Limited resources, whether public or private, demand prioritisation among competing needs to maximise productivity. With a substantial increase in the number of reported HIV cases, little work has been done to understand how resources have been distributed and what factors may have influenced allocation within the newly introduced Enhanced National AIDS Control Program of Pakistan. The objective of this study was to identify perceptions of decision makers about the process of resource allocation within Pakistan's Enhanced National AIDS Control Program.A qualitative study was undertaken and in-depth interviews of decision makers at provincial and federal levels responsible to allocate resources within the program were conducted.ad hoc decision making were thought to reduce resistance to external pressures.HIV was not considered a priority issue by all study participants and external funding for the program was thought to have been accepted because of poor foreign currency reserves and donor agency influence rather than local need. Political influences from the federal government and donor agencies were thought to manipulate distribution of funds within the program. These influences were thought to occur despite the existence of a well-laid out procedure to determine allocation of public resources. Lack of collaboration among departments involved in decision making, a pervasive lack of technical expertise, paucity of information and an atmosphere of Development of a unified program vision through a consultative process and advocacy is necessary to understand goals to be achieved, to enhance program ownership and develop consensus about how money and effort should be directed. Enhancing public sector expertise in planning and budgeting is essential not just for the program, but also to reduce reliance on external agencies for technical support. Strengthening available databases for effective decision making is required to make financial allocations based on real, rather than perceived needs. With a large part of HIV program funding dedicated to public-private partnerships, it becomes imperative to develop public sector capacity to administer contracts, coordinate and monitor activities of the non-governmental sector. Public sector funding, like any resource, is limited; and comDespite development of decision making tools to assist policy makers in reaching unequivocal and optimal solutions for resource distribution -4, the lWhile calls to make prioritisation within the health care setting more rational and evidence-based exist, individIn Pakistan, the portfolio of Health is a provincial mandate, with federal policies providing guidance. ProposaThough efficient resource utilization is a key public health issue, there is insufficient local literature and perspectives of decision makers about the process remain unknown. The objective of this study was to identify perceptions of decision makers about the process of resource allocation within the Enhanced National AIDS Control Program. The program was chosen because current increases in HIV seroprevalence within the high-risk population and recent investments made to this program, both served to increased its public health importance. Despite these developments, influences determining the allocation of resources within the program have not been studied.First reported two decades ago,17, HIV In 1987, the government established the National AIDS Prevention and Control Program (NACP) ,29, withGlobally, HIV/AIDS has received much political and financial commitment, with OfQualitative methodology was applied to develop an understanding of issues related to resource allocation. Persons considered most informed were decision makers involved in the process of allocating resources within the NACP. Study participants thus represented the Ministries of Health (MOH) and Finance (MOF) and the Planning Commission (PC) at both provincial and federal levels. All study participants were working in the public sector for more than five years and were posted in these departments during 2001–2002, the time during which PC1 for the Enhanced National AIDS Control Program was developed and approved. Changes in two provincial chapters of the National AIDS Control Program resulted in vacancies at the Program Manager level. These posts were vacant for two years prior to the study and remained unfilled at the time of the study. The study was thus conducted in two of four provinces in the country. Selection of participants for interviewing involved identifying the current program managers at federal and provincial levels. Once interviewed, these participants were asked to provide information about other decision makers involved in the concerned ministries who were involved in the development of the PC-1 document. The ministries were then approached and the identified persons interviewed. This technique of contact tracing to identify study participants was done at both provincial and federal levels. No study participant refused an interview, but some interviews required two to three attempts at contacting the officials before the interview could be conducted.The study was conducted after obtaining approval from The Aga Khan University Ethical Review Committee. An interview guide was developed and pre-tested on two persons, one working in an HIV/AIDS related field, and the other working in the field of policy development. Themes touched upon in the interview guide included participant's understanding of the national process of resource allocation, strengths and gaps working in the system; process of prioritisation and principles for resource allocation within the National AIDS Control Program and influences working on programmatic allocation of resources. The initial interview guide was modified and this modified, pre-tested interview guide was used to conduct ten in-depth interviews. All interviews were conducted by the first author in June and July 2004. During the course of the study, participant responses were incorporated in the interview guide after each interview. These modifications did not add new questions to the interview guide, but allowed for development of better probes enabling detailed discussions with subsequent participants.The duration of each interview was about 2 hours. Prior to conducting each interview, written informed consent was sought from each participant and written notes were made during all interviews, with an exact transcription of participant responses to questions being noted during the interviews. Most participants (seven in number) refused an audio-recording of the interview, thus increasing reliance on interview notes. Immediately after the interviews, notes were supplemented with observation notes. Recorded interviews were transcribed using MS Word, with notes used to supplement and validate participant responses. Notes of interviews, which were not audio-taped, were similarly transcribed.All transcripts were analysed using QSR NVivo 5 software, which allows management of qualitative data. Using the transcripts, participant responses to individual questions were separated into themes, with constant reference being made to interview and observation notes. All transcription and analyses were done by the first author. Once all participant responses to individual questions were separated into different themes, further analysis was done to collapse themes by linking together similar experiences and participant responses. This process continued till no new themes or codes could be generated from the collected data. Confidentiality was maintained by restricting access to interview notes and analysing data using a list of pseudonyms.Of the ten participants, three represented the Federal government; one each from the departments of Health, Planning and Finance. Of the seven provincial level participants, one represented Finance and three belonged to Health and Planning Divisions of each province. The themes identified through interview analysis are described below, beginning with a description of the process of resource allocation within the public sector to factors thought to influence the process.All study participants agreed that the NACP PC1 was approved through due process, as required by the Planning Commission of Pakistan.(13). An approximately Rs 2859 million proposal (US$ 47.538 million), it received approval by the highest economic authority in the country, the Executive Committee of National Economic Council (ECNEC).The Departments of Finance and Planning have well-defined roles for PC1 evaluation; with technical and costing assessments by the Planning Department, and Finance looking into long-term financial feasibility of the proposal.The system for allocating resources, was thought to be "highly bureaucratic, tending to become a matter of routine" by study participants at both federal and provincial levels. This tended to "drag down the program", especially if the PC1 document required revisions. The sponsoring agency having no authority to approve adjustments has to reapply with a revised PC1. This reinitiates the entire process of developing and evaluating the revised PC1 thereby causing delays in program initiation and attainment of program targets.Appraisal by trained economists in the Planning Division ideally requires "quantifications focusing on tangible project results", however if data is deemed insufficient then "(the) experience of working in the public sector" is relied upon. The role of Finance was described as being "restricted to identifying multiplicity of program activities and determining burden of recurrent cost within the proposed projects". As explained by a Federal Finance representative, this was because"...feasibility of programs in health cannot be done in rupee amounts and is very different from other sectors. As this is technical work, the decision of how much should be allocated to prevention and how much to be kept for cure is that of the implementing agency. We in finance look at the whole envelope and not at individual slots under which allocation is made."The sponsoring department is responsible for initiating the planning process and negotiate the funding required; the health department however was described by a provincial planning department participant as having a "down stream role" with limited powers of negotiation. This was attributed to a relatively low status of the Ministry of Health compared to more economically