Thymus longicaulis C. Presl, collected in Campania and in Sicily, and two samples of Thymus pulegioides L. from the same regions, were extracted by hydrodistillation and analyzed. Considering the four oils together, seventy-eight different compounds were identified: 57 for Thymus longicaulis from Sicily , 40 for Thymus longicaulis from Campania (91.5% of the oil), 39 for Thymus pulegioides from Sicily (92.5% of the oil) and 29 for Thymus pulegioides from Campania (90.1% of the oil). The composition of the oils is different, although the most abundant components are identical in T. pulegioides. The essential oils showed antibacterial activity against eight selected microorganisms.The volatile constituents of the aerial parts of two samples of  Thymus is noteworthy for the numerous species and varieties of wild-growing plants. This genus comprises about 400 species of perennial aromatic, evergreen or semi-evergreen herbaceous plants with many subspecies, varieties, subvarieties and forms; the species are endemic and widely distributed, growing in the temperate and cold regions of the Old World, being native to Southern Europe and diffused in particular in the Mediterranean area. The plants are extensively used, fresh and dried, as a culinary herb. Their essential oils are utilized as flavour ingredients in a wide variety of food, beverage and confectionery products, as well as in perfumery for the scenting of soaps and lotions. Because of their antiseptic, antispasmodic and antimicrobial properties, they are also used for medicinal purposes  and a standardized inoculum of the correspondent test microorganism (standard 0.5 McFarland). Plates were incubated at 37 °C for 24 h. The analyses were carried out in triplicate and the results are expressed as mean ± SD. Control disks with 10 μL of dimethyl sulfoxide showed no inhibition in a preliminary test. Gentamycin (10 μg) and Tetraciclyn (15 μg) served as positive control on Gram– and Gram+ bacteria, respectively.The antimicrobial activity of the oil was evaluated by the n method  against T. pulegioides from different localities, it was of interest to continue research on its chemical polymorphism. Our data reveals that the essential oils studied, from two different localities, belong to a thymol chemotype with an high percentage of p-cymene. The two studied oils of Thymus longicaulis, even if characterized by a prevalence of the monoterpene fraction, are quite different with regards to the relative percentages of monoterpene hydrocarbons and oxygenated monoterpenes and the data obtained serve to highlight the chemical polymorphism of T. longicaulis. Essential oils are extensively used as flavour ingredient in a wide variety of food, beverage and confectionary products. This use and the antibacterial activity of these substances make them potential natural preservatives in food industry.Considering the remarkable variations reported for the essential oil of


Background: The ageing process involves a natural degeneration of physiological function and can imply life constraints, namely during activities of daily life (ADL). Walking can be strongly affected by strength, gait, and balance changes, which affect quality of life. The quality of life of the older adult is associated with available solutions that contribute to an active and safe ageing process. Most of these solutions involve technical aids that should be adapted to older adults’ conditions. Aim: To identify the advantages and disadvantages of two-wheeled walkers and of two different self-locking systems designed and developed by the authors. Methods: Two studies were performed based on the possible walker combinations used, using a walker with no wheels , a two-wheeled walker with self-locking mechanism made of gears and a spring (Approach 1), and a two-wheeled walker with a self-locking mechanism which uses a single spring (Approach 2). These combinations were tested in two quasi-experimental studies with pre–post test design. Results: No significant differences in duration, gait speed, and Expanded Timed Get Up and Go (ETGUG) were found between the walkers, but there was a marginally significant difference in Physiological Cost Index (PCIs), which means that the energetic cost with Approach 1 was greater than that with Approach 2. Users reported a feeling of insecurity and more weight, although no significant differences were observed and they were found to be equivalent in terms of safety. Study 2 found an improvement in duration and gait speed in the ETGUG between the different types of self-locking systems. Conclusions: The PCI is higher in the two-wheeled walker models and with the self-locking mechanism. Approach 2 did not show better conditions of use than the other two walkers, and participants did not highlight its braking system. Although safety is similar among the three walkers, further studies are needed, and the braking system of the two-wheeled walker needs to be improved (Approach 2). The population over 65 years of age seems to be growing fast all over the world , generatChanges associated with poor functional capacity and loss of independence are mainly related to physical and psychological decline. Joint function decline and a decrease in musculoskeletal capacity can contribute to the establishment of gait disorders, namely claudication, impaired gait pattern, and impaired ambulation . ProgresSome functions and systems are required to be intact for normal gait , like loIt is estimated that around 30–40% of older people aged above 65 years can have gait changes, which can lead to falls . AnticipThe necessity and the use of assistive devices increase with age, ranging from 14% to 18% in the healthy senior population to 45% to 96% in frail older adults [Currently, various technical aids that support walking are commercially available, including the so-called “walker” category. Walkers offer a wider and more stable base than other devices (canes and crutches). These devices are available in many sizes and are adjustable. Also, there are walkers with and without wheels, and special types of walkers . They caThere are fixed or articulated walkers with strategically placed fittings, with different structures and materials such as aluminum or light steel, with different slopes and forms of ground support, namely through two or four non-slip wheels. Some feature breaking systems with cables located on the handles; others have different accessories, from lanterns next to the handle, to baskets to transport personal objects; cushioned accent presentations are also possible features. Others show various adjustments and customizations, such as foldable structures and adjustable height, adjustable handles of independent regulation, and/or ergonomic handles. Nevertheless, no equipment has been found that integrates a self-locking wheel-drive system.Many wheeled walkers have important limitations, such as the need to decrease gait speed when bypassing an obstacle or when there is the need to change direction . The eldThe use of walkers is a way to achieve independence and quality of life, for which factors like stability and balance are fundamental . NowadayThe most used walkers seem to be conventional walkers, which have the important feature of specific ground contact configuration . The claThe innovation presented here allows the walker to be braked whenever certain pressure is made on a component, avoiding the occurrence of falls due to forward imbalance by blocking the wheels, showing a competitive advantage for the safety of the user as compared to the available equipment on the market. Two different approaches for the self-locking systems were developed. This paper has the purpose of identifying the advantages and disadvantages specified by older adult users that experienced the self-locking systems through the performance of two quasi-experimental studies with a pre–post test design.The application of self-locking mechanisms for walkers is an innovative proposal, since this equipment is intended to aid people with mobility limitations due to weakness of lower limbs, which affects walking activities. In relation to current walkers with wheels, which slide as the progression of ambulation occurs due to the presence of front wheels, the innovative solution must guarantee that it is not necessary to raise the structure in order to walk. It also must allow, at any time, the locking of the walker whenever a certain sensation of imbalance is felt by the user. This imbalance is, in general, accompanied by an increase in pressure in the hand support of the walker. The new solutions must allow that patients with changes in the function of upper limbs and, at the same time, with changes in the mobility of lower limbs, are