Recent literature and Dutch guidelines for patients with out-of-hospital cardiac arrest (OHCA) recommend screening for cognitive impairments and referral to cognitive rehabilitation when needed. The aim of this study is to assess the uptake of these recommendations for OHCA patients.An internet-based questionnaire was sent to 74 cardiologists and 143 rehabilitation specialists involved in rehabilitation of OHCA patients in the Netherlands. The questionnaire covered: background characteristics, availability and content of cognitive screening and rehabilitation, organisation of care, experienced need for an integrated care pathway including physical and cognitive rehabilitation, barriers and facilitators for an integrated care pathway.n = 17) prescribed cognitive screening. Eighty-nine percent underscores an added value of an integrated care pathway. Barriers for an integrated care pathway included lack of knowledge, logistic obstacles, and poor cooperation between medical specialties.Forty-five questionnaires were returned (16 cardiologists and 29 rehabilitation doctors). Thirty-nine percent (In the Netherlands, only a minority of cardiologists and rehabilitation specialists routinely prescribe some form of cognitive screening in OHCA patients, although the majority underscores the value of cognitive screening in OHCA patients in an integrated care pathway. The uptake of such a care pathway seems hindered by lack of knowledge and organisational barriers. MoCA should be administered routinely after out-of-hospital cardiac arrest (OHCA).A minority of cardiologists and rehabilitation specialists routinely screen for cognitive problems in OHCA patients.A majority of specialists underscores the value of cognitive screening in OHCA patients.Cooperation between cardiac and cognitive rehabilitation is needed.The majority of patients who survive an out-of-hospital cardiac arrest (OHCA) are eligible for cardiac rehabilitation due to the cardiac cause of the arrest –5. CardiMost common cognitive problems in OHCA patients, due to hypoxic brain injury, are memory problems, attention deficits and executive problems . CognitiIn 1996, Grubb recommended paying attention towards cognitive problems after OHCA, subsequently emphasised by Moulaert in 2010 . ThroughAdditionally, the ERC mentions the use of the subjective Checklist for Cognition and Emotion as another possibility to identify possible cognitive symptoms. However, literature suggests that the use of subjective questionnaires merely discovers emotional problems . PatientThis article aims to assess the uptake of the recommendations regarding cognitive screening and rehabilitation in OHCA survivors as described in literature and recent guidelines and to assess barriers and facilitators that influence the uptake of these recommendations for OHCA survivors. Insight in the uptake of these recommendations is needed to enhance future initiatives that aim to improve the quality of care delivered to OHCA survivors.A majority of the 79 hospitals in the Netherlands provides cardiac rehabilitation to low-risk patients, supervised by a cardiologist. Cardiac rehabilitation for high-risk patients and/or cognitive rehabilitation are provided in 35 specialised rehabilitation centres with in total 150 locations under supervision of a rehabilitation specialist. Twenty-nine locations provide both cognitive and cardiac rehabilitation, 33 locations provide only cognitive rehabilitation and 6 provide only cardiac rehabilitation.In May 2015, an internet-based questionnaire was sent to rehabilitation specialists and cardiologists in Dutch rehabilitation centres and hospitals that provide cardiac and/or cognitive rehabilitation. Since most rehabilitation centres and hospitals were staffed with several medical specialists, multiple questionnaires were sent to each location. Reminders were sent two months later. The questionnaire consisted of open-ended, multiple choice or multi response questions. Questionnaires were returned anonymously.Nederlandse Vereniging voor Cardiologie—NVVC) and the Dutch multidisciplinary consultative body on cardiac rehabilitation  were invited. Locations without a member of the Netherlands Society of Cardiology were invited to participate via a general email address. In total, 74 cardiologists were invited.Locations providing cardiac rehabilitation were retrieved by an internet search. Cardiologists registered with the Netherlands Society of Cardiology , a national workgroup on the rehabilitation of stroke patients. Locations not represented in the task force were invited to participate via a general email address. In total, 143 rehabilitation specialists were invited.All rehabilitation centres and locations were found via the website of The questionnaire was based on review of literature and available guidelines , 19, 20.The questionnaire included 30 questions about: (1) background characteristics ; (2) availability and content of cognitive screening ; and (3) experienced need for integrated care pathway in which cognitive screening is included [yes/no], existing barriers and facilitators for an integrated care pathway .P-values ≤0.05 were considered statistically significant.We used descriptive statistics to analyse the data gathered by the questionnaire. The interviews were analysed qualitatively. However, the data from the interviews were only used to develop our questionnaire. We did not report the results of the interviews in our manuscript. The descriptive statistics were used for characteristics and current care for all respondents and for cardiologists or rehabilitation specialists separately. Chi-square tests, Mann-Whitney U tests and unpaired t‑tests (SPSS 22 v.02) were used to test differences between groups where appropriate. In case of expected cell count less than five, Fisher’s exact test was used. The characteristics of respondents are shown in Table n = 16) had 5–10 years working experience with OHCA patients and saw 0–10 OHCA patients per year (n = 18). Fifty-three percent (n = 24) worked in a hospital, 42% (n = 19) in a rehabilitation centre and 5% (n = 2) in both.A total of 45 respondents completed the questionnaire (21% response rate). The median age of respondents was 42 years (range 31–61), the majority (Table n = 17) reported they used a standard cognitive screening in OHCA patients. Of these 17 respondents, 65% (n = 11) used an objective measurement: MoCA, Mini Mental State Examination (MMSE) or neuropsychological assessment.Of the 45 respondents 39% (n = 6). A standardised questionnaire used by 2 of these respondents is the Cognitive Failures Questionnaire (CFQ). Cardiologists more often use a subjective screening  than rehabilitation specialists .Subjective methods are used by 35% (n = 11) or by their teams . In the absence of standard cognitive screening, cardiologists  use a non-structured observation, whereas rehabilitation specialists  refer patients to a cognitive rehabilitation team.Cardiologists who reported using a screening, delegate this task to other health professionals. The majority of respondents who do not screen routinely rely on the observations during intake , psychologist  or social worker (18% n = 3).Respondents who screen for cognitive problems refer, when needed, to cognitive rehabilitation  find it is easy to refer from cardiac to cognitive rehabilitation in case of cognitive problems. Twenty percent has close collaborations in either a pathway (11%) or cardiac and cognitive rehabilitation within the same team (9%).Most respondents  see an added value in an integrated care pathway for OHCA patients (Tab. n = 39), attention deficits , problems in reintegration in work  and relational problems . No major differences were found regarding awareness between responding cardiologists and rehabilitation specialists. Nevertheless, eight rehabilitation specialists (31%) mentioned a lack of knowledge regarding cognitive problems by cardiologists. Organisational barriers that hamper the implementation of a care pathway are logistic problems , difficulties in cooperation between cardiac and cognitive rehabilitation 36% (n = 14) and the small number of patients 36% (n = 14). In addition, 21% (n = 8) of the respondents fears an increase of administrative load and one person (3%) mentioned not achieving production agreements as a financial barrier.Almost all respondents 89%, n = 9 see an  n = 32), more focus on patients’ needs , fewer chances of relapse  and less dropouts during the cardiac rehabilitation programme .An opportunity is seen in the organisational facilitator of already existing co-operations between departments (89%). The majority (89%) sees an added value in a care pathway or co-operative agreement. Most respondents also see opportunities in better alignment of cardiac and cognitive rehabilitation  are also recommended in the ERC resuscitation guidelines. The Cognitive Failures Questionnaire (CFQ) is such an instrument and is used by some of the respondents who routinely screen for cognitive problems. The CFQ, a questionnaire about cognitive mistakes, is not specifically recommended in the ERC guidelines but is similar to the recommended Checklist Cognition and Emotion. Literature suggests that the use of the CFQ might not reveal cognitive deficits but merely emotional problems, and should therefore rather be used complementary to the objective screening for cognitive problems .Respondents who do not standardly screen (61%) indicate that they assess cognitive problems using non-structured observations by the team. Patients they suspect of cognitive problems are referred for cognitive rehabilitation or neuropsychological assessment. It is well known that non-structured observations lead to false-negative results that can be avoided by using either structured observations or screenings .The lack of treatment protocols for both screening and treatment of cognitive deficits after OHCA is striking, given the recommendations in the guidelines.Cognitive rehabilitation has proven to be effective for patients with acquired brain injury . CognitiA positive aspect towards future treatment protocols is that all specialists are aware of one or more possible cognitive problems. The majority of the respondents sees an added value in an integrated care pathway resulting in better alignment of care, better fulfilment of the patient’s needs and decrease of the chance of relapse. Since the vast majority (89%) already has an existing co-operation between departments, rapid implementation of the recommendations should be possible.However, logistic barriers and lack of structural cooperation between cardiac and cognitive rehabilitation hamper the uptake of these recommendations. Specialists also fear an increase of administrative load for a small population.We extensively approached specialists involved in care for OHCA patients. By doing so, multiple specialists at one location were approached. Often only one of them reacted, explaining the low response rate. Probably, this introduces a selection bias with overrepresentation of specialists interested in cognitive problems.Rehabilitation care for OHCA patients is suboptimal in the Netherlands. Patients are not routinely screened for cognitive impairments. To reassure that attention is paid to cognitive problems the MoCA should be administered routinely and cooperation between cardiac and cognitive rehabilitation is needed.