productive sectors.Factors ranging from personal to global were described by study participants to influence the division of resources.Individual motivation and political pressures were thought to engender prioritisation of personal gain over national interests among decision makers. One respondent described "resource allocation is a political decision"; where a limited supply of resources and a plethora of demands cause "political pressures and elitism (to) influence(s) decisions at every level, in every department." Another participant felt that although there is an established system of information based priority setting, political influences tend to "spoil this system." These influences manifest as staff reassignments; unnecessary delays in project assessments; approval by persons uninvolved in initial assessment phases and who may lack technical knowledge of the issue. Political pressure exerted to expedite the review process resulting in less time for critical reviews and discussions of project proposals was another gap.Priority setting for the NACP was described a Federal level exercise, with the degree of provincial involvement in framing policies a "mere cosmetic process". Development of the policy document for the NACP, the National Strategic Framework, had invitations based on "personal choices at the federal level rather than technical merit of candidates". Rural representation was deemed insufficient with an overwhelming dominance of donor agencies in the forum. Federal influence during formulation and approval of the NACP PC 1 document, in staffing and financing decisions existed, as claimed by all study participants at the provincial level. Exerted through a system of reward and punishment; this influence was described by a participant as"sidelining the person who talks a lot and issue(ing) letters to highlight problems, while the persons liked are repeatedly nominated for foreign trainings and trips."Provincial Finance and Planning departments' involvement in developing provincial PC 1s were described by two participants as "(A) 2–3 day negotiation process", with limited consideration to individual program capacities and needs as the PC1s were based on federally developed templates. This claim of limited involvement of the provincial departments was refuted by the Federal program, which declared provincial governments and programs had complete autonomy in developing the PC1 with the federal program providing "guidance, not interruptions".Most study participants considered frequent transfers within the bureaucracy as cause of discontent and apathy within the workforce. One participant described it a "loss of institutional memory and experience", resulting in decision-making positions being filled on basis of experience, not expertise. Lack of technical knowledge within the public sector was also thought to result from a failure to attract proficient personnel owing to low public salary structures. As achievements were considered "highly person-dependent", program management capacity was unequivocally accepted as essential for program success.Retention of trainings and workshops, (soft program elements) along with their associated grants, with transference of loans to the provinces was considered by four provincial participants as Federal influence. The federal program rationalized retention of the Second Generation Surveillance system (funded through CIDA grant component) to enable coordination among the provincial cells. Workshops for migrant workers and educational activities targeting the youth were retained because of the centralized functioning of the collaborating line ministries i.e. Bureau of Immigration and Ministry of Education.Donor agency influence in the development and approval of the PC1 document of the NACP was considerable, as reported by all, but one study participant. This was thought to be a result of limited provincial level data, paucity of trained manpower and non-cooperation among the involved departments. Another suggested reason was the "need to improve balance of payments within the country without consideration to technical aspects of the project", an issue that "could not be fully appreciated at the provincial level". A federally placed participant revealed that despite the existence in the public sector of criteria determining project selection, those projects which received foreign funding, particularly grants topped the priority list for funding and approval."There was a pressure to ignore all things ...it was a political decision to improve the exchange reserves for social and economic benefit."The initial reaction of provincial governments, as revealed by four participants, was a rejection of the program because HIV was not considered a Public Health threat and loans for the program were transferable to the provincial governments. The increased interest in the issue was perceived to be a demonstration of global trends and donor agency influence on local policies, rather than a real need. A provincial planning division representative thought that though AIDS is an issue, the government should not be "blind to real threats (of) diseases like Hepatitis B and C", which are "larger Public Health issues for the country (and) are not receiving international funding and are mostly locally funded".This donor influence was thought to be promoted by "sympathetic agents of interest holding public office", incentives of foreign visits and threats of withdrawing financial assistance altogether. Little rationale could be attributed for such influence other than "donors have their own agenda", and one respondent describing it "(a) tool of colonisation".Four participants at both federal and provincial levels considered the strategy of public-private partnership adopted in the program to be "donor promoted jargon" and shared their concerns in involving NGOs at a national level. One participant felt "the social value attached to the program (NACP) can only be given by the public sector". The costing exercise for the PC1 was described by a provincial program manager as donor driven, with little or no input of local data. This data provided by donor agencies was suspected of being "biased and reflective of their own agenda rather than ground realities". A senior official at the Federal program level however, refuted this claim stating donors were responsive to local program requirements and demands, as evidenced in the National Strategic Framework. Only one participant at the provincial level spoke of the inclusion of Hepatitis B and C testing kits in the PC1 of the NACP as a "triumph for the government in persuading (donor agencies) to agree to funding this activity".Informed decision-making though acknowledged by all participants as being essential for efficient resource allocation, was not being employed owing to a lack of knowledge about the local situation and an existing norm of not basing decisions on evidence. The lack of a standardised system to determine allocation and "program novelty of the NACP" reduced the activity to "a largely subjective exercise, directed by gut-feeling". The federal program refuted this claim, alleging use of costing exercises and scientific data to determine allocation.Study participants supported the importance of generating local data, given a unique local socio-cultural and demographic context in which international data may not find an application. Participants at the provincial level however, claimed international literature and donor-provided data was utilized owing to a lack of valid local studies, their limited dissemination to and use by policy makers. This view contrasted with representatives of the federal government who claimed development of PC1 was based on local studies outsourced by the NACP.All participants at the provincial level and those representing the federal finance and planning departments denied use of any economic tools e.g. cost-benefit/effectiveness analysis or models for allocating resources within the NACP. In fact, most were unaware of the existence of this decision making tool. Use of such information was described as being at a "very primitive stage". They were not employed even in the planning department, which is a "support department". The federal program however reported using "resource need" models to determine allocation.All participants, except one considered public opinion to exert negligible influence in determining priorities and allocation, attributing it to a low priority accorded to health and poor involvement of the public in decision-making processes. Similarly, influence of private sector physicians and physician bodies was limited as a result of poor interest in preventive activities and a limited influence of professional bodies on priority setting.Seven participants thought the principles of equity and efficiency to be "slogans and jargon" that are ignored when allocating resources. This culture was pervasive, be it at the level of the country or at departmental or even programmatic levels. Though the vision guiding activities within the health sector is 'Health for All', participants were not able to describe how this vision was translated into reality through an allocation of resources. As a federally placed participant described"Lack of equity is visible within the macro-financing framework of the country, where a mere US $4 per capita expenditure is on health. This inequity is visible within the health sector as well, with more money being spent on hospitals and tertiary care than on primary care."One provincial program manager however, felt allocation within the NACP had addressed equity and efficiency through planning of activities for both general and high risk populations.The dilemma of allocating resources to the NACP was the distribution of limited funds to a disease considered "irreligious and immoral" by a large conservative section of the society; as expressed by participants not belonging to the program."The cake is small and there are many mouths e.g. should we be putting money in the HIV/AIDS program or should we provide money to provide safe water to people, given that diarrhoea is still the leading cause of death in our country."Differences of opinion existed regarding provision of anti-retroviral medications. Program management and federal level participants felt that lack of treatment incentive may be a potential hurdle in program expansion and acceptability. Other provincial