able to use a walker that integrates a self-locking system to help ambulation, strengthening safety measures.This self-locking walker mechanism  consistsThe self-locking mechanism, shown in This new system can be easily assembled on each of the front legs of the walker. The system features are coupled on a new removable part with a diameter greater than that of the walker leg (8). The connection between the walker leg and the system is guaranteed through a locking pin at both ends. The unidirectional wheel is attached closer to the extremity of the removable part, through a shaft (5), and the side sliding is locked with two washers ((6) and (14)). Two sliding blocks, one interior (7) and other exterior (13), matching the part surface, ensure the correct position of the wheel, allowing the necessary axial sliding of the new feature. The compression spring (11) is blocked in the lower extremity with a stopper fixed inside (12). This stopper has a through hole with the same diameter of the shaft, which holds it in the proper position. In addition, it increases the contact surface of the shaft, reducing the cutting effect in the holes of the assembled part, where it crosses the shaft. The upper end of the stopper has a circular section with the inner diameter of the helical spring, working as a limiter. In the upper extremity, the compression spring is blocked in a spacer newly fixed with bolts ((2) and (10)). The spacer consists of two cylindrical wafers: a lower one (3), which makes contact with the end of the spring, and an upper one (1), with a central thread and a feed screw (9), with the end fixed on the lower wafer. This screw ensures the spacing of the two wafers, allowing the adjustment of the spring stiffness and thus the stiffness of the system. This means that the system can be adjusted to the user, namely to the force required to activate the spring. In fact, when a certain pressure is applied to the “handles” of the walker, the specific force is transmitted to the helical compression spring (11). If the applied pressure is sufficient, the spring compresses and the wheel assembly  slides vertically through the two lateral and longitudinal holes of the new system. As the wheel assembly moves vertically, the lower extremity of the system, where a rubber feet is placed (15), moves down and contacts with the floor, as shown in the Just like Approach 1, this self-locking mechanism eliminates the possibility for the walker to inadvertently roll on a sloping floor or, in other circumstances, prevent the walker’s unwitting movement. However, the lightness and simplicity of these components makes the assembly lighter, eliminating the disadvantage identified in the first system. Furthermore, since the system can be applied independently on each wheel, it makes it more versatile and easy to carry, and may even be applied to the rear wheels, which was an impossibility on the Approach 1.Both mechanisms, Approach 1 and Approach 2, allow mobility without having to raise the walker, in order to progress to ambulation. At the same time, they both prevent unwanted movement by automatic blocking of the system when certain pressure occurs. These devices protect the user from any unbalance, contributing to an increase in safety. Additionally, both systems cumulatively present a structure that is perfectly adjustable and adaptable, just like classic walkers, and easy to carry and sanitize. Nevertheless, the prototypes developed need clinical validation from a functional point of view. This topic is covered in The convenience sample was composed of older adults who used a walker and lived in nursing homes. Variables Expanded Times Up and Go (ETGUG) duration, gait speed, and energetic cost were assessed. From the users’ point of view, we established a comparison between the two solutions developed for the self-locking system: (1) Approach 1—using gears and a spring, and (2) Approach 2—using a single spring and the use of no self-locking system. Furthermore, advantages and disadvantages were identified for the solutions developed.n = 18) of older users with a fixed walker and which were institutionalized in nursing homes. The data collection tool included: (1) Questions for sociodemographic characterization and clinical evaluation, based on the Satisfaction Assessment Scale in relation to a Technical Assistance (version 2.0), and (2) the ETGUG test, which included the action of walking with the classic fixed walker (FW) and the innovative two-wheeled walker with a self-locking mechanism , for a total distance of 20 meters, in which the test was timed. There were measures for cardiac frequency and blood pressure before the test (at rest) and at the end of it. This data was used to calculate the speed  and, subsequently, the Physiological Cost Index /(speed)). The PCI was calculated for each course of the ETGUG test with each walker. All participants had a period of adaptation to the KW before the completion of the ETGUG. The users’ opinion regarding the innovative proposal of the two-wheeled walker with a self-locking mechanism , was obtained through an open response questionnaire developed by the authors.To test the walker with this system, a quasi-experimental study was developed , using a non-probabilistic sample obtained by convenience . The convenience sample was composed of 40 older people living in nursing homes who used a walker. Among other variables, the participants had to perform the Expanded Timed Up and Go (ETGUG) test with the three types of walkers , and four-wheeled walkers) to assess gait, speed, and fall risk. Satisfaction was also assessed with the previously mentioned questionnaire. According to The participants’ perception regarding satisfaction of use suggests greater satisfaction with the FW in terms of weight (55.6%), comfort (66.6%), and effectiveness (66.6%) compared to the KW. Regarding ease of use, participants expressed more satisfaction with the KW (66.6%), as stability and security were considered more important for them (78.4%). As for personal opinion, respondents mentioned the following disadvantage: the KW was heavier, larger, and more insecure because it had wheels. On the other hand, the reported advantages were that they moved more quickly because they had a wheeled walker, which meant less strength exertion with the arms, and that the locking system was important, since it prevented falling events.p = 0.435), gait speed , and ETGUG for both walkers, but a marginally significant difference was found in PCIs . This means that the energetic cost with KW was higher than that with FW.No statistically significant differences were found between duration  and in the final heart rate value . However, significant differences were found in duration  and gait speed  in the ETGUG between the three types of walkers. Regarding user satisfaction for the three walkers, significant differences were found in terms of stability and safety  and ease of use , as summarized in Preliminary results showed no differences in PCI for the three walkers  did not show better conditions of use in comparison to the other two walkers studied, but the wheel-locking system was highlighted by the participants. There is a need for further studies and the improvement of the wheel-locking system of the two-wheeled walker (Approach 2).Currently, a variety of technical aids that support walking, such as walkers, are commercially available. There are fixed or articulated walkers with strategically placed fittings, with different structures and materials , and with different slopes and forms of ground support, namely through two or four non-slip wheels. The equipment has a diverse range of characteristics, including different removable accessories like lights next to the handles, baskets for the transport of personal objects, or even cushioned seats. Some also feature various adjustable and customizable parts allowing for height adjustment, including handles of independent regulation and/or ergonomic handles.Devices like walkers are intended to adapt to the needs of the population, optimizing use through less expenditure of energy with greater (positive) outcomes. The integration of a self-locking wheel-drive system is particularly important for preventing falls, which are a major issue in vulnerable populations like the elderly. In this paper, two different approaches to self-locking wheel-drive systems were presented, and the advantages and disadvantages were demonstrated for each. Both approaches allow walker immobilization after a certain pressure is exerted on the handle, avoiding falls due to forward imbalance. This represents a competitive advantage for the safety of the user with respect to the equipment that is currently on the market.