Maternal satisfaction is one of the most frequently reported outcome measures for quality of care, and it needs to be addressed to improve the quality and efficiency of health care during pregnancy, childbirth, and puerperium to provide quality maternal-friendly services.  To find out the maternal satisfaction on delivery service among postnatal mothers in a government hospital, Mid-Western Nepal.  A descriptive, cross-sectional study was conducted in maternity ward of Bheri Zonal Hospital, Nepal. A total of 178 purposively selected postnatal mothers were interviewed face-to-face using semistructured interview schedules. Analysis and interpretation of the findings were done with the help of descriptive and inferential statistics. p=0.475; OR = 2.710; CI = 0.343–21.4), also postnatal mothers up to primary level were 2.850 times more likely to be satisfied than secondary level and above . Also, in this study, postnatal mothers who were multiparous were 2.352 times more likely to be satisfied with the delivery service than primiparous . Majority (87.1%) of the mothers would like to receive delivery service next time in the same hospital.  The study shows that majority (89.88%) of the mothers were satisfied with the delivery service. The level of satisfaction was higher in interpersonal and technical aspects (93.82%) of care than in informative aspects (91.57%) and health facility-related statements (91.01%). There was no statistically significant association between sociodemographic and obstetric characteristics and maternal satisfaction. Although insignificant, postnatal mothers who were illiterate were 2.710 times more likely to be satisfied than who were literate ( Majority of mothers were satisfied by the delivery service. Care givers need to fully understand the expectations the mothers have and provide care that is consistent with those expectations. The health system should be devised to increase maternal satisfaction in the health institution and provide maternal-friendly service. Quality of care is the degree to which maternal health services for individuals and populations increase the likelihood of timely and appropriate treatment for the purpose of achieving desired outcomes. The use of services and outcomes are the result not only of the provision of care but also of women's experience of that care. The quality of care received by mothers and babies in developing countries is often reported as poor . Client Assessment of satisfaction with maternity services is crucial and helps in future utilization of service , 4. UndeChildbirth is a crucial experience in women's life as it has a substantial psychological, emotional, and physical impact. A positive experience in childbirth is important to the woman, infant's health and well-being, and mother-infant relationship. Furthermore, it is useful for the care providers to guarantee the best preparation, health service, and support to childbearing women . The memInstitutional delivery as percentage of expected pregnancies has been in increasing trend from 44 to 50 percent over the last three consecutive years in Nepal, but the number of women attending 3 postnatal visits has been in declining trend. The coverage of the three postnatal visits is only 44% . Thus, mA nationally representative facility-based survey conducted across 13 districts in Nepal by client exit interviews showed that most of the respondents were satisfied with (very satisfied and satisfied) care received at the facility (86%), provider's skills (85%), involvement in decision-making (77%), cleanliness (70%), information received (69%), and assured confidentiality (67%). The impact of rapid increase in institutional birth rate in Nepal on women's satisfaction and planned future utilization of services is less well known. The measures to improve client experience of maternity care in Nepal should focus on improvement in physical environment along with improving the attitude and communication skill of service providers with prompt response .The conceptual framework was developed to understand the basis of study conducted. The framework was developed with the help of extensive literature review and was modified from the Donabedian model of assessment of quality of care which is shown in Structure/input describes the context in which care is delivered, including hospital environment, knowledge, attitude and practice of staff, financing, and equipment, sociodemographics, and obstetric characteristics of mother. Process denotes the transactions between patients and providers throughout the delivery of healthcare. It includes interpersonal aspects of care, technical aspects of care, and informational aspects of care. Finally, outcomes contain all the effects of healthcare on patients, including changes to health status, patient satisfaction, and health-related quality of life.Descriptive cross-sectional study design based on quantitative approach was used in the study. The setting of the study area was maternity ward of Bheri Zonal hospital, Nepalgunj, which is implementing safe motherhood programme under the government of Nepal. This hospital serves as the referral centre for emergency obstetric care in mid-Western region of the country. It is also skilled birth attendant- (SBA-) training centre with the case load of around 450 deliveries per month. The study populations selected for the study were postnatal mothers who gave live birth at hospital and were about to be discharged from the hospital.The nonprobability purposive sampling technique was used. This was the most appropriate method of sampling as the judgment and deliberate effort were used to select postnatal mothers giving live birth at hospital and who were about to be discharged from hospital. During the data collection period of one month, one hundred and seventy-eight mothers were selected for the study.A study conducted from a nationally representative facility-based survey across 13 districts in Nepal entitled “Women's Satisfaction of Maternity Care in Nepal and Its Correlation with Intended Future Utilization” showed prevalence of maternal satisfaction as 77% .no= desired sample size; Z = the standard normal deviate (set for a 95% CI) = 1.96; p = the prevalence of maternal satisfaction = 0.77; q = 1 − p = 1 – 0.77 = 0.23; level of significance (α) = 5%; absolute allowable error (l) = 0.05; and no = (1.96)2∗(0.77)∗0.23/(0.05)2 = 270.65 = 271. For finite population, the sample size can be adjusted by using the following formula ): n=no/(1+(no − 1)/N) [The sample size was calculated by using Cochran's formula :(1)no=Z2 − 1)/N)  = 169.37The selection was based on the exclusion criteria, that is, mothers who were admitted in the hospital after home delivery, having intrauterine fetal death, and those severely ill and not willing to participate in the study.A semistructured interview-based questionnaire on the basis of objectives and variable under study was developed by the researcher herself based on intensive literature review and consultation with experts.Part I consists of questionnaires related to sociodemographic characteristics of mothers. Part II consists of obstetric characteristics of mothers. Part III consists of five-point Likert scale to access maternal satisfaction on delivery. There were four domains of care, that is, health facility-related statements (6 statements), interpersonal aspects of care (11 statements), informative aspects of care (10 statements), and technical aspects of care (9 statements). Score 5 was given for very satisfied, 4 for satisfied, 3 for neither satisfied nor dissatisfied, 2 for dissatisfied, 1 for very dissatisfied. Likewise, mean score less than or equal to 3 was considered as dissatisfied, whereas mean score greater than 3 was considered as satisfied. In other words, total score less than or equal to 108 was considered dissatisfied and above 108 was considered satisfied. Neutral score was considered dissatisfied, considering the respondents might be reluctant to express their negative feelings as they were interviewed in hospital setting. Part IV consists of questionnaires related to mother's acceptance of service. The research instrument included the following parts:The content validity of the test instrument was established by extensive literature review, consulting with advisors, subject matter experts, and nursing research faculty, as well as by peer review. First of all, the instrument was developed in English language then was translated into Nepali language and retranslated into English version to retain the same meaning. Opinion from the language expert was obtained for comprehensibility and simplicity of language during translation and back translation.Cronbach's alpha was used for reliability analysis for satisfaction level. Result of Cronbach's alpha was 0.825 for overall satisfaction taking all statements.Pretesting of the instrument was done in 10% of mothers admitted in maternity unit of Bheri Zonal hospital for clarity and comprehensibility of the tool. Those pretested mothers were excluded from the study. On the basis of pretesting, the instrument was revised and finalized for use in data collection.Data were collected through face-to-face interview technique and the record review by the researcher herself after getting approval from the Research Committee, Maharajgunj Nursing campus, and Institutional Review Board (IRB) of Institute of Medicine. Permission was taken from the hospital authority with the submission of request letter from Maharajgunj Nursing Campus. Each respondent was briefed with the research objectives and informed written consent was obtained from the participants to ensure the right of the subject. Confidentiality was maintained throughout the study. Participants were given liberty to discontinue participating in the study if they wish. The participants were assured that the names will not be disclosed in the report and the information will be used for the study only. Precaution was taken throughout the study in every step to safeguard the right and welfare of all mothers in the study. The researcher provided needed information after completion of the interview.The data were collected within the given time period of four weeks . An exit interview, that is, the interview just before discharge, was taken with the mothers at their convenient time. The exit interview was selected to cover the maximum possible postnatal period during the hospital stay to assess overall maternal satisfaction on delivery service. About 20–25 minutes was taken to collect data from each respondent. At the end of interview, the collected forms were carefully checked for completeness and accuracy.Data were analyzed on the basis of research objectives and research