level decision makers tended to favor preventive activities, describing high treatment costs and a tendency to emphasize numbers in output as obstacles."If 10 people can be treated versus a single AIDS patient, then numbers will be opted for (as apposed to treatment for infected persons)".The existence of the NACP and a "ten-fold increase in the allocated resources" was considered an indication of governmental commitment to address the issue of HIV in the country. However, provincial planning and finance division participants did not consider HIV to be a Public Health issue owing to the small number of diagnosed cases in the country.The study sought to identify issues that influence allocation of resources within public health programs, a little studied phenomenon in local literature. As the new phase of the NACP began in 2002, experiences of decision makers are relatively recent and less likely to suffer a loss of recall. To gain a variety of perspectives and opinions, interviews of decision makers at various levels and in different departments within the bureaucracy were conducted. The participants selected for interviewing were those who are required to provide the most amount of technical input at the time of developing the PC1. Though several decision makers within the public sector hierarchy are involved, most are not expected to provide technical input to develop the PC1 and make decisions on the proposed PC1s instead. Inclusion of such public officials from different provinces and other stakeholders may have provided greater insight into the process of resource allocation.Although Pakistan has a low reported prevalence of HIV, there exists an enormous potential for viral spread. Given this potential, implementation of comprehensive strategies including preventive activities, surveillance systems to detect cases early and provision of treatment and care for HIV positive individual becomes imperative,38. ThesStudy participants considered the existence of an unambiguous hierarchical system of allocating public money, with well-described responsibilities, authorities and a separation of power at each level of decision-making an asset. The effective functioning of this system however, suffers owing to a paucity of information, lack of trained manpower and political and bureaucratic influence; issues identified in other studies focusing on the decision making structure within the country,14,39. TAn enrichment of public sector expertise in planning and budgeting through staff trainings and attracting technical expertise by revising public pay scales is essential to make decision making more rational, evidence-based and justifiable, and to reduce dependency on external agencies for technical support. Lack of valid information, considered an obstacle by most decision makers, identifies a need for strengthening both the public health database  and research by the local scientific community. A success story that may be an important lesson for the health system is the effective persuasion by decision makers to include test kits for Hepatitis B and C in the NACP. An in-depth analysis of factors that resulted in this relative success could serve to pinpoint strengths within the system that could be enhanced to promote local influences to guide allocation of resources.Federal level respondents and program managers consider HIV a high priority issue because of its potential for spread and the high cost of neglect associated with the disease. Provincial reluctance to accept the program resulted from an underestimation of disease risk and perceptions that "market influences" rather than local need determined program existence. This difference in perceptions may have resulted from the continuous sponsorship by program managers and donor agencies at the federal level. Federal retention of grant components, though explained to be a result of institutional capacity and bureaucratic jurisdiction, was perceived as interference at the provincial level. These reflect a degree of conflict and distrust existing within the institutional structure. The promulgation of an extensively financed program where partners fail to share program vision may create problems in achieving program targets. To address this concern, it becomes important to develop communications among partner departments and maintain involvement of all actors at every stage of program development and implementation.The NACP opens new challenges for developing and maintaining public-private partnerships in an atmosphere charged with scepticism. Much of the program funds are being funnelled to NGO-led activities, at a stage when public-private partnership is viewed as a donor driven agenda rather than local need. Although promoted as a means of achieving efficiency in the public health sector by creating competition, it is essential to consider local NGO capacity to deliver the required service. Also, public sector capacity to administer such contracts and effectively coordinate among various NGOs to achieve program goals and targets will need development.Study participants succinctly identified how taboos associated with HIV present a dilemma to decision makers when funding activities. Although the dilemma is not unexpected for a traditionalist society like Pakistan,29, it uThe allocation of resources, whether within health or other sectors, is not merely based on technical issues but results from a complex interplay of political, ethical and technical judgements. A lack of consensus regarding which principle should guide the allocation of resources has resulted in calls to make the process of allocation one of "procedural justice". This reProper distribution of finances is an essential aspect of planning within any sector, more so in the public sector of Pakistan, given its resource constraints. Though there is an existing institutionalised system to allocate resources through a process of informed debate, the system is not functioning ideally. There is extensive influence of external factors including personal and political influences. Resource allocation within the NACP of Pakistan was thought to have undergone similar influences. Donor influence could be accounted for by its unique nature of being extensively financed through International Development Assistance. EthicalTo promote efficient allocation of resources in such a system requires making decision makers knowledgeable about HIV, building technical capacity for effective resource allocation, instilling the importance of data based decision making within the institutional set up and ensuring availability of relevant, updated and valid information. Development of consensus enhancing mechanisms ensuring broader participation is essential to enhance ownership, develop a unified vision of action and ensure accountability.The author(s) declare that they have no competing interests.This manuscript is derived from the thesis of the Corresponding Author, SH. SH conceived the idea, developed the study design, collected and analysed data and drafted the document. MK provided technical input in the study design and helped draft the document. ZF provided technical feedback and helped draft the document. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


A safe home environment is the first line of defense in protecting children’s health. And since many kids spend a great amount of time in schools and child care facilities, safeguarding their health in those places is also essential. The Community Outreach and Education Core (COEC) of the Environmental Health Sciences Center in Molecular and Cellular Toxicology with Human Applications at Wayne State University, in collaboration with the Detroit Head Start and the EPA, has developed the Healthy Homes = Healthy Kids Train-the-Trainer Program to ensure that parents and other caregivers receive information that allows them to create a hazard-free atmosphere for kids. These participants can then pass information along to other parents and caregivers. By training the trainer, the program ensures that a larger number of teachers and caregivers, and ultimately, children can be effectively reached and introduced to the basic concepts of environmental health science.Participants in the workshops are introduced to common household safety issues including toxic heavy metals (such as lead and mercury), indoor air pollutants , drinking water quality, food safety, pest control, and poisonous substances  that children could mistake for food or drink.Next, the participants learn about the health effects of these hazards, and are taught healthy practices to follow in the home, available methods for detecting and screening for poisonings, and ways to tap into additional local, state, and national resources. The program also provides hands-on activities for the participants that let them practice reacting to possible hazardous situations, such as finding a child playing with a toxic household cleaner.The content of each workshop covers about six hours, but can be broken up over several days if needed. Program developers use pre- and post-tests to measure knowledge gained by participants, and also conduct follow-up surveys to gauge the effectiveness of the program and track how much the information is being used by workshop attendees. In addition to hands-on training, the program also provides a poster that highlights the hazards discussed in the sessions and a variety of fact sheets detailing common environmental hazards and prevention strategies. The fact sheets and poster are all available in English, Spanish, and Arabic.The COEC recognizes the importance of community partnerships in providing effective outreach initiatives, and credits its outreach partners with helping keep the program responsive and successful. Train-the-trainer workshops have been conducted at Head Start in Detroit and the nonprofit Child Care Coordinating Council of Detroit/Wayne County.“The COEC, through interactions and input from community groups . . . utilizes the scientific knowledge and research of center members to provide assistance to the community through education, prevention, and resource identification,” says COEC project coordinator Lisa Pietrantoni.Materials for the program are continuously updated as new information becomes available, and new topics are currently being developed. A total of 174 caregivers have been trained so far, and additional training sessions are scheduled for this spring.