Background: The relative age effect is essential throughout all of the talent selection processes in sports, especially during adolescence, which leaves fewer athletes within each cohort that are born late in the selected year. The aim of the present study was to examine the role of relative age in anthropometric and physical performance characteristics of youth handball players by gender. Methods: The sample that was selected included 47 participants . The data collection included anthropometric, body compositions parameters, and physical performance levels. Results: There was a significantly higher representation of players in the first semester in comparison with the second semester, for all of the gender groups, except for the selected male players. In males, statistically significant differences were found in height, sitting height, weight, wingspan, arm and leg circumferences, and in throws speed (in support and in suspension) between those players that were born in the first and second semester. Conclusion: The results confirmed an effect of relative age in the players born in 2002 that were selected to participate in the Spanish Championship, which was different for males and females. In spite of this effect, which only appeared in females, significant differences in the anthropometric and physical conditions appeared in the male players. Over recent years, talent identification has produced great interest among coaches and sport scientists. The concept of ‘talent’ involves both a genetic predisposition and a capacity to improve performance through intensive practice . DiffereAnthropometric parameters and physical and motor test have been identified as fundamental in order to determine the success of the performance in handball. Thus, some of the previous studies have provided the specific performance measures that could be the most useful . RegardiThe relative age effect (RAE) is essential throughout the talent selection processes in team sports, such as ice hockey, football, and handball ,10, espeWhile the RAE is often large at the younger levels of sports, the effect is smaller among adults, and some researchers have even reported a possible inverse RAE . In team2; and VO2max: 49.21 ± 3.18 mL·min·kg) that took part in the study were born in the first constituent year. Therefore, it was assumed that the selected players were to be divided by their semesters of birth. The sample included 47  handball players. All of the subjects that took part in the study were field-players. The goalkeepers were evaluated but their data was excluded for this analysis because of the specific required abilities [All of the selected players , arm span (0.1 cm), hand span (0.1 mm), biacromial span (0.1 cm), arm perimeter (0.1 cm), leg perimeter (0.1 cm), body fat-free mass, and body fat mass were measured through the recommended standardized techniques. The arm span, biacromial span, arm relaxed perimeter, and leg perimeter were assessed using a tape [Firstly, the height , sitting height , body mass , body mass index  and abalakov jump (ABK), a contact platform was used . Two maximal jumps of each type were recorded, with 30 s rest between them. The attempt in which the highest jump length or height was obtained was taken for further analysis.−1) was assessed using a speed gun  held 1 m to the side of the goal post, and perpendicular to the player. The players completed a maximal jump shot with 3-step run-up from 9 m. In addition, a medicine ball throw was carried out where subject’s knee had to be parallel. The weight of the ball was 3 kg. The distance (m) was measured from the front of the knee to where the ball had landed. In both of the tests, the participants threw the ball twice as far as possible, and the furthest attempt was used for the analysis.Throwing tests: The throwing velocity (m·s2max) in mL·kg·min−1 [Aerobic capacity tests: The ‘Course Navette’ test was used to assess player’s aerobic capacity. The test consisted of 20 m shuttle runs performed at increasing velocities. The highest velocity that was covered during the tests was considered as the testing score and was used to calculate the maximal oxygen uptake  v.20 for MAC . Firstly, the normality and homoscedasticity were explored. To study the relative age effect, a Chi-Square test was performed. The absolute and relative data were reported. To analyze the differences in the anthropometric and physical performance characteristics, a t-test was carried out for the impaired samples. The mean and a 95% coefficient interval (95% CI) were reported. The level of error was set at 5%, considering the differences with a It is essential to take into account the RAE in the talent identification processes in handball , especiaIn addition, the general female players were distributed unequally with a higher representation of players born in the first semester. In this case, the selected female players presented an unequal distribution, with more players born early in the year. There were not significant differences in anthropometric and physical conditioning between selected female players born in the both semesters. The maturation process in the female athletes finished before the male athletes, when compared , and theThe anthropometric dimensions used to be the selection criteria that was used in order to select players among the youth handball players . In the However, these could be affected by the maturity state and not take into account the other important performance factors, such as the cognitive ability or emotional competence . BiologiRegarding the birth distribution that has been observed in the present study, studies on RAE in handball are rare and there are plenty that show a RAE in handball sport ,46,47,48The female players seemed to be less likely than the male players to show RAE. Thus, as previous studies showed , the effThe present study contains some limitations. It shows data for the general players from the championship who had already been selected. Thus, there was a need to compare the general distribution of players from 2002 (14 years) that played handball in Spain. Secondly, previous studies had shown a direct correlation between the RAE and the specific position in the court ,47,53. IThe results confirm an effect of the relative age in the players that were born in 2002 and that were selected to participate in the Spanish Championship that was celebrated in 2016, were different in males compared with females. Regarding the selected sample, in spite of this effect that only appeared in females, significant differences in anthropometric and physical conditions appeared in male players. Education about the existence and impact of RAE should be taken into account by those who are responsible for selecting players, by delaying competition until later and de-emphasising the ‘cultural need’ to be the best at the developmental stages. Additionally, they should design and use strategies that can reduce the consequences of this phenomenon.


Choosing Wisely campaign highlights the importance of clinical reasoning abilities for competent and reflective physicians. The principles of this campaign should be addressed in undergraduate medical education. Recent research suggests that answering questions on important steps in patient management promotes knowledge retention. It is less clear whether increasing the authenticity of educational material by the inclusion of videos further enhances learning outcome.The In a prospective randomised controlled cross-over study, we assessed whether repeated video-based testing is more effective than repeated text-based testing in training students to choose appropriate diagnostic tests, arrive at correct diagnoses and identify advisable therapies. Following an entry exam, fourth-year undergraduate medical students attended 10 weekly computer-based seminars during which they studied patient case histories. Each case contained five key feature questions (items) on the diagnosis and treatment of the presented patient. Students were randomly allocated to read text cases (control condition) or watch videos (intervention), and assignment to either text or video was switched between groups every week. Using a within-subjects design, student performance on video-based and text-based items was assessed 13 weeks (exit exam) and 9 months (retention test) after the first day of term. The primary outcome was the within-subject difference in performance on video-based and text-based items in the exit exam.p = 0.026) but not the retention test . An additional Bayesian analysis of this retention test suggested that video-based training is marginally more effective than text-based training in the long term (Bayes factor 2.36). Regardless of presentation format, student responses revealed a high prevalence of erroneous beliefs that, if applied to the clinical context, could place patients at risk.Of 125 eligible students, 93 provided data for all three exams (response rate 74.4%). Percent scores were significantly higher for video-based than for text-based items in the exit exam  contains supplementary material, which is available to authorized users. Choosing Wisely campaign has added another important feature to the professional approach to patient management [Choosing Wisely campaign. Vice versa, these recommendations result from a stringent application of the principles of clinical reasoning. Thus, the choice of teaching formats that lend themselves to the discussion of these recommendations should be guided by a discussion of instructional formats used to address clinical reasoning itself. One effective approach to enhancing the complex cognitive functions related to clinical reasoning is case-based learning [One of the most important aims of undergraduate medical education is to enable future physicians