questions. After collecting data, data were checked for accuracy, completeness, and consistency. The collected information was edited, coded, and entered in excel and afterwards transferred to SPSS version 16 for further analysis.Analysis and interpretation of the findings were done with the help of descriptive statistics . In inferential statistics as Pearson's chi-square, Fisher's exact tests were used to test the association between the dependent and independent variables, and values ≤ 0.05 were taken for statistical significance at 95% confidence interval. Odds ratio was computed to find out the strength of association.p=0.475; OR = 2.710; CI = 0.343–21.400); also, postnatal mothers up to primary level were 2.850 times more likely to be satisfied than secondary level and above .p=0.111; OR = 2.352; CI = 0.801–6.907).In response to an open-ended question regarding suggestions for improving service, the postnatal mothers gave many suggestions that are presented in 11 themes in Regarding statements related to health institution, 82.6% were satisfied with providing of necessary medicines and supplies, 92.1% were satisfied with the free-of-cost service, among whom 52.8% were very satisfied. Furthermore, the study shows 93.9% were satisfied with transportation allowance and incentives and 90.4% were satisfied with the prompt service. Also, only 64.6% were satisfied with the cleanliness of health institution and 41.5% were satisfies with the cleanliness and accessibility of toilet. Also, mean satisfaction score was lowest for cleanliness of the toilet. Consistent with this, the study conducted at Paropakar Maternity Hospital of Nepal showed that almost all (98.5%) of the respondents were satisfied with the free-of-cost service and transportation allowance (99.3%) and 78.2% were satisfied with general cleanliness of the facility. About 72.46% of the respondents were satisfied with the drug availability. Higher percentages were not satisfied with hospital environment (sanitation) . AnotherRegarding statements related to interpersonal aspects of care, 85.4% were satisfied with warm welcome on admission, 82.5% were satisfied with orientation given, 84.3% were satisfied with maintenance of privacy, and 88.2% were satisfied with explanation given about treatment. In relation to involvement in decision-making, 85.4% were satisfied and 87.1% were satisfied with decision supported and respected. Consistent with the study, a study conducted in Ethiopia showed that 98% were satisfied with respect and assurance of privacy, 78.4% were satisfied with involvement in decision-making, and 92.3% were satisfied with given explanation about the treatment . AnotherRegarding statements related to informative aspects of care, the study reveals that maternal satisfaction on receiving as much information as desired was 80.9%, result of examination and freedom of position 85.4%, benefits of diet 73.6%, state of newborn 82%, breast-feeding 81.4%, perineal and personal hygiene 76.4%, and information regarding baby care and immunization 62.9%. Only 46% were satisfied with information about postnatal follow-up visits, and 40.5% were satisfied with advice about danger signs. Thus, more information needs to be provided regarding postnatal visits and danger signs, but this area seems to be neglected. The study concludes that special attention should be focused on advices related to both postnatal mothers and their neonates. Postpartum women still required and needed guidance, more support, and assistance with baby care and their personal care. The study conducted in Tambacounda showed that maternal satisfaction increased when they received enough information on what to do in case of health problems, and the study showed that most of the mothers (93%) responded they received enough information as they wished .Regarding technical aspects of care, majority (95.5%) were satisfied with monitoring of blood pressure immediately after delivery among whom 50.6% were very satisfied, and also 89.9% and 89.3% were satisfied with monitoring of fetal heart sound and the progress of labour, respectively. Similarly, 82.5% were satisfied with comfortable position and 69.6% with pain management. The study also shows maternal satisfaction on assisted in perineal care/wound care 60.2%, breast-feeding 54.5%, and early ambulation 53.4%, whereas in the study conducted in Ethiopia, pain control was the poorest source of satisfaction with 82% reporting dissatisfaction .The study reveals that majority of the postnatal mothers (93.82%) were satisfied and 6.18% were dissatisfied with interpersonal and technical aspects of care. Likewise, 91.57% were satisfied and 8.4% were dissatisfied with informative aspects of care. Similarly, 91.01% were satisfied and 8.99% were dissatisfied with health institution related statements. The study reveals higher satisfaction in all aspects of care.Regarding overall satisfaction, majority 89.88%) of the postnatal mothers were satisfied and only 10.11% were dissatisfied with the delivery service. Thus, the study shows that the mothers are satisfied with the service they have received. The study findings correspond to the study done in different countries. In consistent to the study, a nationally representative facility-based survey conducted across 13 districts in Nepal showed 86% were satisfied and very satisfied with the care received at the facility . In cont9.88% of In the present study, there is no statistically significant association between sociodemographic characteristics and maternal satisfaction. This may be due to small sample size. This is consistent with the study done in India, which showed that age, religion, type of family, occupation, dietary pattern, and obstetrical score were not significant with maternal satisfaction at 0.05 level .Although insignificant, postnatal mothers whose age was 25 and above were more likely to be satisfied with delivery service than below 25 , and homemakers were more likely to be satisfied than other occupations . This finding is consistent with the study done in Lebanon, which showed that patients who are older are more satisfied with the childbirth experience and unemployed mothers were more satisfied with the childbirth experience than employed mothers [p=0.475; OR = 2.710; CI = 343–21.400); also, postnatal mothers up to primary level were 2.850 times more likely to be satisfied than secondary level and above . Literates were less satisfied with delivery service may be due to more expectation of quality service. These findings are consistent with the findings of the study done in Oromia, showing that respondents who had no higher education were more satisfied than those who had diploma and above [Also, in this study, postnatal mothers who were illiterate were 2.710 times more likely to be satisfied than who were literate . This finding is consistent with the study done in Lebanon that showed multiparous women were slightly more satisfied than primiparous [In this study, there is no statistically significant association between obstetric characteristics and maternal satisfaction. In contrast to this study, the study done in Oromia showed that there is positive and significant association between ANC follow-up, wanted (planned status of pregnancy), maternal and fetal outcome, and maternal satisfaction . AlthougThe present study shows majority (87.1%) of postnatal mothers would like and 4.5% would not like to receive delivery service next time in the same hospital. Majority (94.9%) would like to recommend the hospital to friends and relatives. This suggests that the hospital has skilled professionals providing an acceptable quality of care. Similarly, the study done in Oromia showed that most of the delivering postnatal mothers were very likely to recommend the facility to friends and family and also for themselves (99.4% and 97.5%), respectively .Regarding the reason for choosing the hospital, 70.78% replied convenience, followed by quality care 23%, 11.2% referred, and only 0.6% replied availability of operation facility. In this study, postnatal mothers chose the particular hospital on the grounds of convenience. Consistent with the study, the study conducted in India showed that majority (95%) replied convenience and 94% of postnatal mothers chose the particular hospital because of the availability of good doctors, and referred from other hospital 84%, whereas 33% of postnatal mothers selected the particular hospital because of quality care by the staff nurse .Regarding the mothers' responses for improving service, the postnatal mothers who suggested maintaining cleanliness were 42.7% followed by postnatal mothers who suggested to provide treatment properly were 22.5%. Likewise, 0.6% of the postnatal mothers suggested to take responsibility and not to scold. Also, 35.4% of the postnatal mothers replied that everything was good in the facility and required no improvement (no suggestions). Thus, the hospital environment should be clean so that the postnatal mothers can be satisfied. Consistent with the study, a nationally representative survey on maternal satisfaction conducted in Nepal showed that respondents suggested maintaining clean/hygienic health facilities (42%). About 17% of maternity clients responded that everything was good in the facility and required no improvement .On the basis of study findings, it is concluded that majority of the postnatal mothers are satisfied with the delivery service. The level of satisfaction was higher in interpersonal and technical aspects of care than in informative aspects and health facility-related statements. The higher the education level, the lower the level of maternal satisfaction, and multiparous are more likely to be satisfied with delivery service than primiparous. Most of the postnatal mothers would like to receive delivery service next time in the same hospital. More than two-thirds of the postnatal mothers chose the hospital due to convenience. Although the majority of postnatal mothers are satisfied by the delivery service, lack of dissatisfaction by a minority of postnatal mothers may result in a limited ability to engage in health facility, which further contributes to maternal mortality.Further studies can take into consideration the findings and limitations of this study for better results. The study could be done in community setting where postnatal mothers could freely express their satisfaction regarding the service they have received.Care givers need to fully understand the expectations that the mothers have for their care and provide care that is consistent with those expectations. The health system should be devised to increase maternal satisfaction in the health institution and provide maternal-friendly service.