Meta-analysis has become a well-known method for synthesis of quantitative data from previously conducted research in applied health sciences. So far, meta-analysis has been particularly useful in evaluating and comparing therapies and in assessing causes of disease. Consequently, the number of software packages that can perform meta-analysis has increased over the years. Unfortunately, it can take a substantial amount of time to get acquainted with some of these programs and most contain little or no interactive educational material. We set out to create and validate an easy-to-use and comprehensive meta-analysis package that would be simple enough programming-wise to remain available as a free download. We specifically aimed at students and researchers who are new to meta-analysis, with important parts of the development oriented towards creating internal interactive tutoring tools and designing features that would facilitate usage of the software as a companion to existing books on meta-analysis.We took an unconventional approach and created a program that uses Excel as a calculation and programming platform. The main programming language was Visual Basic, as implemented in Visual Basic 6 and Visual Basic for Applications in Excel 2000 and higher. The development took approximately two years and resulted in the 'MIX' program, which can be downloaded from the program's website free of charge. Next, we set out to validate the MIX output with two major software packages as reference standards, namely STATA  and Comprehensive Meta-Analysis Version 2. Eight meta-analyses that had been published in major journals were used as data sources. All numerical and graphical results from analyses with MIX were identical to their counterparts in STATA and CMA. The MIX program distinguishes itself from most other programs by the extensive graphical output, the click-and-go (Excel) interface, and the educational features. or .The MIX program is a valid tool for performing meta-analysis and may be particularly useful in educational environments. It can be downloaded free of charge via  The amount of data produced by researchers in health sciences has been growing explosively and advances in genetics, genomics, and information technology are likely to further contribute to this growth. In the past two decades, meta-analysis has evolved into the statistical method par excellence to make sense out of the growing number of research reports. As the quantitative analytical part of a systematic review, it has been used for evaluating data from both experimental and observational studies in therapeutic, diagnostic, prognostic, and etiologic settings. In the commonly used definition of the hierarchy of scientific data for medical decision making, meta-analyses are considered as providing the highest level of evidence ,2. As suAlthough meta-analyses can be applied to all types of medical research, its primary application so far has been in the therapeutic realm. One of the main forces behind the rise of therapeutic meta-analysis is the Cochrane Collaboration , whose eMany general statistical software packages have included options for meta-analysis in their basic program configuration, and user-communities have written numerous meta-analysis add-ons. Specialized software packages, meant exclusively for meta-analysis, are also available in various types and price ranges. Although the number of software packages for performing meta-analysis is substantial, in our opinion, most share one common limitation: low applicability in educational settings or environments with beginning researchers. Even though numerous researchers in health care are nowadays confronted with data from published meta-analyses or are even requested to do a meta-analysis themselves, there is still little or no electronic educational material and none of the existing software has explicit educational features. Cost is another issue that may have an impact on the use of software by students and lecturers: only a few of the modern meta-analysis packages are free and if academic pricing is available, prices can still be rather high for many.After reading previously published software reviews -15 and uOur primary objective was to develop a free program for meta-analysis of causal research  that could be applied in both analytical and educational settings. Our secondary aim was to validate the analytical tests in the program with output from established reference standards.Before the actual development, we started with making an inventory of the most important meta-analytical tests and approaches, and brainstormed on ideas for an interface. Since causal meta-analysis methods are relatively well-established , we focused on meta-analysis of controlled trials and cohort or case-control studies. In these studies, outcome differences between exposed or treated and non-exposed or untreated groups are compared to assess a causal relationship between the determinant (treatment or exposure) and an outcome . As far as the program structure was concerned, our a priori idea was to create an add-in for Excel. Although a rather unorthodox approach in this area , Excel provides a sophisticated calculation and graphics platform that is well-suited to many meta-analytical methods and at the programmer's disposal before any programming is done. Consequently, development and maintenance is relatively easy and costs can be kept to a minimum (one of the main aims in our program development). Furthermore, the spreadsheet environment of Microsoft Excel is familiar to almost all researchers in medical, social, and economical sciences, which was very much in line with our attempt to develop a package that is fit for beginning researchers. Although we realized that even recent versions of Excel can be inaccurate with regard to some statistical calculations -23, we wSince we wanted to move beyond the occasional spreadsheet that can perform meta-analytical calculations, we started by designing a programming structure in which the already existing Excel functionality could be exploited to its maximum. Sophisticated procedures were custom-programmed with Visual Basic in the Visual Basic for Applications (VBA) editor of Excel 2003 (and tested in Excel 2000 and onward). The so-called front-loader (a start-up program initiated with an icon) and some small assistant programs, all being non-Excel entities, were developed with Visual Basic 6.0 (VB6).The current version of the program (version 1.5) is still only compatible with Windows operating systems running Excel 2000 or later, but versions for use with Excel on Macintosh and Linux are in preparation. The descriptions below apply to the Windows version, though most of it can be extended to future versions for other operating systems.®-based program introduction. The MIX menu item contains an icon for starting up the MIX program, a folder with a shortcut to the uninstall program, a folder with shortcuts to programs for loading and unloading the Excel add-in, and a folder with educational programs and information. Loading the small MIX add-in that is supplied with the main program  results in a MIX menu-item under the Tools menu in Excel. This MIX menu contains several functions that can be accessed when the MIX program itself is not running. The files that form the core of the program are recognizable by their Mix file extension (*.mix) and currently contain approximately 16,000 lines of command code in 26 code modules and 17 custom user forms. These core files take up approximately 22 Mb of space on a hard-disk and their primary functions are (A) running interface procedures, (B) showing and manipulating output, (C) performing analyses, and finally (D) exporting and communicating with external files and programs. One of the core files is a large Excel workbook with 23 worksheets that forms the calculation engine of the program. It contains 6 sheets with primarily worksheet formulas and 10 sheets with various kinds of pre-calculated graphical and numerical results from meta-analytical tests. The remaining sheets contain information for help functions or programming purposes. This Excel workbook remains hidden from the users at all times. Figure Installation is made easy with a set-up program that installs the necessary files in a folder that can be specified by the user (default is C:\Program Files\MIX). It will also create a MIX item in the Windows Start Menu  and provides the option to start a FlashAt start-up, a dedicated instance  of Excel is created and becomes visible once all regular Excel menus and toolbars are hidden and replaced by the MIX graphical interface. The Excel instance used by MIX is secured for exclusive use by the MIX program and does not interfere with existing Excel windows or settings.The interface consists of a menu bar, two toolbars, and several shortcut menus. The menu bar and toolbar are directly accessible and the shortcut menus pop