to arrive at correct diagnoses and treatment recommendations based on the results of appropriate diagnostic tests. Making correct decisions is at least as important as avoiding unnecessary tests and incorrect diagnoses, and both need to be considered in the context of clinical reasoning . Recentlnagement , 3. In onagement  advise anagement , 6. Clinlearning , which ilearning  or at thlearning . Given tlearning  has beenlearning , 12.p < 0.001).Digital interventions in medical education need to be informed by educational and psychological research. One recent example of this type of ‘translational research’ in medical education is the growing body of evidence showing that test-enhanced learning enhances knowledge and skills retention in undergraduate medical students. The basic idea is that questions can be used to stimulate learning processes , 14. ThuWhile this study showed that repeated case-based testing with key feature questions is more effective than repeated case-based study of the same material, the overall retention of procedural knowledge related to clinical reasoning at the 6-month follow-up was suboptimal. One reason might be that all the case-based material used in that study was presented as text on computer screens. While text can easily be scanned for relevant information, students might have found it harder to immerse in the clinical problem presented. This assumption is supported by psychological research dating back to 1975, when Godden and Baddeley demonstrated the importance of similarities between the learning environment and situations in which the learnt material needs to be recalled . In addiChoosing Wisely recommendations can ideally be addressed in key feature questions. To our knowledge, no previous study has reported student performance in this context. In addition, incorrect answers to key feature questions have rarely been analysed although they may reveal specific shortcomings in teaching that could be easily remedied.In summary, test-enhanced learning with video-based, computer-assisted exams could be an efficient way of enhancing student performance with regard to making the right choices about diagnostic tests and taking appropriate therapeutic action. In addition, the avoidance of unnecessary interventions as set out in the This randomised cross-over study was designed to test the hypothesis that repeated testing with video-based key feature questions produces superior retention of procedural knowledge related to clinical reasoning compared to repeated testing with text-based key feature questions. The second aim was to investigate the effects of (non) alignment between presentation formats in the learning phase and subsequent exams on student performance. The third aim of this study was to identify common errors evident in student responses to key feature questions.This was a randomised, controlled, non-blinded cross-over study involving fourth-year undergraduate medical students. At Göttingen Medical School, clinical reasoning is mainly addressed in study years 4 and 5. In addition to small-group case-based discussions and bedside teaching, students work on predefined patient case histories in computer-based ‘electronic seminars’ (e-seminars) lasting up to 45 min each. E-seminars are facilitated at the institution’s e-learning resource centre.Students enrolled in the first term of the fourth year were eligible for study participation during the summer of 2015. During the first 14 weeks of term (‘learning phase’), students attended three thematic modules on cardiology, pulmonology, nephrology, rheumatology, haematology and oncology. Following stratification by sex and prior performance levels, they were randomised to one of two groups (A and B). Students in both groups attended weekly e-seminars during which they were presented with three patient case histories related to teaching content of the previous week. Case histories  were adapted from an earlier study . Each paCase content was identical for all students but the format varied each week between ‘text cases’ or ‘video cases’. In text cases, content was presented on the computer screen in written format while dealing with video cases involved watching five short films (mean duration 68 s), and answering a question (i.e. one item) after each film. Films were scripted based on written cases that had been piloted in two consecutive student cohorts. Wherever possible, videos were closely aligned to text cases. However, inevitably, minor differences arose in the exact wording of content, which are fundamental to the difference between written information and audio-visual material showing a true interaction between a patient and a physician. For a sample video, please refer to Additional file 2.Additional file 2: Sample video. Example of a video key feature item. This MP4-file is an example of a video key feature item featuring a 74 year-old simulated patient called “Mr. Teschke”  with increasing shortness of breath. The interaction was scripted and both the patient and the doctor were played by actors who were not affiliated to the study team. Both individuals consented to participate in the research project and to be shown in this sample video. (MP4 7365 kb)During the learning phase, students in the two study groups were alternately exposed to video-based or text-based e-seminars with all students being exposed to the same content in any given week. For example, in week 2, students in group A worked on video cases , students answered a total of 150 items during the learning phase. Of these, 14 items in group A were predefined as intervention items which meant that these items were presented as video-based questions. The same items were used as control items (i.e. text-based questions) in group B. Conversely, 14 intervention items for students in group B were used as control items in group A. Item assignment to the two study groups was balanced with regard to item difficulty as derived from an earlier study using the same items . InterveEach of the 28 intervention/control items was presented in two out of the 10 e-seminars during the learning phase. As a result, any student – regardless of group assignment – was exposed to 14 intervention (video) items in two e-seminars and to 14 control (text) items in two different e-seminars. During the final week of term, students took a formative exit exam consisting of these 28 items that had been arranged into four new cases containing 6 or 8 key features each. Again, cases were only used to provide a structure to accommodate the items, and analyses were done on the item level. A formative retention test was taken 6 months later.Given the impact of context and format on exam performance with regard to the learning environment , presentDescriptive analyses involved calculation of student mean scores achieved for intervention and control items in the three exams as well as in the first and second occurrence of an item in an e-seminar. The primary outcome for this study was the within-subject difference in percent scores in the exit exam for those 14 items that had been presented in video format during the learning phase compared to those 14 items that had been presented in text format. The difference was assessed in a paired T-test. Based on an expected sample size of 90 and the results of a previous study , the stuWith regard to the third aim of this study, common errors were addressed by calculating the proportion of students making incorrect choices in e-seminars (learning phase) and the exit exam and retention test, respectively.p < 0.05. This study was approved by the local Ethics Committee (application number 22/4/15), and all participants provided written consent.Statistical analysis was performed using SPSS 22.0  and the Bayes factor calculator provided by Dienes . Data arn = 60) were female.The flow of participants through the study is displayed in Fig. T = 2.263; df = 92; p = 0.026). A similar but non-significant difference was found in the retention test . Using the mean difference of 2.8% and the corresponding standard error (1.7%) yielded a Bayes factor of 2.36, supporting the hypothesis that video items were more effective than text items. In the aggregate sample, the probability of correctly answering an item in the retention test following three failed retrievals in preceding e-seminars and the exit exam was 27.7%; the corresponding percentage for one, two and three correct retrievals were 51.3%, 70.2% and 87.5%, respectively. A descriptive analysis of all exam results on the level of individual items is presented in Additional file Mean percent scores in the entry, exit and retention exams were 28.5 ± 13.5%, 74.3 ± 17.4% and 67.8 ± 18.5%, respectively . A detailed analysis revealed that, while video items were more beneficial for learning purposes than text items, the opposite was true for presentation format in the formative exams in that students achieved higher scores in text items than in video items  , ECG diagnosis of a conduction block instead of atrial fibrillation (13.7%), rapid sodium supplementation for chronic hyponatremia (11.0%), and medical or surgical treatment for hyperthyroidism in a patient still receiving amiodarone (17.2%). A detailed analysis by item type (video or text) and data collection point is included in Additional file Given the small differences between video and text items, data from the two study groups were collapsed for the analysis of common errors. Table oisoning 6.9%, ECGThis randomised cross-over study yielded two main findings. First, repeated testing with video-based key feature questions elicited higher short-term learning outcomes than testing with text-based questions regarding diagnostic accuracy and initial management issues with only weak evidence in the long-term. Second, we found a high