A search for new physics in top quark production is performed in proton-proton collisions at  Because of its large mass, close to the electroweak (EW) symmetry breaking scale, the top quark is predicted to play an important role in several new physics scenarios. If the new physics scale is in the available energy range of the CERN LHC, the existence of new physics could be directly observed via the production of new particles. Otherwise, new physics could affect standard model (SM) interactions indirectly, through modifications of SM couplings or enhancements of rare SM processes. In this case, it is useful to introduce a model independent approach to parametrize and constrain possible deviations from SM predictions, independently of the fundamental theory of new physics.Several searches for new physics in the top quark sector including new non-SM couplings of the top quark have been performed at the Tevatron and LHC colliders –4, 4–10.In this paper, the EFT approach is followed to search for new physics in the top quark sector in the dilepton final states. In Refs. , 16, allmentclasspt{minimain Refs. , 16, 17.r decays . The ope physics , 20. Theument}CG , \docume channel , 23. Thet-channel production and measurements of the A variety of limits have been set on the mentclass2pt{minimy the D0  and CMS y the D0 , 5 Collan events . Searchen events , 8 and Ln events , 9 via sIn this paper, a search for new physics in top quark production using an EFT framework is reported. This is the first such search for new physics that uses the The paper is structured as follows. In Sect. The central feature of the CMS apparatus is a superconducting solenoid of 6 m internal diameter, providing a magnetic field of 3.8 T. Within the solenoid volume are a silicon pixel and strip tracker, a lead tungstate crystal electromagnetic calorimeter (ECAL), and a brass and scintillator hadron calorimeter, each composed of a barrel and two endcap sections. Forward calorimeters extend the pseudorapidity ( in Ref. .Powheg-Box event generator (v1 for pythia (v8.205) [pythia tune CUETP8M1 [powheg is reweighted to match the differential top quark MadGraph 5_amc@nlo (v2.2.2) event generator [pythia v8 for parton showering and hadronization. The events include the effects of additional Geant4  (v9.4) [The Monte Carlo (MC) samples for the diboson) –28 at th(v8.205)  to simulCUETP8M1  is used CUETP8M2  is used.CUETP8M2  set of tectively , 34. In  in Ref. . Other Senerator –38, inte  (v9.4) , 40, folFeynRules output (UFO) format [FeynRules package [MadGraph 5_amc@nlo (v2.2.2) event generator [K factors are given in Table In order to calculate the total cross sections for the mentclass2pt{minim) format  through  package . The outenerator , 37. If mentclass2pt{minimectively , 34, wheument}OG , 43, 44.mentclass2pt{minimThe event selection for this analysis is similar to the one used in Ref. . The eveectively .Offline, the particle-flow (PF) algorithm  aims to ndidates . Muon candidates , 48. TheThe PF candidates are clustered into jets using the anti-r of 0.4 –51. Jetsr of 0.4 . Jets wilgorithm ; this alately 1% . The mishe event . CorrectEvents are required to have at least two leptons (electrons or muons) with opposite sign and with an invariant mass above n-jets”) and number m-tags”) in the final state. The largest number of The events are divided into the entclass1pt{minimaThe contributions of SM processes leading to two prompt leptons in the final state are estimated from simulated samples and are normalised to the integrated luminosity of the data. These contributions originate mainly from To correct the DY simulation for the efficiency of the s window .The nonprompt lepton backgrounds which contain fake lepton(s) from a misreconstructed n-jets,m-tags) categories. We find generally very good agreement between data and predictions, within the uncertainties of the data.After all selections, the expected numbers of events from entclass1pt{minimaThe purpose of the analysis is to search for deviations from the SM predictions in the All the effective couplings introduced in Sect. analysis  and confn-jets, m-tags) categories is shown for the The deviation from the SM b vertex . The \doibutions . For thehrm{q}}^{}$$\end{dn-jets, 1-tag). The comparison of the NN output for data, SM background and signal  categories is considered. The impact of the difference between the kinematic distributions of In order to constrain the entclass1pt{minimaThe results of the fit for the individual channels and for all channels combined are listed in the first row of Table The results of the likelihood scans of the powheg matching method for In order to set limits on the effective couplings n-jets, 1-tag). The observed (median expected) Since the The observed best fit together with one and two standard deviation bounds on the six Wilson coefficients, A search for new physics in top quark interactions is performed using


Simple sequence repeats (SSR) – also known as microsatellites – have been used extensively in genetic analysis, fine mapping, quantitative trait locus (QTL) mapping, as well as marker-assisted selection (MAS) breeding and other techniques. Despite a plethora of studies reporting that perfect SSRs with stable motifs and flanking sequences are more efficient for genetic research, the lack of a high throughput technology for SSR genotyping has limited their use as genetic targets in many crops. In this study, we developed a technology called Target SSR-seq that combined the multiplexed amplification of perfect SSRs with high throughput sequencing. This method can genotype plenty of SSR loci in hundreds of samples with highly accurate results, due to the substantial coverage afforded by high throughput sequencing. We also detected 844 perfect SSRs based on 182 resequencing datasets in cucumber, of which 91 SSRs were selected for Target SSR-seq. Finally, 122 SSRs, including 31 SSRs for varieties identification, were used to genotype 382 key cucumber varieties readily available in Chinese markets using our Target SSR-seq method. Libraries of PCR products were constructed and then sequenced on the Illumina HiSeq X Ten platform. Bioinformatics analysis revealed that 111 filtered SSRs were accurately genotyped with an average coverage of 1289× at an extremely low cost; furthermore, 398 alleles were observed in 382 cucumber cultivars. Genetic analysis identified four populations: northern China type, southern China type, European type, and Xishuangbanna type. Moreover, we acquired a set of 16 core SSRs for the identification of 382 cucumber varieties, of which 42 were isolated as backbone cucumber varieties. This study demonstrated that Target SSR-seq is a novel and efficient method for genetic research. Simple sequence repeats (SSR) – otherwise known as microsatellites – exist ubiquitously throughout prokaryotic and eukaryotic genomes . Based oTraditional gel electrophoresis cannot distinguish base differences or changes correctly in SSR amplicons, often causing false positive or false negative results in SSR detection, likely caused by sequence variations in the SSR motifs or their flanking sequences; these variations may affect the PCR process and hence, the resultant products. Recently, genome-wide analyses of SNPs, SVs, and transposon insertion polymorphisms  were conducted based on large-scale resequencing studies in genetic variome research . HoweverA recent study established Ampli-seq as the first high throughput SSR genotyping method based on second-generation sequencing technology utilizing the Illumina MiSeq platform . This stIn this study, we developed a novel method called Target SSR-seq, which combined the high throughput sequencing system X Ten platform with genome-wide perfect SSRs that harbored stable motifs and flanking sequences derived from 182 resequencing datasets of a core collection of cucumber lines. This method enables the genotyping of hundreds of targeted SSR loci in a large number of samples with high coverage, simultaneously in a single Illumina HiSeq lane . By addiA total of 382 commercial cucumber varieties were utilized in this study , includiFirst, the cucumber reference genome 9930 V2 was analyzed to uncover genome-wide SSRs using GMATA software with the following parameters: motif repeated at least three times, motif length at least 3 bp, and repeat length up to 100 bp . In ordeIn addition, 58 well-known SSR loci used to distinguish cucumber varieties in China (NY/T 2474-2013)  were anaTaq enzyme, 18 μL pure water, and 1 μL of primers with the following sequences: forward 5′-AATGATACGGCGACCA-CCGAGATCTACACTCTTTCCCTACACGACGCTCTTCCG-3′ and reverse 5′-CAAGCAGAAGACGGCATACGAGATXXXXXXXXGTGACTGGAGTTCCTTGGCACCCGAGA-3′ (barcodes are indicated by underlined sequences). The PCR conditions were as follows: 95°C for 3 min then 7 cycles of 95°C for 15 s, 58°C for 15 s, and 72°C for 30 s, and extension at 72°C for 4 min. The second round PCR products were purified with 100 μL 80% alcohol and 23 μL Tris–HCl buffer . Thereafter, the Target SSR-seq library was ready to sequence on the X Ten platform (Molbreeding Biotechnology Company). To verify the repeatability of Target SSR-seq, DNA of cucumber 9930 and pure water were set up as positive and negative controls in PCR amplification, respectively.The Target SSR-seq library construction consisted of two rounds of PCR : the fir1 under accession numbers CRA001490. The raw Target SSR-seq data were de-multiplexed to determine the exact genotypes for each variety using the Illumina bcl2fastq pipeline . Adaptor and low-quality sequences were filtered out from raw reads using Trimmomatic with parameters as “SLIDINGWINDOW: 4:20 LEADING:3 TRAILING:3 MINLEN:40” (2 using BWA with default parameters and 15-bp flanking sequences of SSR loci on reference genome were isolated to determine the perfect SSR genotype using MISA software3 (The raw data reported in this study have been deposited in the Genome Sequence ArchiveNLEN:40” . The reaoftware3 . Based ooH), genetic diversity, polymorphic information content (PIC) value  value , and inbC) value  were call is the allele locus and iP and jP represent the population frequency of the ith and jth allele.where Population structure was inferred by a model-based program STRUCTURE V2.3 with the following parameters: 100,000 burn-in length, 10,000 iterations, admixture model . The optFst. AMOVA was performed in the poppr R package ; the pairwise  package  and the To select a core SSR set for variety identification, we developed a new Perl method to choose the best discernibility group based on the principle of minimum numbers