up with a right click of the mouse. The MIX menu bar has eight main menus  via which all functions of the MIX program can be executed. Most of the common functions require only a single click on the toolbars. Double clicking graph items skips the shortcut menu and directly provides options for changing the graph item's format. Figure The MIX program provides several options for importing or creating data sets for meta-analysis. The most convenient option is to create an Excel or CSV file with data (standard output option in Excel) and import this file into the MIX program. The variable ranges are then selected in Excel-manner to create a data set , single study influence, and cumulative trends are also available in MIX. The graphical output is particularly comprehensive, with no less than eighteen informative plots that can be formatted in detail.Possible association measures from continuous outcome data input are mean difference (MD), Hedges' g (HG), and Cohen's d (CD), analyzed by inverse variance fixed or random effects models. Data from studies with dichotomous outcomes can be analyzed with a risk difference (RD), risk ratio (RR), or odds ratio (OR), weighted by inverse variance, Mantel-Haenszel, Peto (only odds ratio), or Dersimonian-Laird approaches. Analyses based on correlation coefficients or Fisher's Z are also possible, though only if the data are provided as comparative input, e.g. the association measures itself with their standard error. If correlation or effect size data are not in this format, they can be transformed via the MIX Statistics Converter that comes with the program. Table ®-based Theory Tour that explains the fundamentals of systematic reviews and meta-analyses and a Program Tour that shows the basics of how to use the program. The educational materials take up approximately 25 Mb and can also be downloaded separately.The most important educational features are the program's Output Tutor and Concept Tutor. Both are interactive dialog boxes that provide information about epidemiological and statistical concepts and tests. The Output Tutor changes with each analysis and always explains tests and results that are displayed or changed at the very moment. Additional teaching material includes a FlashTo increase program stability and prevent users from accidentally altering the Visual Basic procedures, the source code cannot be accessed while the program is running. Codes to unlock the VBA modules are provided by the first author upon request.metan program [metabias program [metatrim program [Version 9.2 of STATA , and mor program , version program , and ver program  were use program -27. The  program  was used program ,29-35.The data sets represent three of the most often used types of data for meta-analysis in health care research: 1) descriptive data for dichotomous outcomes, 2) descriptive data for continuous outcomes, and 3) comparative (association measure) data. For all three data types we chose a relatively small (less than 10 studies) and large data set (more than 20 studies) and we used two extra data sets in the 'descriptive dichotomous' category . The data sets are summarized in table Results from the analyses of the eight data sets with MIX and the reference software were entered independently in identical custom-made spreadsheets. These spreadsheets were later compared in separate analysis sheets that used a cell-based formula to check for discrepancies of results up to 4 decimals.In summary, we have been able to achieve our objective of developing a comprehensive and yet free program for meta-analysis. The Excel platform, although not without problems, has proved to be flexible enough to create an easy-to-use, and graphically and numerically comprehensive program.metan, metabias, and metatrim commands in STATA. The small study effect regression test by Macaskill [regress command also turned out to be accurate. Table In its current state (version 1.5) all results from the MIX program are identical  to results from the most recent versions of the acaskill  that wasWith regard to the trim-and-fill analysis , the MIXAlthough we are in the process of completing a formal software comparison project, we are confident that the MIX program can compete in many respects  with most of the existing meta-analysis programs like Comprehensive Meta-Analysis , MetaWinAnother important issue that we will focus on in upcoming updates is meta-regression. Although some univariable regression methods are integrated in the tests for small study effects, the MIX program can currently not perform meta-regression. We realize that meta-regression, especially with multiple independent variables, is a valuable tool for assessing heterogeneity and adapting a meta-analysis accordingly, but it requires matrix calculations that are far more difficult to program in Excel or VBA than the standard tests. Currently, univariable meta-regression is possible with Comprehensive Meta-Analysis  and MetaFinally, because we are still frequently updating the program and including new features, we have postponed the making of a hard-copy manual or methods guide until this process has stabilized.The MIX program provides researchers, students, and lecturers with a free tool to perform state-of-the-art meta-analyses and learn or teach about what it is they are doing. It uses an innovative approach with Excel as a computing platform and even provides some numerical and graphical output that is not provided by other software. Results from version 1.5 of the MIX program are identical to those from STATA, and MIX can be regarded as a comprehensive and valid tool for performing causal meta-analyses.Project name: MIX or Project homepage: Operating system(s): Microsoft WindowsProgramming language: Visual Basic Other requirements: Microsoft Excel 2000 or laterLicense: Open Source, freeThe author(s) declare that they have no competing interests.LB designed and developed the MIX program, under supervision of NI and HT and with testing by and recommendations from all authors. The validation was performed by LB and LY and supervised by KGM. LB drafted the manuscript and all authors participated in the writing.The pre-publication history for this paper can be accessed here:


Recent research has shown a backlash against the enthusiastic promotion of technological solutions as replacements for traditional educational content delivery. Many institutions, including the University of Virginia, have committed staff and resources to supporting state-of-the-art, showpiece educational technology projects. However, the Claude Moore Health Sciences Library has taken the approach of helping Health Sciences faculty be more comfortable using technology in incremental ways for instruction and research presentations. In July 2004, to raise awareness of self-service multimedia resources for instructional and professional development needs, the Library conducted a "Multimedia Bootcamp" for nine Health Sciences faculty and fellows.Case study.Program stewardship by a single Library faculty member contributed to the delivery of an integrated learning experience. The amount of time required to attend the sessions and complete homework was the maximum fellows had to devote to such pursuits. The benefit of introducing technology unfamiliar to most fellows allowed program instructors to start everyone at the same baseline while not appearing to pass judgment on the technology literacy skills of faculty. The combination of wrapping the program in the trappings of a fellowship and selecting fellows who could commit to a majority of scheduled sessions yielded strong commitment from participants as evidenced by high attendance and a 100% rate of assignment completion. Response rates to follow-up evaluation requests, as well as continued use of Media Studio resources and Library expertise for projects begun or conceived during Bootcamp, bode well for the long-term success of this program.An incremental approach to integrating technology with current practices in instruction and presentation provided a supportive yet energizing environment for Health Sciences faculty. Keys to this program were its faculty focus, traditional hands-on instruction, unrestricted access to technology tools and support, and inclusion of criteria for evaluating when multimedia can augment pedagogical aims. Recent research has shown a backlash against the enthusiastic promotion of technological solutions as replacements for traditional educational content delivery,2. Many Support for the program came from a collaboration of Library faculty and local and national vendors. Program design, administration, and instruction were coordinated by the Library's Educational Technology Coordinator. This Library faculty member served as the program's director and lead instructor, and recruited other Library staff and faculty to teach appropriate program topics. The approach of the program was to provide intensive, hands-on