prevalence of erroneous beliefs in medical students irrespective of item format (video or text). These misconceptions have the potential to negatively impact the quality of patient care unless corrected before graduation.Choosing Wisely recommendations emerged from clinical reasoning processes. Thus, the initiative could serve as a paradigm of quality assurance in clinical care that should be addressed in medical education. Albeit not having been specifically designed to match any of the top five lists, some of the key feature questions embedded in the patient cases presented to our students alluded to current Choosing Wisely recommendations. For example, the lists of both the American College of Chest Physicians and the American College of Emergency Physicians cover the treatment of pulmonary embolism, and our results (Table 2 poisoning). Medical education research preferentially focuses on correct responses and aggregate scores. In the light of the Choosing Wisely campaign, a more thorough assessment of misconceptions and frequent errors appears promising in that it could guide improvements in the way clinical reasoning is being taught. This process should be informed by educational research. The present study suggests that repeated testing with key feature questions is effective in enhancing clinical reasoning performance.Clinical reasoning abilities are essential for competent and reflective physicians. Undergraduate medical education needs to equip students with a solid knowledge base and train them to apply that knowledge in a given clinical context. The ts Table  show thaSince the introduction of test-enhanced learning to the field of medical education research, a number of studies on undergraduate medical , dental There is a strong rationale for using audio-visual material in higher education as learning resources that are more closely aligned to the context in which knowledge will be applied is likely to produce more favourable learning outcomes . HoweverTest-enhanced learning is an emerging concept in medical education, and this is one of the first studies using video-based key feature questions to enhance clinical reasoning performance. The questions used during the learning phase and in formative exams referred to highly prevalent or important clinical problems, and all questions were piloted extensively . The resDespite these strengths, the generalisability of our findings is limited by the monocentric nature of the study. Given that the cases used focussed on internal medicine, we cannot draw conclusions on the potential of test-enhanced learning with key feature questions for other medical specialties. Finally, this study did not assess whether repeated testing with key feature questions impacts on actual student performance in the clinical setting. Although one study suggests such a link , more reChoosing Wisely campaign lends itself to being part of this process aimed at supporting students to become reflective and competent physicians.Repeated video-based key feature testing was associated with significantly better clinical reasoning performance compared to text-based testing in the short term. However, student responses revealed a high prevalence of erroneous beliefs that – if applied to the clinical context – are potentially harmful to patients. Efforts to improve clinical reasoning training in medical education are warranted, and the Additional file 1:Methods. Description and example of a key feature question. eTable 1. Proportions of correct answers for the 28 key feature items in the exit exam and the retention test. eTable 2. Frequent or relevant incorrect answers (proportion). (DOCX 59 kb)


Yarrowia lipolytica, the isomaltulose production reached the highest (102.6 g L−1) at flask level with pretreated cane molasses of 350 g L−1 and corn steep liquor of 1.0 g L−1. During fed-batch fermentation, the maximal isomaltulose concentration (161.2 g L−1) was achieved with 0.96 g g−1 yield within 80 h. Simultaneously, monosaccharides were completely depleted, harvesting the high isomaltulose purity (97.4%) and high lipid level (12.2 g L−1). Additionally, the lipids comprised of 94.29% C16 and C18 fatty acids, were proved suitable for biodiesel production. Therefore, the bioprocess employed using cane molasses in this study was low-cost and eco-friendly for high-purity isomaltulose production, coupling with valuable lipids.Cane molasses is one of the main by-products of sugar refineries, which is rich in sucrose. In this work, low-cost cane molasses was introduced as an alternative substrate for isomaltulose production. Using the engineered  Cane molasses is one of the main by-products of sugar refineries, which contains saccharides  and a small amount of nitrogenous compounds, vitamins, and trace metal elements as well as colloids ,2. SugarPantoea dispersa [Erwinia spp. [Enterobacter spp. [Serratia plymuthica [As a functional sweetener from microbial fermentation, isomaltulose has attracted extensive attention. Isomaltulose  is a structural isomer of sucrose, sharing similar sweet sense and fine taste with sucrose. It has been approved that a safer sucrose substitute with some advantages, including higher stability, lower digestibility, lower glycemic index and more tooth-friendly . Isomaltdispersa , Erwiniania spp. , Enterobter spp. , and Serymuthica . Howeverymuthica ,20.Saccharomyces cerevisiae (S. cerevisiae), Yarrowia lipolytica (Y. lipolytica), Bacillus subtili (B. subtili), and Lactococcus lactis (L. lactis), has been proved effective for isomaltulose production [Y. lipolytica expressing SIase gene has exhibited a prominent isomaltulose yield advantage over other hosts, which meets the requirement of isomaltulose commercialization [Recently, heterologous expression of SIases in non-pathogenic or food-grade strains, such as oduction ,18,21,22lization . Since sY. lipolytica S47, which is capable of expressing SIase and transforming monosaccharides to lipids as shown. To further develop an economical fermentation and recycling efficiently by-products using strain S47, fed-batch fermentation was also conducted.In traditional cane molasses fermentations using sucrose as the carbon source, sucrose was hydrolyzed into monosaccharides and utilized by microorganisms. However, the strain used in this study can just utilize monosaccharides, leaving sucrose not hydrolyzed for no sucrase generating. The high sucrose content in cane molasses makes it a promising substrate for isomaltulose production. On the other hand, the synthesis of isomaltulose from cane molasses can greatly improve the value of cane molasses. In this study, pretreated cane molasses (PCM) was used as the only carbon source, and corn steep liquor (CSL) was selected as substrate to replace yeast extract for the recombinant −1) was obtained with the SIase activity of 3.6 U mL−1 at 350 g L−1 PCM, and the yield achieved 0.96 (g g−1). Although the SIase activity (3.6 U mL−1) was limited, which is lower than 5.2, 7.4 and 49.3 U mL−1 [Sucrose in cane molasses can be hydrolyzed into monosaccharides by microbial enzymes, which is believed to be suitable for microbial growth and metabolite production ,13. In t3 U mL−1 ,24, this3 U mL−1 . The res−1, which accounted for 43.1% (w/w) of cell dry weight, respectively  presented might infer that yeast extract is not desirable nitrogen source in the medium. Therefore, an alternative nitrogen source will be needed to solve the residual sugar.In addition, as strain S47 cells grew to the peak, intracellular lipids continuously accumulated and reached 5.3 g Lectively . When PC content . This mi content . However−1) with 0.96 g g−1 yield, followed with enhanced SIase activity by 20.5% and biomass by 11.8% at the optimal CSL concentration (1.0 g L−1) compared with those in control (−1) by 35.8% with 44.7% (w/w) content , respectively  was also evidently higher compared with those  from strains L. lactis, S. cerevisiae and S.plymuthica using sucrose or molasses as the substrate, respectively (−1) was achieved by a recombinant Escherichia coli expressing SIase using cane molasses and CSL substrates, while it lacks isomaltulose concentration and yield [High osmotic pressure strongly affects product biosynthesis of ca cells . To reduectively . Generalubstrate ,24. The ectively . It indind yield .−1 and the content reached 57.3% (w/w) during the two–stage fermentation (−1 production at flask level above and that (8.1 g L−1) produced by the same strain from sucrose [Rhodotorula kratochvilovae  and engineered Ashbya gossypii  using cane molasses, respectively [Y. lipolytica strains and Aureobasidium melanogenum, and even co-cultured strains using other substrates [In addition, lipids accumulated to 12.2 g Lentation , which i sucrose . The lipectively ,33. Straectively . It alsohvilovae %, w/w anbstrates ,34,35. CY. lipolytica S47 using PCM and CSL substrates in fed-batch fermentation, thus, avoiding the effect of residual sugar on isomaltulose crystal.It is noteworthy that original monosaccharides and bits of them produced by SIase catalysis from strain S47 were depleted and only small amounts of trehalulose were detected, leading to produce a high isomaltulose purity of 97.4%. This purity is comparable with that (97.8%) by strain S47 using sucrose . In fact14:0, C16:0, C16:1, C18:0, C18:1 and C18:2, especially C18:1 (45.14%)  . This istty acid . Moreovebstances ,26. Indety acids ,37.Y. lipolytica S47 cells is a promising feedstock for biodiesel production.Biodiesel was prepared from the transesterification of obtained intracellular lipids. In this work, the conversion rate of lipids into biodiesel reached near 83.2% (data not shown), which is comparable with others (85–86.7%) ,38, indiY. lipolytica S47 was previously constructed and cultivated as seed culture in YPD medium  [Y. lipolytica