of SSRs representing the maximum genetic diversity. Discernibility by pairwise comparison of all samples was as the first filter condition, and the dataset with the same discernibility were then selected with higher PIC. The highest discernible SSR loci were chosen as an initial core dataset and each SSR were subsequently added to the initial core dataset to form a new dataset. The second SSR were chosen from the new dataset with highest discernibility and were added to the core dataset. The following selection were the same as the second SSR until the discernibility reached the maximum. Finally, a best-discernibility group of SSRs was obtained as the core SSR set, and the saturation curves of its discernibility were plotted by pairwise comparison of varieties genotypes.According to the international standards for identifying crop varieties , we set In this study, we developed a novel approach for SSR genotyping using a target sequencing technology called Target SSR-seq, which can be applied in genetic research, DNA fingerprinting, variety identification, and molecular breeding . This stCompared with existing methods for SSR detection, Target SSR-seq combined multiplexed PCR with target deep sequencing and was immediately capable of highly accurate SSR genotyping . This neWe acquired 208 139 SSRs in the cucumber reference 9930 V2 genome, of which 10 404 SSRs were suitable for multiplexed PCR capture. Based on the resequencing data for 182 cucumber varieties, 1700 SSRs exhibited polymorphisms. Furthermore, 844 perfect SSRs were obtained with read frequency of the major alleles greater than 0.7 and stable flanking sequences. In this study, 91 evenly distributed perfect SSRs in the cucumber genome were randomly selected to test in Target SSR-seq.In addition, the current Target SSR-seq panel included 31 SSR loci that are often tested in genetic research on cucumbers, which were used to compare the genotyping efficiency with that of the genome-wide perfect SSRs. Finally, a total of 122 target SSRs were successfully designed in the next multiplexed PCR procedure.In total, the Target SSR-seq obtained 230 million reads and 34 billion bases in 382 cucumber varieties . In the Ho varied from 0 to 0.95 with a mean of 0.17, and seven SSRs exhibited higher Ho (>0.4)  . The lowThe STRUCTURE and Evanno’s correction results indicated that 382 cucumber varieties were divided into two main populations (Pop1 and Pop2), based on the optimal number of K = 2 . In geneHCPC analysis was used to validate the results from STRUCTURE. The variance between cluster and the variance gain were significantly decreased when the cluster number increased . The recFst result demonstrated that population differentiation between Pop1 and Pop2 is moderate (Fst = 0.35), which was similar to previous research in cucumber germplasms, ranging from 0.30 to 0.33 based on 23 SSRs (Fst between four subpopulations ranged from 0.14 to 0.47 (Fst between Pop1A and Pop1B showed a low level of differentiation (Fst = 0.14). The distinct differentiation was observed in other pairwise Fst analysis.AMOVA analysis of 111 SSR genotypes in 382 varieties indicated that the maximum variation of 29.2% resulted from differences within samples, while the minimum variation of 17.6% was accounted for between subpopulations within populations . The Fst 23 SSRs . The pai to 0.47 . Among tFst between Pop1 and Pop2 was 0.25. Hence, this set of 16 core SSRs was sufficient in representing the genetic diversity and identifying cucumber varieties in Chinese markets.The core SSR set was used to analyze the genetic diversity and variety identity in crops . This stThe genetic background of Chinese cultivated cucumber was considerably narrow, given that breeders follow similar breeding goals, resulting in many varieties with close genetic relationships. In this study, we built a genetic similarity matrix in four subgroups by counting the number of differential SSR genotypes between each DNA sample . High geSimple sequence repeats (SSRs), also known as short tandem repeats (STRs) or microsatellites, exist extensively throughout eukaryotic genomes and are therefore used widely in genetic background selection and MAS breeding, as well as in map-based cloning, QTL mapping, seed identification and purification . HoweverWith the development of domestic and international seed trade, the commercial quality of seed based on authenticity and purity is becoming more important for both seed producers and farmers . The tra4. However, the genetic background has remained unclear, as well as the diversity of cucumber varieties in current Chinese markets. This study created a novel method called Target SSR-seq, which successfully genotyped 111 genome-wide SSRs in 382 cucumber varieties in Chinese markets. The results showed four subpopulations were found: northern China type, southern China type, European type, and Xishuangbanna type (It was well known that China has a long history in the cultivation of cucumbers since the Han dynasty, when it has been reported that cucumber was first introduced into China through the Silk Route . Over senna type , which wnna type . Howevernna type , which wIn view of its high accuracy and efficiency, Target SSR-seq associate with genome-wide perfect SSRs has great potential application not only in varieties identification, but also in many other research fields , such asCW designed the research. JY did the bioinformatics analysis. CW, RH, FZ, AM, and HT prepared the research. JianZ, JL, BD, and HL performed the research. JiananZ designed the multiple PCR. YJ, JianZ, and RH analyzed the data and wrote the manuscript. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


N = 531), and matched healthy controls (N = 571). Since ongoing studies suggest that non-standard populations have important differences in their HRFs when compared with healthy control, this data set is valuable in studying variability of HRF in ASD group and inferring the underlying pathology that also affects the HRF. It also has implications for fMRI analyses like resting-sate connectivity analysis.In Functional magnetic resonance imaging (fMRI), the blood oxygen level dependent (BOLD) signal is modeled as a convolution of the hemodynamic response function (HRF) and the unmeasured latent neural signal. Although most cortical and subcortical brain regions share the canonical shape of the HRF, the temporal structure of HRFs are variable across brain regions and subjects. This variability is induced by both neural and non-neural factors. The variability between subjects can be examined by three parameters that characterize the HRF: response height (RH), time-to-peak (TTP) and full-width at half-max (FWHM). This data provides three HRF parameters at every voxel, obtained from Autism Spectrum Disorder (ASD) patients ( It could be used to assess the HRF variability in these two populations. Moreover, the shape of the HRF is affected by both neural and non-neural factors •In pathological populations, the non-neural factors that control the HRF shape also contribute to the brain pathology. For example, imbalances in GABA, nitric oxide, glutamate or serotonin in the ASD population may also impact the shape of the HRF •As mentioned above, the HRF shape could be related to ASD pathology. Therefore, the differences in HRF parameters between ASD patients and matched controls could be used in classifying these two populations.•This data could be used to study the impact of HRF variability on resting-state fMRI data analyses such as effective and functional connectivity modeling 13. The provided data is organized as six 4-dimensional matrices stored as two MAT-files (.mat). The parameters for the ASD and control groups were constructed as separate MAT-files. Each mat-file contain three 4D matrices, representing three HRF parameters  for every subject. The first dimension of the file represents the number of subjects and the remaining three dimensions represent the three spatial coordinates of each brain volume. Since the fMRI data used to estimate HRF parameters were provided by different institutions, a one-way ANOVA analysis was performed to investigate inter-site differences.The data presents three HRF parameters  at each brain voxel for 1102 subjects, which includes 531 ASD patients and 571 healthy controls. For each parameter in each subject, the 3-dimensional data consisted a volume dimension of 91 × 109 × 91. The 3D matrix was coregistered to the Montreal Neurological Institute (MNI) space with the voxel dimension of 2 × 2 × 2 mm22.1http://fcon_1000.projects.nitrc.org/indi/abide/.The resting-state fMRI data was obtained from the Autism Brain Imaging Data Exchange (ABIDE-1) database 2.2® platform using the Data Processing Assistant for Resting-State fMRI (DPARSF) toolbox The pre-processing pipeline for this dataset was confined to the steps performed by ABIDE prior to publication of this public dataset. For each individual participant, the first four temporal image volumes were discarded. The remaining volumes were pre-processed with the following steps. Slice timing correction was performed first. For each volume, the signal measured in each slice was shifted relative to the slice that was acquired at the mid-point of each TR. All the images were realigned by using the six rigid body motion parameters. Spatial normalization was then performed and all the images were normalized to the Montreal Neurological Institute (MNI) template. In order to reduce the effects of head motion, motion regression was carried out by applying a 24-parameter  model 2.3We further studied a recent blind deconvolution method Based on the HRF parameters obtained from the ASD and control populations, we further studied the systemic aberration of the HRF between these two populations, and the possible confounds introduced by the variable HRF in resting-state connectivity analysis. These findings have been published as a full article at NeuroImage: Clinical