practice in creating multimedia content. In support of this approach, each instructional session was staffed by two or three staff dedicated to providing individualized assistance, in addition to the instructor. Participants were also given assignments to complete between sessions. Support from the Apple Seeds for Education Program gave each program fellow exclusive use of a multimedia capable laptop and video camera for the duration of the month-long program. Digital still cameras, recordable media, and a large-format poster to used an example of the kind of print media possible with digital imaging technology were all donated by vendors. See Table The Multimedia Bootcamp was designed as a fellowship program to secure the commitment of faculty participants. Rather than sign up for a selection of training classes or consultations with knowledgeable Library staff, faculty were encouraged to nominate themselves or colleagues as "Bootcamp Fellows" willing to participate in a four-week program. Nominees were asked to submit a short statement of how they planned to apply skills from the Bootcamp curriculum to benefit their academic endeavors, and were asked to detail any conflicts with the scheduled sessions. Preference was given to participants who were able to attend a majority of the sessions. The selection committee consisted of four Library faculty members familiar with the capabilities of the multimedia studio or faculty technology needs. Faculty selected for the program received letters informing them of their nomination as fellows and detailing their responsibilities for safekeeping of loaned equipment. Such efforts may seem inconsequential to providing instruction, but it was our hope that wrapping the program in the trappings of a fellowship would increase the level of interest and commitment from busy clinical and teaching faculty for a program which required a significant commitment of time (two to four hours per week for four weeks).Five of the six sessions were held in the Library's Tolleson Wireless Classroom, which has moveable tables and chairs, wireless network connectivity, a reliable projection system, and plenty of electrical outlets for cameras, computers, and presentation equipment. Given the right environment, it was expected that relaxed but focused learning could take place.Fellows had unrestricted access to high-quality multimedia equipment for the duration of the program. The ten multimedia equipped PowerBook G4 laptops and ten consumer grade digital video cameras made it possible for each fellow to have a dedicated set of equipment to use both in class and for homework assignments. The still digital cameras were assigned to fellows for the first two weeks of the program, including the period between the first two sessions.A series of six two-hour sessions spread over four weeks in July focused on skills integrating multimedia into instructional and presentation materials. Footage of one instructional session was captured see . The schWhile most of the skills taught during the program were within the normal repertoire of Library classes and consultations, content was created with the needs and interests of Health Sciences faculty in mind. An instructional design perspective on the effective use of multimedia was introduced during the first session to reinforce the pedagogical finding that merely adding electronic educational resources does not necessary improve instruction ,4. UnlikWhile in-class demonstrations and hands-on exercises used the neurology case study materials, fellows were encouraged to use their own content for the weekly homework assignments. Compliance with completing assignments was 100%. Table The program was promoted with the endorsement of faculty who had used the Library's Media Studio services in the past, as well as through various Health Sciences faculty outreach lists and publications. In addition to direct e-mail to Media Studio patrons asking for nominations of appropriate colleagues, e-mail solicitations for nominations were sent to lists of nursing, clinical, and basic sciences faculty. Notices were also published in the Library's monthly newsletter, the School of Nursing's weekly faculty communiqué, the hospital's faculty and staff newsletter, through the Library Departmental Liaison Program, and contacts with the Housestaff Office, which is responsible for teaching fellowship programs.The leadership of a single Library faculty member to shepherd the inaugural program to completion required approximately 50% of the person's time during the two months leading up to the program. While it was a significant staffing commitment, the time devoted contributed to the delivery of an integrated learning experience. The expectation that fellows would ply us with many questions and requests for individualized support between sessions turned out to be false. The month of the program was actually rather quiet except for the sessions themselves, leading us to conclude that the amount of time required to attend the sessions and complete homework assignments was the maximum fellows had to devote to such pursuits.The presence at each session of two or three additional staff devoted to individual hands-on support was effective to ensure that fellows had adequate support for complex tasks such as image manipulation and video editing techniques. However, except for the most advanced session when fellows were completing the final edits on their video projects, one hands-on assistant would probably have been sufficient. While most fellows came into the program with little experience creating multimedia, they seemed more comfortable experimenting with the technology than we anticipated when designing the program. The inclusion at the outset of the program of an overview of the Macintosh environment also served to bring all of the fellows onto a level playing field. It can be difficult to imparting basic technology skills to faculty without being perceived as patronizing of their computer literacy. The benThe Multimedia Vendor Day fulfilled its promise to offer sponsoring vendors access to prospects in return for their support of the Bootcamp. The four sponsors put together excellent displays and presentations, and hosted over 70 visitors from the health sciences center, University, and community, footage of this event was captured see . All of Our initial expectations of interest in the program by potential fellows were far exceeded. The original plan was for a maximum of eight Health Sciences faculty to receive fellowships. To reflect the Library's patron base, we hoped to offer fellowships to at least one basic sciences researcher, one member of the School of Nursing faculty, and the remainder to clinical faculty or teaching fellows. Because we received credible nominations from thirteen faculty members or teaching fellows, the program was expanded to support nine Bootcamp fellows and a waiting list was created for those applicants for whom we did not have space in the inaugural program. While we would have liked to admit all thirteen applicants, we were limited to ten laptops and cameras, and one set was needed for the instructor and hands-on instruction. In addition, it was important to keep the group to a relatively small size to facilitate individualized, hands-on assistance during instructional sessions. With nine fellows, one lead instructor, and two hands-on assistants, we were able to keep the ratio of instructional staff to fellows at three to one.Selection of fellows followed the guidelines outlined in the methods section. Nominations were collected and evaluated in order of submission, which was easy to track, given the required e-mail format of submissions. Preference was given to nominees who were able to commit to a majority of scheduled sessions. Since all nominees included a clear statement of their academic goals for the program, it was not necessary for us to eliminate any application based on that criterion. Instead, we were able to rank nominations by arrival date, availability for sessions, and representativeness of the Library's patron base. Selected goal statements included:A professor and pediatric urologist said, "I...perform quite a bit of reconstructive surgery on infants and children. Our department has acquired a Da Vinci Robot Assisted Surgical System, and I have already completed my first case using this exciting minimally invasive surgical technology (the first pediatric case at UVA). There are relatively few pediatric institutions in the country with this technology, and I will [be] presenting data at regional and national talks in the near future. The surgeries are completely recorded in digital video, and I would very much like to learn how to edit, integrate, and share this important information with my pediatric surgical sub-specialists."An emergency medicine professor who provides paramedic education said, "I envision utilizing the skills