempt, violence and aggression was also recorded over a 30-day period.Data were analysed using SPSS version 18 and STATA v.10. Simple descriptive statistics were used to examine differences in numbers of group activities and one-to-one contacts by service user demographic characteristics, the inpatient setting and the associations of these with clinical measures of symptoms , nurse observations (NOSIE) and service user views (VOICE). Statistically significant bivariate associations were further explored using generalised estimating equations to fit a poisson regression model with the frequency spent in either group activity or one-to-one time as the dependent variable. As patients on the same ward were likely to be more similar in terms of exposure to group and one-to-one contacts these data were treated as clustered at ward level.Eight single-sex wards  were included in this analysis. With the exception of a ward-in-the community that had a specific remit to provide crisis care for women, all were typical of hospital-based inpatient care. The ward in the community falls under the remit of inpatient services in the trust so it was, therefore, included. Ward sizes range from 8 to 25 beds with an overall average of 18 beds per ward. Staffing levels do not vary greatly by ward with, on average 0.3 (SD 0.03) staff per bed during the day . An additional 1.3 staff per ward are employed from 9 am to 5 pm. There are slightly fewer staff on the wards at night, around 0.2 (SD 0.04) staff per bed. A total of 257 patients were admitted to these wards over a 30-day period.There were nine violent incidents (four on one ward), and three incidents involving self-harm (one on each of three wards). There was no significant difference between wards in terms of participants’ acuity , level of functioning  or satisfaction with care between the wards.n = 26) or did not want to participate (n = 49). The average age of participants was 39 years (SD 13) and 47 % (n = 54) were women (average age for women = 41 years). Seventeen (15 %) were married or had a partner. Sixty-four were white (56 %) with the remaining 50  belonging to black or ethnic minority communities. Forty-three participants (38 %) had some further education, and 31 (27 %) were in employment. The average length of stay was 93 days (median 47) with a range of 5 days to 3 years and 3 months. Over half of the patients in the current study were diagnosed with psychotic  or bipolar  disorders, 13 % with mood disorders  and personality disorder , substance abuse  and other disorders . The remaining two individuals did not give consent for us to look at their medical records. The mean PANSS total score was 55.36 (SD 12.9) with that for the positive subscale being 12.41 (SD 4.1) and 12.33 (SD 4.5) on the negative subscale. Just under a third (n = 33) described delusions rated at least moderate severity (a rating of four or more on the PANSS).116 of the eligible service users on the eight wards agreed to participate in the study. This constituted 60 % of all people eligible on the ward during the data collection period; the remaining service users were either too ill to be approached (n = 79) of all this activity involved formal therapy , 32 % (n = 142) were attendance at community/daily planning meetings and 49 % (215) were classed as other activities . Looked at from the perspective of individual participants, over a quarter  did not report participating in any formal activity. Of the 83 who took part in at least one activity, 42 (51 %) attended formal therapy, 42 had attended at least one community meeting and 61 (73 %) were engaged in activities such as bingo, discussion groups and arts and crafts. Taken together participation in group activities occupied on average, only 3.5 h per week.Across all 8 wards, 116 participants took part in 436 group activities organised by ward staff over the previous 7 days, an average of 3.8 (SD 5.1) per participant. Eighteen per cent , but one ward, the female-only ward-in-the-community, had very high rates of attendance across all categories. If this ward is excluded as a sensitivity analysis then the discrepancy in activity between wards remains  but cannot be explained by whether the ward was male only  or female only .The numbers of activities attended by each participant varied considerably between wards, from an average of 14.8 (SD 8.1) to 1.4 (2.4). This variability in attendance between wards was statistically significant . Again, there was a high frequency in the ward in the community and when this was removed in a sensitivity analysis the differences were no longer significant (mean 6.0 SD 3.4–2.1 SD 1.9).In addition to group activities, participants reported a mean of 4.6 (SD 4.9) one-to-one sessions with mental health staff over the past week, with a range of 0–25. The majority of these were with nursing staff. Eighteen participants (16 %) reported that they had no meaningful contacts at all. The total amount of time spent in one-to-one sessions was a reported mean of 50.3 (SD 54.6) minutes per week and this differed between wards . They also reported significantly fewer one-to-one sessions with staff . There was no statistically significant correlation between levels of participation in group activity and GAF, NOSIE or PANSS positive or negative symptoms. However, participants who reported a complete absence of participation in activity had significantly higher average PANSS negative symptom scores than those who reported attending at least one group in the week . Individual negative symptoms that were associated with an absence of activity were emotional withdrawal, passive social withdrawal and difficulty with abstract thinking.Of those taking part in activities, participants with a diagnosis of a psychotic condition reported taking part in fewer group activities than those with other diagnoses, though this was not statistically significant  and low GAF function scores . NOSIE scores, which were a nurse-based measure of inappropriate behaviour, were also associated with fewer one-to-one contacts .Fewer