However, hyperglycemia is not included in this scale. The purpose of the present study was to explore whether the A2DS2 scoring system and hyperglycemia could predict the risk of SAP more effectively than the conventional A2DS2 scale.Stroke-associated pneumonia (SAP) is a common complication of cerebrovascular disease. The A2DS2 scores, fasting blood glucose level and blood glucose level on admission were collected. Regression analysis was used to identify the independent risk factors of SAP. ROC curve analysis was used to evaluate the specificity and sensitivity of the combined A2DS2 score and fasting hyperglycemia for predicting SAP.This retrospective study enrolled 2552 patients with acute ischemic stroke. The AP < 0.001). The area under curve of the combined A2DS2 score and fasting hyperglycemia was significantly higher than that of the A2DS2 score alone .Fasting hyperglycemia was an independent risk factor for SAP  is more effective in predicting the risk of SAP. Pneumonia is a common critical complication following acute ischemic stroke, and the risk factors include senior age, severe basic diseases, and long duration of hospitalization. Pneumonia increases the duration and expense of hospitalization, and has well been associated with high mortality . Therefo2DS2 scoring system, which was proposed by Hoffmann et al., is a simple and effective evaluation tool for predicting the risk of SAP during hospitalization [2DS2 assessment can easily be completed on admission. However, it is still not widely used in clinical practice.Stroke-associated pneumonia (SAP) refers to pneumonia occurring during the first seven days after stroke onset in non-ventilated patients . Its inclization . This halization –11, Franlization , Spain [lization , the Unilization , and Denlization . The A2D2DS2 scoring system [2DS2 score and hyperglycemia for predicting SAP remains unclear.Several studies have indicated that hyperglycemia may also be a risk factor for SAP , 14, 15 g system , and rel2DS2 score and hyperglycemia for the risk of SAP in patients with acute ischemic stroke during hospitalization.The purpose of the present study was to investigate the predictive ability of the combined A2DS2 scoring items, or (e) mechanical ventilation.This retrospective study focused on patients with acute ischemic stroke hospitalized in the First Hospital of Shanxi Medical University from January 2012 to December 2016. Inclusion criteria: (a) magnetic resonance imaging (MRI) revealing an acute cerebral infarction; (b) the patient was admitted within seven days after onset of stroke; (c) random blood glucose level on admission and fasting blood glucose level at the next morning after admission are available. Exclusion criteria: (a) transient ischemic attack (TIA), (b) patients who were discharged or died within three days after onset, (c) patients with pre-existing pneumonia before admission, (d) the lack of more than one of the A2DS2 scoring system comprised of the following: (1) 1 point for elderly age (≥75 years old); (2) 1 point for male gender; (3) 1 point for atrial fibrillation; (4) 2 points for dysphagia; (5) 3 points for an National Institute of Health stroke scale (NIHSS) score within 5–15 points; (6) 5 points for an NIHSS score > 16 points.The ADemographic data (age and gender) were collected. Previous and present medical history  were reviewed. An electrocardiogram was performed for all patients, and atrial fibrillation was recorded. Our department belongs to the stroke unit and has a professional rehabilitation doctor. At admission, all patients were assessed by rehabilitation physicians based on the Kubota Drinking Test which was conducted by Wata Junfu of Japan  for dyspAdmission hyperglycemia was diagnosed when the random blood glucose level on admission was ≥11.1 mmol/L, while fasting hyperglycemia was diagnosed when the blood glucose level at the next morning after admission was ≥7.1 mmol/L.SAP was diagnosed according to the modified Centers for Disease Control and Prevention (CDC) criteria  and/or MThe assignment rules for the independent risk factor of SAP were as follows: 1 point was assigned for 1.25 < adjusted odds ratio (OR) < 2.0; 2 points were assigned for 2.0 ≤ adjusted OR < 4.0; 3 points were assigned for 4.0 ≤ adjusted OR < 6.0 .SPSS 20.0 software  and MedCalc 15.2.2 software  were used for the statistical analyses.2DS2 scoring system was designed by combining the conventional A2DS2 items and assigned hyperglycemia points.The following analysis used SPSS 20.0 software. Continuous variables were expressed as the mean ± standard deviation (SD). Categorical variables were expressed as percentage. Continuous variables were compared using nonparametric tests, and categorical variables were compared using Chi-squared test. Logistic regression was used to calculate the adjusted OR value after balancing the confounding factors. Hyperglycemia was assigned according to the above assignment rules, and the a modified A2DS2 scoring system and modified A2DS2 scoring system. The cut-off values that represented the sensitivity and specificity of each evaluation tool were analyzed. Points with the maximal Youden’s index were obtained as the optimal cut-off values. The ROC curve comparison method was used to compare whether the improved A2DS2 score was superior to the A2DS2 score.Receiver operating characteristic (ROC) curve analysis method in MedCalc 15.2.2 software was used to calculate the area under the curve of the conventional Ap) values ≤0.05 were considered statistically significant.Probability (P > 0.05). The incidence of SAP in patients with the following factor(s) was significantly higher than that in patients without the following factor(s) (P < 0.05): elderly age (≥75 years old), atrial fibrillation, dysphagia, random hyperglycemia, fasting hyperglycemia, or random or fasting hyperglycemia. Therefore, these factors were considered as potential risk factors for SAP. These patients were classified into three subgroups according to stroke severity (NIHSS score), and there was a statistically significant difference in the incidence of pneumonia among these three subgroups (P < 0.05). The clinical characteristics of patients in the SAP group and non-SAP group, and the relevant statistical results are summarized in Table In strict accordance with the inclusion and exclusion criteria set in this study, a total of 2552 patients were included in this study. The average age of the enrolled patients was 61.9 ± 12.7 years. SAP were observed in 7.8% (200 cases) of all patients. There was no significant difference in gender and infarction site between the SAP group and non-SAP group (P < 0.05). The detailed statistical results are prsented in Table 2DS2 scoring system , male gender, atrial fibrillation, dysphagia, an NIHSS score of 5–15 points, NIHSS of ≥16 points, and fasting hyperglycemia were independent risk factors of SAP  for predicting SAP was investigated. It was found that fasting hyperglycemia is an independent risk factor of SAP, which may be a valuable indicator for predicting SAP. Moreover, the predictive value of the modified A2DS2 scoring system is better than that of the conventional A2DS2 scoring system.In the present study, the value of the modified A2DS2 scoring system, in which scoring items include age, gender, atrial fibrillation, dysphagia and severity of stroke, has been proven to be a simple and reliable scoring scale. However, in literature, hyperglycemia has also been reported as a potential risk factor of SAP, although the evidence remains controversial. Hoffman et al. found that the history of diabetes was not an independent risk factor for SAP [In present clinical practice, evaluating the risk of SAP remains challenging. The A for SAP  . It is According to the international diagnosis and treatment guidelines for acute stroke, blood glucose level is recommended as a routine screening index for all patients. In the present study, the random blood glucose level after the onset of stroke represented stress hyperglycemia. Fasting hyperglycemia represented diabetes with poor glycemic control or newly-onset diabetes. Random or fasting hyperglycemia represented an increased blood glucose level caused by different causes. After statistical comparisons, merely fasting hyperglycemia entered the logistic regression model. It was speculated that stress hyperglycemia may be not an independent risk factor for SAP, and occasional transient hyperglycemia cannot increase the risk of SAP. Patients with fasting hyperglycemia (diabetes with poor glycemic control or newly-onset diabetes) are more likely to have SAP, which is consistent with previous findings , 14, 15 The present study indicated that fasting hyperglycemia is an independent risk factor for SAP. Acute ischemic stroke can cause hyperglycemia mainly through the following mechanisms: the activation of the sympathetic and parasympathetic nervous system –20, and A number of studies have shown that hyperglycemia is significantly correlated with the occurrence of pneumonia and the poor outcome of acute ischemic stroke, especially in patients without diabetes. Dziedzic et al. noted that the incidence of pneumonia was higher in non-diabetic patients with fasting hyperglycemia. Nevertheless, the multivariate analysis revealed that fasting hyperglycemia was not significantly associated with pneumonia . Hirata The management of hyperglycemia should be highlighted during hospitalization for reducing the risks of SAP. Blood glucose level is correlated to the functions of various intracranial systems, such as the cerebrovascular system, inflammatory system, and metabolic system . Appropr2DS2 scoring system was significantly higher than that of the conventional A2DS2 scoring system, suggesting that the modified system (including the item of hyperglycemia) is more effective for predicting SAP. This modified A2DS2 scoring system may help to predict the risk of SAP in early stage of stroke patients more effectively, allowing timely prophylactic treatment, such as antibiotic therapy and the prophylactic use of aspiration.Furthermore, the average age of patients in the present study was lower than that reported in the study conducted by Hoffman et al. (61.9 ± 12.7 vs. 71.2 ± 13.1) [2DS2 scoring system and AIS-APS scale [2DS2 scoring system and evaluation of hyperglycemia. The present findings may improve the predictive value of the A2DS2 scoring system.The present study has some strengths. At present, reliable tools for predicting the risk of SAP include the APS scale , 7. In tThere were still some limitations in the present study. First, the dynamic changes of the blood glucose levels of patients were not monitored throughout hospitalization, and only the random blood glucose level on admission was assessed. Second, the single-center and retrospective design was an inherent defect of the present study. In the future research, more external verifications are needed to arrive at a definitive conclusion.2DS2 score and fasting hyperglycemia) is more effective in predicting the risk of SAP.Fasting hyperglycemia is an independent risk factor for predicting SAP. Compared with the A2DS2 score, the modified A2DS2 score (combined AAdditional file 1. Supplementary material