learned to refine and invigorate offerings of [the local] paramedic program didactics, where we are trying to increasingly shift to online offerings through Blackboard and web-enhanced curricula. Now that we have obtained national accreditation, my next project is to begin pursuing national accreditation to provide online continuing education programs for EMS providers. I have [PC-based video editing equipment] and have imported and used some small clips embedded in PowerPoint lectures given at regional and statewide continuing education lectures. I would like to learn how to do it with greater skill and finesse, [since] so far my knowledge in this area is all self-taught."A veterinarian who is a lead animal researcher said, "I am responsible for training all individuals using laboratory animals for research purposes at the University of Virginia. This training currently includes a monthly orientation seminar, a monthly hands-on rodent handling workshop, maintaining a website with training information, and individualized training as needed. The orientation seminar format is [PowerPoint] presentations which could be improved upon by better use of multimedia. I am also writing a chapter on rodent surgery for an on-line textbook which allows use of digital still-images and video. Finally, I plan to expand the training services offered to include a series of interactive web-based training modules. One of these will be an annual re-training mandatory for all animal researchers; the others will be specific to a particular species or procedure. I believe that a class in multimedia skills would be an immense asset in helping me to develop new teaching and presentation tools that are interesting, relevant, and effective."A professor of graduate nursing said "I am currently teaching an entirely on line graduate level class in the UVa School of Nursing using Blackboard as the platform and I would like to enhance my skills in media use beyond the use of [PowerPoint]. I am also involved in continuing education in geriatrics through the UVa Health System and would like to explore how the geriatric content NetLearning [the Health System's online education portal for staff] educational modules could be more appealing and interactive through the use of media."The entire cohort included an associate professor in cardiovascular medicine, assistant professors in obstetrics and gynecology, physical medicine/rehabiliation, emergency medicine, nursing, pediatric urology; and two fellows in family medicine.The combination of wrapping the program in the trappings of a fellowship and selecting fellows who could commit to a majority of scheduled sessions meant that not only were attendance levels extremely high , but participation in homework assignments was also 100%. Fellows were invested enough in the program that they requested certificates of completion at the conclusion of the program. The program administrator had thought this type of acknowledgement would be unimportant to this highly credentialed group, so had not prepared certificates for distribution at the last session. In response to the fellows' request, certificates and copies of the class portrait were prepared and mailed out following the final session, along with follow-up evaluation materials. Follow-up evaluation comments, as well as continued use of Media Studio resources and Library expertise for projects begun or conceived of during Bootcamp, bode well for the long-term success of this program.Five of the six sessions were held in the Library's Tolleson Wireless Classroom. This space proved ideal for the intimate, hands-on nature of the instruction. Moveable tables and chairs, wireless network connectivity, a reliable projection system, and plenty of electrical outlets for cameras, computers, and presentation equipment provided the right environment for relaxed but focused learning. Fellows and instructional staff alike were able to move about the room for help and collaboration during sessions. The remaining session, which required the use of Windows workstations for integrating multimedia into the ubiquitous PowerPoint for Windows, was conducted in the Library's traditional computer classroom. The different dynamic of that session (faces hidden behind stationery computer monitors and little room for fellows to work with their laptops) highlighted the benefits of the more flexible setting used for the other sessions. The wireless classroom also served as a viable setting for the Multimedia Vendor Day event, since the numerous network connections and moveable furniture allowed the teaching space to be configured for multiple vendor displays and effective crowd flow. The attached video shows the wireless classroom during the second hands-on session and also during the vendor day.Fellows' unrestricted access to high-quality multimedia equipment for the duration of the program gave them the ability to take the equipment out of the Library and into labs, classrooms, and their diverse educational settings. This flexibility meant that fellows were able to immediately apply what was learned in class to their real world instructional circumstances.A Kirkpatrick Level One Evaluation was collected at the conclusion of the final session. Eight of the nine fellows responded to the level one survey. The questions and their results are shown in Table A debriefing meeting including available Library staff that participated in Bootcamp as instructors, hands-on assistants, or logistical help, was held six weeks after the program's conclusion. By combining a review of participant feedback with the staff debriefing, we will implement changes small and large in future programs. Key revisions are anticipated to include:• Adding an intensive, two-day session specifically for staff that support faculty presentation and instruction projects• Moving the PowerPoint integration topic to the final session to allow more time for experimentation with DVD burning between sessions five and six• Dropping digital still camera use in favor of more time spent editing still images• Inclusion of previous Bootcamp projects as examples• Merging of the Multimedia Vendor Day with the Library's InfoFair, a popular yearly information and technology event, which drew over 700 visitors in 2003A Kirkpatrick Level Three Evaluation was conducted eight weeks after the program's conclusion. Surveys were mailed to fellows with the following three questions:1. Have you used any of the concepts that you learned in Multimedia Bootcamp? If yes, briefly describe how.2. If you haven't yet used any of the concepts or skills that you learned in Bootcamp, do you anticipate you will? Why, or why not?3. What can we do to help you get the most out of the resources you learned about?Five of the nine fellows responded to the survey. Three respondents indicated they had already used skills acquired at Bootcamp, including integrating multimedia with PowerPoint, creating posters with digital images, purchasing and using a new digital camera, and making a prototype teaching video. The respondents who had not yet applied any of the new skills indicated that they anticipated using them when writing new lectures or needing to integrate video clips from surgical procedures into PowerPoint. Responses to the question about how the Library could help fellows utilize our resources included requests for assistance with planned projects, anticipation of using Media Studio resources, and appreciation for assistance already provided.In addition to the level three survey responses, we have been able to see the longer-term effects of the program through requests to Library staff for assistance on projects originating at Bootcamp. In particular:The emergency medicine professor who provides paramedic education worked on a prototype DVD for a trauma-response training program for emergency medicine first-responders. Since the conclusion of bootcamp, she has worked the national organization that sponsors this training on specifications for the final DVD, which will replace an out-of-date VHS resource currently used for this certification training. Recently, we have collaborated with this clinician on shooting the video for this project so that we may use it as the basis for sample exercises during future Bootcamp programs.The veterinarian and lead animal researcher shot footage of the animal lab facility, then encoded it for inclusion in PowerPoint presentations highlighting the requirements for training in humane care and use of animals at the University of Virginia. The addition of live video to these presentations will be helpful to her role of conveying key concepts regarding use of animals in biomedical research.An incremental approach to integrating technology with current practices in instruction and presentation provided a supportive yet energizing environment for busy Health Sciences faculty. Keys to this program were its faculty focus, traditional hands-on instruction, unrestricted access to technology tools and support, and inclusion of criteria for evaluating when multimedia can augment pedagogical aims.For libraries interested in presenting a faculty multimedia training program, lessons which can be learned from our experience include:• Design and promote the program as a fellowship or other prestigious series• Enlist the support of multimedia services vendors• Espouse criteria for appropriate use of multimedia in instruction and presentation• Enlist familiar instructional strategies to gently introduce new technologies and approaches to faculty wary of the "bleeding edge."