ACA-DC 50109, which can transform extracellular sugars into cellular lipid [w/v), glucose (5.71%) and fructose (7.78%). Glucose potassium phosphate buffer (GPPB) medium with added different concentrations of PCM  instead of glucose was optimized to improve isomaltulose production by strain S47 at 30 °C for 96 h, pH was adjusted to 6.0 [The recombinant rose 2%) . The prorose 2%) . Furtherar lipid . Cane moar lipid . The comd to 6.0 . By the −1) to enhance isomaltulose production and purity, together with lipid synthesis compared to those from strain S47 fermentation using 0.5 g L−1 yeast extract. pH was adjusted to 6.0.Corn steep liquor (CSL) was derived from a local corn processing facility, which was used as a substitute for yeast extract in the fermentation medium. The fermentation was performed at different concentrations of CSL  and CSL (1.0 g L−1). After inoculation , the strain fermented to secrete SIase for isomaltulose synthesis and express some enzymes like ATP citrate lyase to accumulate intracellular lipids under the conditions of aeration rate (50 L min−1), rotate speed (300 rpm), and temperature (30 °C) [−1 PCM at the initial 32 h of fermentation. During bioprocess, samples (50 mL) were taken at intervals of 7 h to detect isomaltulose and lipid contents, SIase activity and monosaccharides as well as biomass. pH was controlled at 6.0.Fermentation was scaled up in a 10-L Biostat fermentor  with the obtained medium (6.0 L), which contained optimized PCM (350 g L (30 °C) . Fed-batg to obtain the supernatant, and SIase activity was measured according to previous methods [−1) that dissolved in phosphate buffer (50 mM and pH 6.0) in a ratio of 1:1; the mixture was then incubated at 30 °C for 10 min. The process was terminated through boiling for 10 min and centrifuged  to eliminate denatured proteins. Finally, the new supernatant was filtered through 0.22 μm membrane and properly diluted for high-performance liquid chromatography (HPLC) analysis using Agilent 1200 system . One unit (U) of enzyme activity was calculated as the SIase amount responsible for the release of 1.0 μmol isomaltulose per min at 30 °C and pH 6.0 [The fermented broth from strain S47 was centrifuged at 5000×  methods ,22. Bried pH 6.0 . The ferThe contents of isomaltulose, trehalulose, residual glucose and fructose in fermentation supernatant were also determined using HPLC after membrane (0.22 μm) filtration. Biomass and quantification of intracellular lipids were gravimetrically detected . All tes2SO4 solution (in methanol) through thermocatalytic treatment as described in previous research [Lipid was extracted and fatty acid esters were determined using gas chromatography (GC) . 1 μL ofresearch .p < 0.05 (*) and p < 0.01 (**).The results obtained above were subjected to a one-way analysis of variance (ANOVA) using SPSS 22.0 software , and presented as the mean ± standard deviation. Statistically significant differences between groups were showed as −1 and yielded 0.96 g g−1. Monosaccharides were completely consumed and transformed into intracellular lipids and biomass, which resulted in a high isomaltulose purity of 97.4% and 12.2 g L−1 lipids. The lipids produced from Y. lipolytica S47 cells have potential as a candidate for biodiesel production. An efficient, economical strategy to produce isomaltulose from cane molasses was established. During the fed-batch fermentation, the maximal isomaltulose concentration achieved 161.2 g L


One major barrier to uptake of diabetic retinopathy (DR) services is lack of knowledge and awareness of DR among the people with diabetes (PwDM). Targeted health education (HE) can be a key element in improving the uptake of eye care services. Such interventions are lacking in Sri Lanka.A local context specific HE intervention (HEI) was developed by adopting available resources and incorporating views from PwDM and key stakeholders. Four sessions of participatory workshops with PwDM  and two stage 12 stakeholder interviews were conducted to both develop and pre-test the material. The products were a video and a leaflet, delivered at a medical clinic to a sample of 45 PwDM identified as having DR. Semi-structured interviews were conducted after 4 weeks, to evaluate the acceptability and comprehension of the HEI. Additionally, nine interviews were conducted with clinical providers to explore process issues related to delivery of the HEI. Data analysis was conducted using thematic analysis.The lack of knowledge and awareness on DR, and of the importance of regular DR screening and follow up, combined with poor information on referral pathways were key elements identified from the workshops with PwDM. The stakeholders prioritised the importance of using simple language, and the need for emphasis on improving understanding about the asymptomatic phase of DR. The overall acceptability of the HEI material was satisfactory, although there was some difficulty with interpretation of medical images. Overall, although PwDM liked the ideas of the video, the leaflet was seen as a more practical option, given the busy clinic environment. The key issue was both formats required interaction with the provider, in order to support understanding of the messages.The process of adapting HE material is not simply translation into the appropriate language. Instead, a tailored approach in a country, context and particular health services setting is needed. This study illustrates the value of using a participatory approach and involving PwDM and stakeholders in the adaptation and pilot testing of a HEI to improve uptake of screening for DR in the context of Sri Lanka.The online version of this article (10.1186/s12889-019-6880-4) contains supplementary material, which is available to authorized users. Diabetes mellitus (DM) is a global epidemic. Evidence suggests that there will be an increase in the number of people with DM (PwDM) globally with a higher increase in low and middle income countries (LMIC) . One majA review conducted on interventions to promote DRS, highlighted the need for strategies to improve PwDM’s awareness on DR . StudiesIn Sri Lanka, despite free eye care being provided through the public sector, the uptake of DR services is low. The current method of detecting DR is opportunistic screening by ophthalmologists following referral from general physicians or when PwDM present for other eye problems. The highest recorded prevalence of DM of 18.6% (95% CI 15.8–21.5%) in Sri Lanka is in the Western province , where aback bone” of the health promotion efforts [Health education forms an essential component of the health promotional activities for chronic diseases such as DM . A revie efforts . One maj efforts . There a efforts . A syste efforts . TherefoIn the development of any HE intervention (HEI), there are a variety of behaviour change models which can be applied. Social Cognitive Theory (SCT) underpins many approaches to behaviour change , and wasThe overall purpose of this study was to develop a relevant, acceptable and comprehensible HEI for the Sri Lanka context to improve referral uptake at the ophthalmologist’s clinic. This was part of a larger feasibility study to develop an integrated DRS program in the Western province of Sri Lanka.It is a descriptive qualitative study which details the process of the development and field testing of a relevant and acceptable HEI. The different phases are described in Fig. Ethics approval was obtained from the Ethics Review Committees of the London School of Hygiene and Tropical Medicine-United Kingdom and from the National Eye Hospital-Colombo-Sri Lanka. Written informed consent was obtained from all participants for participation, audio recording and usage of anonymous quotes in publications.Initially a search was conducted for existing HE resources over the last 10 years that promoted uptake of DRS or DR services. Details of the electronic data search are provided in Additional file The second step was one of the two-stage consultation process with 12 key stakeholders who worked in clinical management and health promotion of DM and DR in the public sector  and Tamil . The diagnosed PwDM identified at the medical clinic were selected considering gender, main language and to represent various levels of education and income levels. The overall aim was to explore the participants’ views on the selected materials in terms of (1) cultural acceptability of key messages, (2) comprehension, (3) content, (4) layout and design and (5) medium of delivery of the HEI. Details of the participatory workshops are available in Table The next step was running a total of eight participatory workshops with a purposive sample of PwDM in Sinhala , were incorporated into the adaption and development of the HEI. The end result was the production of a video and leaflet, available in two local languages  were audio recorded and for stakeholders’ meetings detailed notes were taken. A simple thematic analysis was undertaken which included covering themes of comprehension, readability and cultural acceptability. The analysis was conducted in local languages by experienced sociologists. Recordings were transcribed, and together with field notes, were coded in Sinhala and Tamil by local sociologists and then cross checked by the lead sociologist and by the lead investigator. Final themes were translated into English.n = 9, 5 in Sinhala and 4 in Tamil language) were also interviewed from medical and eye clinics to explore their perspectives on the process of delivery of the HEI. The field-testing interview topic guides details described in Additional file The video and leaflet were then field tested at a tertiary level medical clinic setting by administering to a purposive sample of 45 PwDM who had diagnosed any level of DR . Sixty-three sources were reviewed for adaptation