Physical rehabilitation, as one of the rehabilitation disciplines, can play a great role in humanitarian reliefs. The effectiveness of physical rehabilitation services is completely dependent on time of intervention, the importance of good timing in providing services during disasters is not well understood. The objective of this study was to systematically review the physical rehabilitation services provided in disasters and emergencies.An electronic search of PubMed, Scopus, Cochrane, and PEDro (Physiotherapy Evidence Database) was undertaken from Jan 2000 to Sep 2017. All English studies reporting physical rehabilitation services in natural and man-made disasters were selected regardless of study design. The included studies were analyzed by descriptive and analytical method.Thirteen studies were included after reviewing by title, abstract and full text in this study. Most of the physical rehabilitation studies come back to recent years. Most of the disaster physical rehabilitation services were physiotherapy and occupational therapy. The physical rehabilitation experts have been attended in the affected area from the few first hours until several months after disasters in order to provide the required services to the affected population.There are few studies about physical rehabilitation services provided in the disaster-affected areas and this study showed that the services were limited and at different times. Physical rehabilitation services post disasters should have a comprehensive service model, like other health services. Therefore, it is necessary to conduct further studies to achieve this aim. Many major health conditions need rehabilitation to improve outcomes following disasters and emergencies –3. RehabArticle 11 of the United Nations (UN) convention on the rights of persons with disabilities mandates countries to support persons with disability in disasters and conflicts . The UN Physical rehabilitation plays an important role in the rehabilitation process and it is an essential part of fully integrating disabled people in society . SeveralAccordingly, this study aimed to investigate the physical rehabilitation services provided in disasters and emergencies.This study was conducted to answer this research question as follows: what are the characteristics (kind of service and time of service delivery) of physical rehabilitation services in provided in past disasters and emergencies?For the purpose of this review, PubMed, Scopus, Cochrane, and PEDro (Physiotherapy Evidence Database) databases were the main sources of information in this study. Since research on disaster physical rehabilitation is a relatively new concept, the time of the search was limited to Jan 2000 to Sep 2017.They were accessed and searched in Dec of 2017. In addition, for locating gray literature, we used different searching strategies: 1) Google search engine, 2) purposive websites, and 3) consultation with national and international experts. The reference lists of founded studies were other fruitful sources of material.All sources of written material were obtained using the same search strategy. Terms such as physical rehabilitation, physiotherapy, physical therapy, occupational therapy, speech therapy, orthotics, prosthetics, disaster, and conflict were applied by using Medical Subject Headings (MESH). MESH terms were also used to find more relevant articles .Included articles were that published in academic journals, reported one or more kinds of physical rehabilitation intervention such as physiotherapy, occupational therapy, speech therapy, orthotics and prosthetics in natural/man-made disasters and conflicts.Excluded articles focused only on the importance and effectiveness of rehabilitation services or the epidemiology of injuries of disaster and conflicts. Moreover, studies with no intervention about providing rehabilitation services in disasters and conflicts were removed from the study. Non-English studies and studies published before 2000 were also excluded.The first author reviewed titles of all articles retrieved by searching in databases. Every article that met the inclusion criteria was selected. Selected documents were entered in Microsoft Excel Spreadsheet and duplicate titles were removed. Finally, all articles were reviewed by the second author. In order to perform a blind-review, the names of authors and journals were removed . The revTotally, 2281 studies were obtained through electronic search in databases and other resources. After removing duplicate articles, 2150 titles were selected for further review. By reviewing studies based on title and abstract, 1959 studies were excluded from the study and three abstracts were not found. Full-text review excluded 170 articles while eight full texts were inaccessible for review. Altogether, 13 qualified studies were analyzed in this review.Four articles of the thirteen (31%) were affiliated to China and Canada (2 articles per country), three articles were affiliated with USA (23%) and the 6 other countries, including Haiti, Netherlands, Iran, India, Australia and Philippines were attended with one article in this study (46%). Ten articles of the thirteen (76.9%) were published during 2010–2016. One study had cohort design, one study was with design of quasi-experimental and the two researches has been designed cross-sectional while the other nine resources were review of programs, experiences, clinical notes or perspective. Most studies (69.2%) focused on providing services of physical rehabilitation after the earthquake, two (15.4%) on hurricane and two (15.4%) were related to man-made disasters including bombing attack and conflict.Overall, 11 of the 13 included studies (84.6%) were physical rehabilitation relevant services in past six major natural disasters, including Bam, Kashmir, Sichuan, Haiti and Nepal earthquakes and the Hurricane Katrina. Two (15.4%) studies focused on physical rehabilitation service delivery in man-made disasters. The earliest document in this review was about providing physical rehabilitation services after the Bali bombing disaster 2002 that published in 2005.There was no publication on physical rehabilitation in disasters and emergencies in 2006. In 2007, two articles were published, Bam earthquake 2003, and Hurricane Katrina 2005, respectively. There was another gap between 2008 and 2009. However, in 2010 three articles were published in relation to the Haiti earthquake and establishing physical rehabilitation services to affected population. During 2012, 2013 and 2014, two, one and two articles were published, respectively. One article was published in 2015 and one article was published in 2016 .Most studies indicated the multidisciplinary physical rehabilitation including physical therapy, occupational therapy and assistive devices as the provided rehabilitation services in the earthquake zones. Two studies focused on physical therapy as an intervention, one study highlighted on prosthetics delivery in humanitarian action and the other research was related to orthotics and physiotherapy. In such disasters, the physical rehabilitation services were established temporary in periods of time and depended on existing cases in the affected area. In the other disasters, the provided rehabilitation services completely relied on modern and professional equipment that was incompatible with the conditions and facilities of the region before occurring disaster.In addition, there is not a consensus on time of physical rehabilitation service delivery in disasters and emergencies. In some cases such as bombing attack, the mentioned services have been provided during hospitalization for victims, while in a conflict, access to rehabilitation services may postpone for several months. We observed in other studies that this time between the occurring of disaster and delivery of rehabilitation services varies from medical stabilization of the injured persons in first or two weeks to one or two months following disasters. In all studies, physical rehabilitation services were established by rehabilitation professionals. In the Bam earthquake, first, the international providers established rehabilitation services to affected local people and then the Iranian specialists were involved in the delivery of rehabilitation services. In relation to preparedness of physical rehabilitation relief teams, most of these teams that attended at the disaster scene were not previously prepared. Only, in one case the coordination between international organizations and national service providers were organized prior to disaster. The main aim of the study was identifying characteristics of physical rehabilitation services in past disasters and emergencies. A number of included articles for review obviously showed that research related to disaster physical rehabilitation was limited and interest in research on disaster rehabilitation relief has been recently increased. Therefore, before 2012 research on this subject was sporadic.The few publications on disaster physical rehabilitation are supported by some past studies , 19–21. This study showed that physical rehabilitation reliefs were conducted sporadically in past disasters and emergencies. Emergencies, and that the services provided, especially during the early phase, were by and large, uncoordinated.Our findings confirm that physical rehabilitation relief is either not provided or provided insufficiently during the early phases of disasters. After the Bam earthquake, the first rehabilitation specialists entered the earthquake zone after at least one month, and this delayed arrival was of little help to patients due to a lack of physical rehabilitation equipment , 22. In Among the different aspects of therapy, physical therapy and prosthetics were the most available needs for disaster and emergency victims , 24. PhyHealth system response to disasters requires disaster preparedness on three levels: prevention, medical treatment and rehabilitation . Many stResearch on disaster physical rehabilitation is relatively new and limited evidence exist. Moreover, many of the existing studies in this scope are experience-based. This review recommends the integration of physical rehabilitation interventions into response plans of the health system at the time of disasters and emergencies. This issue needs further studies to be able to create a comprehensive model to deliver coordinated and appropriate services of physical rehabilitation following disasters and emergencies, so does the other healthcare models.Ethical issues  have been completely observed by the authors.