®, which makes text files readable on different operating systemsPDF: Portable Document Format; a standard developed by AdobeCD-R: Compact Disc (recordable); optical storage which holds at least 700 Megabytes of dataDVD-R: Digital Video Disc (recordable); optical storage which holds at least 4.7 Gigabytes of data, enough for a full-length movie.VHS: Video Home System; the common 1/2 inch consumer videotape formatThe author(s) declare that they have no competing interests.ER designed and administered the Bootcamp program and drafted the manuscript.Video 1 – Multimedia Bootcamp 2004 Instructional Session. QuickTime version: MMB_video1.mov. Windows Media Player version: MMB_video1.wmv.Click here for fileVideo 2 – Multimedia Bootcamp 2004 Vendor Day. QuickTime version: MMB_video2.mov. Windows Media Player version: MMB_video2.wmv.Click here for file


Traditionally metastatic melanoma of the distal leg and the foot metastasize to the lymph nodes of the groin. Sometimes the first site of nodal disease can be the popliteal fossa. This is an infrequent event, with rare reports in literature and when it occurs, radical popliteal node dissection must be performed.We report a case of a 36-year old man presented with diagnosis of 2 mm thick, Clark's level II-III, non ulcerated melanoma of the left heel, which developed during the course of the disease popliteal node metastases, after a superficial and deep groin dissection for inguinal node involvement. Five months after popliteal lymph node dissection he developed systemic disease, therefore he received nine cycles of dacarbazine plus fotemustine. To date (56 months after prior surgery and 11 months after chemotherapy) he is alive with no evidence of disease.In case of groin metastases from melanoma of distal lower extremities, clinical and ultrasound examination of ipsilateral popliteal fossa is essential. When metastatic disease is found, radical popliteal dissection is the standard of care. Therefore knowledge of anatomy and surgical technique about popliteal lymphadenectomy are required to make preservation of structures that if injured, can produce a permanent, considerable disability. Involvement of the regional lymph nodes is the most important predictor of outcome in patients with cutaneous melanoma . Traditi2 plus dacarbazine 900 mg/m2 intravenously, every three weeks, for a total of nine cycles) and in September 2006 the patient is alive with no evidence of disease . Preoperative lymphoscintigraphy showed uptake of the radiotracer in three nodes of ipsilateral groin that after removal resulted on final pathology negative for metastatic melanoma. In the February 2005 the patient presented at follow-up with clinical nodal disease in the left groin confirmed by fine needle aspiration cytology (FNAC). Preoperative staging did not reveal signs of systemic disease, therefore the patient underwent an inguinal lymph node dissection, that revealed 1 positive lymph node out of 8, and concomitant iliac and obturator lymph node dissection, with 3 positive nodes out of 11. Three months later he developed a mild-grade lymphedema of the inferior left extremity. Ultrasounds study (US) and magnetic resonance imaging (MRI)  were recorded as having developed metastatic disease in a popliteal node. Five of 13 patients with popliteal disease had metastatic inguinal node at the time or before the presentation of popliteal disease. Eight of the 13 patients with popliteal node metastases subsequently developed distant metastatic disease, at mean interval of 39 months (range 3–127 months) from the time of treatment of their primary melanomas. At last follow-up reported  seven of the patients had died of melanoma and six were alive, all clinically disease free. Thompson demonstrated that if a node in the popliteal fossa is observed on lymphoscintigraphy, a sentinel lymph node biopsy is indicated. If the specimen is positive for melanoma, a popliteal node dissection is the logical next step. So they concluded that there are two indications for popliteal node clearance: a histologically positive sentinel node in the popliteal fossa or clinical evidence of metastatic disease in this area [et al., recognized 106 patients with melanoma at the knee or distally. Ten patients (9%) had drainage to the popliteal basin at lymphoscintigraphy. They identified a 2.8% rate of metastatically involved popliteal nodes. Metastasis was detected in one patient by immunohistochemical analysis and were palpable in two at presentation. All had concomitant drainage to the groin, evident clinically or by lymphoscintigraphy. In the patient, with positive popliteal sentinel lymph node, groin sentinel node was disease free, so he underwent radical popliteal dissection. Two patients, with synchronous palpable popliteal and groin metastases, underwent radical popliteal and groin dissection. All 3 patients relapsed a short time after surgery with systemic and in-transit metastases; all 3 subsequently died. The authors concluded that popliteal area should always be examined when the primary lesion involves the distal lower extremities and when metastatic disease is found, radical popliteal dissection is the standard of care [Thompson  of care .In the extremities drainage of cutaneous melanoma is considered more predictable than in the head and neck . Usuallyet al., showed that positive nodes in the popliteal fossa can be expected from a lesion located anywhere below the knee [Previous authors have suggested that sites which drain to the popliteal nodal basin are located on the posterolateral aspect of the heel, below the lateral malleolus. However, Thompson the knee .et al., considered that in case of patients with popliteal involvement having metastatic inguinal nodes at the time or before the presentation of popliteal disease, popliteal metastasis could represent "backflow" from inguinal metastasis or in transit metastasis [In our case primary site was at the postero lateral aspect of the left heel. At presentation there was no evidence of clinical disease in the ipsilateral groin or popliteal fossa. SLNB showed three negative nodes. Recurrence after tumour-negative SLNB may result from an error in the technique of sentinel node detection at the time of lymphoscintigraphy or the operation, an inaccurate histopathological stain, or the biologic features of the melanoma . In our tastasis .The utilitarian surgical approach to the popliteal fossa involves a Z-plasty incision, to obtain optimal exposure of diamond shaped popliteal space. The initial step of popliteal dissection is adequate exposure of the popliteal fossa and identification of the neurovascular bundle. Identification of the popliteal fascia, which is very thin and friable, is a basic surgical step. This structure serves as a landmark because of its close proximity to the neurovascular bundle. As the fascia is exposed, the most superficial key anatomic structures are the lesser saphenous vein, that must be ligated and divided, and some small cutaneous nerve terminal branches. Next the incision of the deep fascia must be careful because of the superficiality of the nerves. The tibial nerve is the most superficial structure within the popliteal fossa  likewise the common peroneal nerve. A fat pad overlying and alongside the popliteal vessels is reported to enclose two to seven lymph nodes . With caThe case described was peculiar in the time of appearance of popliteal and groin metastases. Although the clinical evidence of groin involvement come as first site of recurrence, it must be considered as a consequence of popliteal metastases probably present since the sentinel node biopsy. In all cases of groin metastases from melanoma of distal lower extremities, clinical and ultrasound examination of ipsilateral popliteal fossa is essential, especially where the foot is the most frequent site of malignant melanoma, like in Japan . When meThe author(s) declare that they have no competing interests.UM conceived the study, carried out the literature search, and draft the manuscript; CC helped in management of the patient and preparation of the manuscript; MGC and GB carried out literature review and manuscript drafting; NM shaped the idea for the manuscript, coordinated the study and edited the manuscript.All authors read and approved the final manuscript.