after exclusion of material based on the relevance  attended participatory workshops. Overall there were low levels of knowledge of DR and DRS, a lack of perceived threat of DR blindness, combined with DR not being seen as a life-threatening condition, in particular during the asymptomatic phase. Commonly, for example, cataract surgery or the provisions of spectacles were understood to be the solution for all eye health problems. The use of medical terms, often in English, was also identified as a barrier to their understanding, including terms such as ‘retina’ and ‘pupil dilation’, although these terms could not be easily translated into the local languages. Knowledge about treatment options in government hospitals was also limited, combined with poor understanding of the referral pathways, and of the need for regular screening. The confusion about referrals and forgetfulness about appointments was often exacerbated by the lack of a printed referral form, and/or lack of information available in the local languages. Another barrier to uptake of services was negative attitudes about very long waiting times at clinics which deterred patients from regular screening. Fear about the procedures, such as pupil dilation, was another barrier.In terms of environmental factors, social norms emerged as a key theme, which influence management of DM. Some PwDM practiced indigenous medication, whilst a common belief was also that blindness was an inevitable part of ageing, karma or faith which was not avoidable and therefore difficult to treat. The decision making on accessing services and requirements of an escort, especially for women, mostly happened at the family level, in what is a patriarchal society system. Therefore, development of HEI needed to be family-centred and any materials to be developed in a way that it would be easy to share.In terms of readability of the HEI a common request was for clear and colourful images and to use large page size and font size for printable material. Stakeholders identified that an animated video could enrich understanding of biological changes to the eye. In terms of the mode of delivery there was an overall preference from the Tamil speaking groups for the video, whilst in contrast the Sinhala groups in general expressed a preference for printed reading material. All groups agreed that the medical clinic provided a useful space to deliver this HEI, whilst waiting for appointments.Overall as a result of the field testing of the video and leaflet, there were a number of lessons learnt about the relevance and acceptability of the HEI, reflected in 3 major themes; 1) levels of comprehension and readability, 2) actionability of uptake of services and 3) views on mode of delivery. The details of themes and sub-themes are available in Table Overall the majority of the participants in both language groups stated that key messages were clear in both media of delivery. However, a common difficulty was interpreting some of the biological images, such as fundus images depicting the progression of DR and how vision varies. There were also difficulties in interpreting and understanding the relevance of numbers and percentages that described the disease burden of DR. PwDM also requested more information on the dangers of DR in the leaflet.“This is Jaffna Tamil, so it is difficult to follow the video”. The Moor PwDM highlighted the limited representation of Moors in the video and were critical of the unintentional background footage of images of Tamil religious symbolism. A major theme across most patients and providers was the need to interact with someone about the video or leaflet to aid clarification. This was illustrated by a 65-year woman who explained that “I didn’t understand the animations straight away. But after several explanations I could understand some of it”.In terms of the cultural appropriateness of the language, the majority of the Sinhala patients were satisfied with the use of language in the video and leaflet. Whilst in contrast, some phrases and terms were in a different regional language for the Tamil group, and therefore more difficult to follow, as one 65 year old female explained, The providers as well as the PwDM, suggested that lay-out and design of the leaflet and showing the directions to the eye clinic could be improved further; suggestions included incorporation of segments of the eye care hospital into the video.“I think the more serious message I captured from the video is that the ‘right follow up’ is very important to protect the sight. The old lady’s story was interesting for me”. Participants also showed an indicative positive attitude about intention to seek care. However, improved maps of the location of services were a common request.Overall there was good understanding of the key steps to undertake for referrals, including the need for regular screening and follow up, and of facilities available in the public sector eye hospitals: sounds and voices were not clear in some parts, because of the noisy environment inside the clinic”. Providers also highlighted the practical difficulties in delivering the video at the clinic setting when there were no facilities for a larger number of PwDM.In terms of mode of delivery, the majority of the participants reflected on the usefulness of receiving the leaflet whilst waiting for the consultation. PwDM said they liked delivery of leaflet and video to be facilitated by their physician, so that it could support an interactive session. Yet at the same time a common complaint was that the environment was too noisy for the video: “A central component of the HEI was that it would prompt a willingness to share the resource with other family members. However, the field testing showed that in practise, there was limited showing of the video, and it was unclear the extent to which the leaflet was shared. The main reasons given were lack of any facility to watch and/or lack of time for a family member to watch a video. Overall there was a small preference for the leaflet in the field testing, because of the practical ease of carrying it and being able to refer to it.Both PwDM and providers suggested that lay-out and design of the leaflet and showing the directions to the eye clinic could be improved further; suggestions included incorporation of segments of the eye care hospital into the video.“A clinical setting at a hospital is very congested and busy. A Few doctors are there to provide for the needs of hundreds of patients. A single patient has a very limited time to spend with the doctor, not enough time for an efficient health educational intervention”. Providers emphasised that unavailability of proper technical facilities and limited space to display the video was the main challenge they faced in delivering the HEI at the medical clinic. “The video has a more likelihood of capturing people’s attention, but there must be proper tools to deliver it. There must be enough space and facilities for all this. In my opinion, the leaflet is far more practical when it comes to congested hospital setting.”.The physicians who delivered the HEI stated that major practical issue was lack of time to deliver and talk through the material. One physician expressed her view as follows. We observed the value of bringing the providers and other stakeholders along the journey from early consultation through to the final field testing. This was helpful to build their ownership to the developed material with a greater likelihood of utilising it as a HEI in future.This study showed that the process of adapting HE material is not simply translation into the appropriate language. Instead adopting a participatory process, and working with PwDM and with providers, we identified important content and process issues, necessary to make the material relevant and acceptable, with some lessons learnt for scaling up. The key findings were, PwDM had low levels of knowledge and awareness on DRS, referral pathways and follow ups. Stakeholders prioritised the importance of using of simple language and need of highlighting the importance of DRS in asymptomatic phase. In the field testing we found that most of the PwDM could comprehend the content with overall good understanding of the key steps, except on a few occasions among Tamil and Moor ethnic groups. Additionally, we observed that there were technical and human resources constraints to deliver the HEI at a medical clinic setting. Our HE video and leaflet had satisfactory level of acceptability to the PwDM based on their verbal responses. This HEI would have a greater potential of using as an HEI to improve the referral uptake following further refinement according to the contextual requirements.The World Health Organization (WHO) Shanghai Declaration stated that health promotion should be an essential component in all health systems to have an equitable access  and eye The use of participatory methods targeted at the intended community has been shown in a study to be an effective way to develop material which has a high level of acceptability . This meOur study showed that overall knowledge on DM and DRS was low, and this needed to be addressed with the HEI. A study conducted in South India, in a population similar to Sri Lanka showed that only about 40.7% of PwDM had good knowledge on DM and DR and 9.6% has undergone DRS . In addiThe field-testing phase showed that despite high level of literacy in Sri Lanka , the funOur study showed that socio-cultural adaptation of the material is a crucial factor to improve uptake, in a patriarchal society like in Sri Lanka. A study from Sri Lanka showed that PwDM behave with regard to DM based on various socio-cultural beliefs . TherefoOur study showed an overall satisfactory level of acceptability for the leaflet and video material. We