Alcoholic liver disease (ALD) is caused by heavy alcohol consumption over a long period. Acetaldehyde-mediated toxicity, oxidative stress, and imbalance of lipid metabolism are generally considered involved in the initiation of ALD. There is an increasing requirement for alternative and natural medicine to treat ALD. Recently, aldose reductase (AR) has been reported to be involved in the development of ALD by affecting inflammatory cytokines, oxidative stress, and lipid metabolism. Here, we review the effect of plant-derived AR inhibitors on ALD in rodents. And we conclude that AR inhibitors of plant origin may enhance antioxidant capacity, inhibit lipid peroxidation and inflammatory cytokines expression, and activate AMP-activated protein kinase thereby subsequently suppressing alcohol-induced lipid synthesis in liver to achieve ALD protection. This review reveals that natural AR inhibitor may be potential therapeutic agent for ALD. Alcoholic liver disease (ALD) is caused by heavy alcohol consumption over a long period. Metabolism of alcohol in the body produces harmful substances, which lead to liver damage and a series of pathological changes in the liver. The incidence of ALD is relatively high among liver diseases. The spectrum of ALD includes alcoholic fatty liver (AFL), alcoholic steatohepatitis (ASH), progressive fibrosis, cirrhosis, and in some cases hepatocellular cancer (HCC) . AFL is The pathogenesis of ALD has not been fully elucidated. Acetaldehyde-mediated toxicity, oxidative stress, and imbalance of lipid metabolism are generally considered involved in the initiation of ALD –9. The “α) or AMP-activated protein kinase (AMPK) expression. PPAR-α, a nuclear receptor closely related to lipid metabolism, regulates genes involved in the uptake, binding, transportation, and activation of fatty acids. PPAR-α is mainly expressed in hepatocytes and involved in lipid metabolism in the liver. It plays a key role in regulating lipid transport and fatty-acid oxidative degradation in the liver, so it can prevent the development of fatty liver to some extent [α in the development of ALD [Many studies have suggested that alcohol-induced imbalance in lipid metabolism may be caused by alcohol-induced abnormal expression of genes involved in lipid metabolism, e.g., peroxisome proliferator-activated receptor alpha  levels and electron flow in the electron transport chain in the mitochondria, activating nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) and microsomal ethanol oxidase system (MEOS) to generate a large quantity of reactive oxygen species (ROS) . In addiDuring alcohol metabolism, some antioxidant pathways become activated and so interfere with oxidative stress damage in the human body. For example, the endogenous antioxidant superoxide dismutase (SOD) can interfere with alcohol-induced damage in the liver. Antioxidants such as SOD and catalase in the liver and vitamin C in food can eliminate a large proportion of ROS produced after alcohol intake. Long-term heavy consumption of alcohol can cause gastrointestinal dysfunction and reduce the absorption of antioxidants from food sources. Further, the process of alcohol metabolism also consumes large quantities of antioxidants, causing ROS to accumulate in the body , 7.AR is part of the NADPH-dependent aldehyde-keto reductase superfamily. It is multifunctional and acts as a rate-limiting enzyme of the polyol pathway in sugar metabolism. Through the regulation of cytokines, growth factors, oxidative stress, and other mediated intracellular signal transduction pathways, AR participates in a variety of disease pathological processes . AR is wα) overexpression to improve alcohol-induced lipid accumulation in hepatocyte [In addition to being highly expressed in organs and tissues that are relative to diabetic complications, AR expression is also induced in the livers of ALD patients  and alcopatocyte . In anotpatocyte . Our metpatocyte .Activation of AR increases the consumption of NADPH and competitively inhibits nitric oxide synthase, which also uses NADPH as a coenzyme. Nitric oxide plays an important role in maintaining the physiological functions of vascular endothelium and nerve tissues. Consumption of large amounts of NADPH causes significant reductions in the amount of nitric oxide synthesized, which ultimately disrupts the reduction-oxidation (redox) system and damages tissue. Increases in NADPH consumption also allow competitive inhibition of the normal synthesis of glutathione (GSH) reductase, which also uses NADPH as a coenzyme, resulting in a significant decrease in the levels of the important antioxidant GSH in cells . EthanolμM), guaijaverin (IC50=0.18 μM), and desmanthin-1 (IC50=0.082 μM) exhibited potent inhibitory activity on rat lens AR [μM, 2.2 μM, 2.2 μM, 3.7 μM, and 3.8 μM respectively, although their activities were weaker than epalrestat, a commercial synthetic aldose reductase inhibitor that inhibits AR with an IC50 of 0.172 μM. In another study, a phenolics, ellagic acid, isolated from Chrysanthemum morifolium exhibited inhibitory activity with an IC50 of 0.2 μM, which is stronger than that of quercetin (1.2 μM) in this study [μM, 44.7 μM, and 25.1 μM, respectively [μM in a noncompetitive manner in one study [μM in the other study [μM [AR inhibitors are generally divided into three categories according to the sources: natural AR inhibitors of plant origin, natural AR inhibitors of microbial origin, and synthetic AR inhibitors such as carboxylic acids, hydantoins, and phenylpyrrolidone compounds. Among the three categories of AR inhibitors, plant AR inhibitors, which mainly include flavonoids, polyphenols, terpenoids, and alkaloids, have seen widespread use because of their wide range of sources and low rate of adverse reactions. Plant-derived compounds with AR inhibitory effect have been extensively reviewed by Veeresham et al.  and Kawa lens AR . Howeveris study . These sis study . In addiectively . And curne study , or wither study . Chlorogtudy [μM . These s S. quelpaertensis extract (SQEA) was reported to exert cytoprotective effect against ethanol-induced toxicity in HepG2 cells and exhibit antisteatosis effect via the activation of AMPK signaling pathway in alcohol challenged livers [Previously we demonstrated that zopolrestat, a chemically synthesized AR inhibitor, improved ethanol-induced liver injury in mice through suppressing oxidative stress, reducing proinflammatory cytokines expression and modulating AMPK/SREBP-1c pathway to attenuate fatty acid synthesis . The samd livers . InteresIn summary, as depicted in