one-to-one contacts with staff was correlated with higher PANSS negative symptoms .When these analyses were run separately for men and women these findings were broadly replicated. PANSS negative symptoms were associated with lower rates of one-to-one contact and those scoring high on the NOSIE reported fewer one-to-one contacts with staff  and with the number of group activities attended . Four VOICE items ask specifically about satisfaction with ward activity, and all show significant negative correlations (i.e. reflecting dissatisfaction) with levels of activity  and one-to-one sessions: ‘staff are available to talk to when I need them’ ‘activities on the ward meet my needs’; ‘I find one-to-one time useful’ and ‘I find sharing experiences in a group useful’. The item ‘I find one-to-one time useful’ also has a negative correlation with number of contacts .VOICE total score reflecting perceptions of the quality of the ward was correlated with the frequency of one-to-one staff contact (p = 0.04) and lower participation in activities .Tests for gender associations showed that high VOICE scores reflecting dissatisfaction with the quality of care on wards were associated in women with fewer one-to-one contacts  p < 0.01] but did not differ in terms of PANSS or NOISE scores or number of activities or contacts with staff.Formally detained service users did not differ from those who were in hospital voluntarily on any measure of activity or one-to-one contact. Longer stay patients  were found to have poorer levels of function [GAF-F mean 37.5 SD 6.8 vs. 42.7 SD 9.0, The bivariate associations for the frequency of contacts were further explored through generalised estimating equations with total number of contacts treated as clustered by ward. Table A great deal of effort, time and money has gone into improving mental health services over the past 50 years and few would doubt the importance of activity and occupation in recovery. It would be expected, therefore, that of all the changes in inpatient settings, the delivery of activity both therapeutic and leisure would be most prominent.r = 0.494), poverty of speech (r = 0.472) and social withdrawal (r = 0.634). In contrast, activity was not correlated with either incoherence of speech (r = 0.130) or delusions (r = −0.077).The Three Hospitals Study  carried In our study, we also observed a considerable variation between wards in the amount of activity and number of one-to-one contacts with staff and even after the sensitivity analysis there were still significant differences between wards. This variation did not seem to be explained by service user characteristics such as diagnosis, gender, ethnicity or length of stay. Considerably less time was spent in all forms of activity than in even the least active of the three hospitals 50 years ago at just over 3.5 h per week. Fully a quarter of patients reported no activities at all, this despite the much higher staff to patient ratio than in the 1960s. Curson et al.  replicatAlthough mental health problems in our participants did not prove to be a barrier to taking part in activities, the explanation for the apparent dearth of activity lies in part with the severity of illness in the inpatient settings with the nurses immersed in immediate crisis management or dealing with the demands of paperwork and administrative tasks. Nurses in our study also reported gaps in activity due to staff shortages or absence so that the staff member skilled in running an activity was not available. This puts strain on the nurses who are on the ward, and bank staff may not have the knowledge to run the groups and neither do they know the patients as well. Furthermore, it is no longer common practice to involve service users in activities such as grounds keeping.One of the reasons often given by staff for not providing or running groups on acute wards is that service users are too ill to appreciate or take part in structured activities. However, as with the earlier studies we found no significant association between activity and positive symptoms or general distress, and the association with negative symptoms was only significant for the relatively small number of patients who took part in no activity at all. Counts of group activity were correlated with the frequency of one-to-one staff contact which also was not correlated with positive symptoms and only weakly associated with negative symptoms.Importantly, both activity and one-to-one sessions were associated with service users’ perceptions of the quality of care. In recent times, across all areas of health care, engaging stakeholders in their care has been seen as an important step in improving care. These findings demonstrate that even those on an acute ward can engage in and appreciate the activities provided and the meaningful time they can have with staff which is reflected in their perceptions of the ward. Moreover, this reiterates the importance of involving our clients in their care planning as their contributions and expertise have proven value.Our study is a snapshot of 1 week in the life of a small number of acute inpatient wards in one mental health Trust that serves a largely urban and inner city community and may not be representative of other Trusts. Furthermore, with a 40 % being either too ill to consent or refusing to participate, our sample may not be representative. Being a cross-sectional study, we only report associations: it is not possible to determine the causal direction of the association between rates of contact with staff and negative symptoms or dissatisfaction with services.Since our measures were based on service user self-report, it is possible that taking part in therapeutic activities is underreported. We did not measure informal leisure activities between service users and although not measured directly, we did observe brief casual encounters between nurses and service users throughout the day and these everyday exchanges certainly contribute to the ward atmosphere and are normalising practices that mitigate institutionalisation.