showed and expressed preference among the participants about the use of a video during the participatory development phase. A systematic review of assessing the efficacy of video-based HE to modify behaviour in handling health related issues showed that videos showing actual people can be more effective than graphical presentation . HoweverOne of the key findings in our study was that HE benefits from a more interactive approach where there is an opportunity to discuss the material with a provider and seek clarification. The clinic work load , lack ofOne limitation of the study was that, we assessed the acceptability of the HEI using subjective responses of the PwDM and providers. We did not assess knowledge and awareness of the PwDM at the baseline. Our study sample consisted mostly of elderly PwDM. Further, the small sample size may not represent the diversity of the community in this region. Therefore, conclusions drawn from this study may not generalisable. We did not assess the variations in acceptability by age, gender or socio-economic status.The development of HE material in DR is a complex process, requires adaptation and development suitable to the local context. The process of adapting the health educational material is not simply translation into the appropriate language but rather an individualised tailored approach in different health services to meet the needs of variuos patient communities. Socio-cultural norms should be considered when defining the actionable steps. We can conclude that there is a satisfactory level of acceptability for this HEI and to deliver at a medical clinic setting would require further development of human resources and infrastructure appropriate to the intervention.▪ Improve functional health literacy by further simplification of the resource, including minimal use of medical jargon.▪ Strengthen the interactive use of HEI, with a skilled educator to discuss, clarify and counsel.▪ Explore options for task sharing or task shifting the educator role from the physician to another staff member and or expert person with DM.▪ Use the waiting time at the medical clinic as a dedicated and targeted time for HE. This should include ensuring there is adequate space, including a quiet space for delivery of the video material.▪ Develop the video into shorter film clips for use at the waiting areas of the medical clinics before consultation, prompting to clarify the queries during consultation to improve access.▪ Consider options for developing a cadre of expert patients who could work in local dialects and may be in better position to work with minor ethnic groups, and to engage with other family members.▪ This HEI should be one component of a wider health promotional strategy to improve the uptake of DRS in Sri Lanka. A next step is then to test the effectiveness of this strategy in a controlled trial.Additional file 1:Search on health educational interventions / material on improving the referral uptake. (DOCX 16 kb)Additional file 2:2.1: Leaflet health educational intervention in English and local languages  and 2.2: Outline and script in English and local languages  of the video healtheducational Intervention. (ZIP 3663 kb)Additional file 3:Topic guides for field testing of the HEI – for service users and service providers. (DOCX 18 kb)


Malnutrition is a common problem in patients with liver cirrhosis and tools for nutritional assessment are under debate. We conducted this study to assess prevalence of malnutrition in cirrhotic patients using PCM score and BIA. Additionally we compared BIA to PCM score for detecting malnutrition in this patient population.This was a cross sectional study conducted in two tertiary care hospitals of Karachi Pakistan on adults with liver cirrhosis. Malnutrition was assessed by PCM score using anthropometric measurements and biological specimens and (ii) Body cell mass was assessed using BIA. Malnutrition as estimated by the PCM score was present in 122 (73%) of patients in which most patients had mild malnutrition (n = 72 (45%)), followed by 34 (21%) with moderate malnutrition and 3 (1.9%) with severe malnutrition. Malnutrition according to BIA estimated through body cell mass could detect it in 98 (61%) of patients. There was optimal correlation of PCM score with body call mass ). We conclude that majority of the patients with liver cirrhosis had malnutrition as determined by PCM score. BIA underscored the malnutrition in this patient population. Cirrhosis is the late and irreversible stage of hepatic fibrosis, which is characterized by destruction of hepatic architecture and the development of nodules . Almost BIA is a simple, noninvasive, inexpensive and quick method to estimate BCM , and it This was a cross sectional study conducted in the outpatient medicine clinic of Aga Khan University hospital Karachi (AKUH) and Jinnah postgraduate medical center (JPMC) Karachi. All patients aged ≥ 14 years, with either history of viral CLD (HBsAg or HCV) or non-viral CLD who had established diagnosis of liver cirrhosis of any etiology were recruited in the study after obtaining the informed consent. Consent from parent or guardian was taken for those who were minors. Liver cirrhosis was diagnosed based on ultra-sonographic evidence of chronic liver disease including shrunken liver, dilated portal vein, splenomegaly. We used nonrandom purposive technique for recruiting participants in this study , 14.Study measurements included demographic information, measurement of anthropometric measures, history of decompensation  biological specimens (urine and blood) and assessment of total body water and fat free mass using BIA.Height was measured with portable stadiometer to the nearest of 0.1 cm and mean of three readings were documented. Triceps skin fold thickness was measured with a Lange caliper . Mid armculation . Malnutrculation , 20. PCMBIA was performed using a BIA 2000M   applyingApproximately 200 patients were invited to participate, out of which 161 (response rate = 80%) patients with liver cirrhosis were enrolled. The reasons for not participating was inability to come back for an outpatient visit due to a distant residence outside the city. There were 76 (47.2%) males and mean age was 49.1 (11) years. Hepatitis B or C were the cause of cirrhosis in 138 (87.8%) patients while in 23 (14%) patients these markers were negative. There were 61 (37.9%) patients in child class A, 60 (37.3%) in child class B and 17 (10.6%) in child class C.Overall and comparison of malnutrition by PCM score and BIA measurements in cirrhotic patients with and without Malnutrition is shown in Table There was moderate correlation of PCM score with Body call mass ). Specificity of BCM for detecting Malnutrition in patients with cirrhosis (presumed gold standard PCM score) is 28% and sensitivity is 60% with a positive predictive value of 60% and a negative predictive value of 39%  or C (n = 150), 199 (86.5%) patients were well nourished, and 31 (13.5%) were malnourished. This is a much lower prevalence of malnutrition in contrast to our figure of 67%. In fact a large number of participants in this study from Brazil were overweight. We on the other hand did not see such trends in our patient population. In another study on 315 patients from china prevalence of malnutrition (73%) was higher in the cirrhotic group due to viral hepatitis. In a study from India the prevalence of malnutrition was 68%. Our study shows similar pattern of malnutrition in our patients with liver cirrhosis. The seventy percent prevalence of malnutrition is however higher than the reported figure of 52% from the study by Naqvi et al. which might be underestimated due to use of a partially subjective tool of assessment in the later study . These hInternational literature shows conflicting results about BIA in cirrhotic patients where one author concluded that it is a reliable bedside tool for the determination of body cell mass in cirrhotic patients with and without ascites . While aAlthough our study suggests that PCM is more sensitive in detecting malnutrition, it however has its limitations like collection of cumbersome biological specimens which patients might not consent for and also this strategy might not be cost effective. The nutritional state assessment in these patients is complicated, and besides anthropometry is based on several other tools in order to be more accurate . We suggThe strength of this study is that two different methods were used for assessment of malnutrition both measures were objective. The use of these objective measures decreases the chances of misclassification bias. A response rate of 80% in the study is considered as optimal.We conclude that majority of the patients with liver cirrhosis had malnutrition as determined by PCM score. BIA underscored the malnutrition in this patient population. The correlation of PCM score and BIA was moderate.There are several limitations in this study, (1) it has limited external validity because it included only patients visiting outpatient clinics in 2 hospitals, hence the results cannot be generalized to the entire population. (2) This is certainly a limitation and future studies ideally should be from population based samples. Being in outpatients setting only patients with well compensated cirrhosis could be recruited while those with advanced disease were not recruited leading to selection bias. (3) Presence of ascites and edema is a limitation for measuring BCM from BIA and also for measuring BMI for PCM score. (4) We did not include information on food intake, type of treatment for cirrhosis which could have been a major determinant in correlating it with malnutrition. (5) While objective measures were used for assessment of malnutrition some degree of observation bias might be involved while measuring MAC and TSF.