Web-based programs for health promotion, disease prevention, and disease management often experience high rates of attrition. There are 3 questions which are particularly relevant to this issue. First, does engagement with program content predict long-term outcomes? Second, which users are most likely to drop out or disengage from the program? Third, do particular intervention strategies enhance engagement? To determine: (1) whether engagement (defined by the number of Web sections opened) in a Web-based smoking cessation intervention predicts 6-month abstinence, (2) whether particular sociodemographic and psychographic groups are more likely to have lower engagement, and (3) whether particular components of a Web-based smoking cessation program influence engagement. A randomized trial of 1866 smokers was used to examine the efficacy of 5 different treatment components of a Web-based smoking cessation intervention. The components were: high- versus low-personalized message source, high- versus low-tailored outcome expectation, efficacy expectation, and success story messages. Moreover, the timing of exposure to these sections was manipulated, with participants randomized to either a single unified Web program with all sections available at once, or sequential exposure to each section over a 5-week period of time. Participants from 2 large health plans enrolled to receive the online behavioral smoking cessation program and a free course of nicotine replacement therapy (patch). The program included: an introduction section, a section focusing on outcome expectations, 2 sections focusing on efficacy expectations, and a section with a narrative success story . Most of the analyses were conducted with a stratification of the 2 exposure types. Measures included: sociodemographic and psychosocial characteristics, Web sections opened, perceived message relevance, and smoking cessation 6-months following quit date. The total number of Web sections opened was related to subsequent smoking cessation. Participants who were younger, were male, or had less formal education were more likely to disengage from the Web-based cessation program, particularly when the program sections were delivered sequentially over time. More personalized source and high-depth tailored self-efficacy components were related to a greater number of Web sections opened. A path analysis model suggested that the impact of high-depth message tailoring on engagement in the sequentially delivered Web program was mediated by perceived message relevance. Results of this study suggest that one of the mechanisms underlying the impact of Web-based smoking cessation interventions is engagement with the program. The source of the message, the degree of message tailoring, and the timing of exposure appear to influence Web-based program engagement. Web-based programming for smoking cessation is now reaching millions at a relatively low cost ,2. MoreoA consistently troubling finding, however, is the relatively low rate of long-term engagement produced by many Web-based programs . Brief eEysenbach  discusseOperational definitions for “engagement” must also be defined. Danaher and colleagues  identifyThis study, which uses a fractional factorial design with multiple treatment components ,10, focuParticipants were recruited from the memberships of 2 Health Maintenance Organizations participating in the National Cancer Institute’s (NCI) Cancer Research Network (CRN): Group Health (GH) of Seattle, Washington, and the Henry Ford Health System’s Health Alliance Plan (HFHS) of Detroit, Michigan. Both GH and HFHS are not-for-profit health care delivery systems. Individuals were eligible to participate if: (1) they had smoked at least 100 cigarettes in their lifetime, currently smoked at least 10 cigarettes per day, and had smoked in the past 7 days; (2) were seriously considering quitting in the next 30 days; (3) were 21 to 70 years old; (4) were a member of GH or HFHS; (5) had home or work access to the Internet and an email account that they used at least twice weekly; (6) were not currently enrolled in another formal smoking cessation program or currently using pharmacotherapy for smoking cessation; and (7) had no medical contraindications for nicotine replacement therapy (NRT).All participants in the study received access, free of charge, to an individually tailored smoking cessation program delivered via the Web, although specific intervention components received by participants varied by the experimental group to which they were assigned. All participants also received, free of charge, a 10-week supply of NRT patches. The purpose of the NRT provision was to minimize the potential confounding effects of adventitious differences in physiological addiction and to allow participants to focus on the cognitive-behavioral aspects of smoking cessation. A previous trial combining a Web-based behaviorally-tailored smoking cessation program with NRT demonstrated positive and relatively high rates of cessation 3 months post quit date . The stuParticipants were recruited through a combination of individual- and population-level strategies between September, 2004 and July, 2005. Each of the 2 health care organizations identified likely current smokers via automated smoking status data collected during recent medical appointments, documentation of smoking in electronic medical charts, an internal list of smokers collected during prior research, or lists of patients with smoking-related conditions who had previously been prescribed cessation medications. Thus, all invitees were likely to have been recent smokers with a high probability of being current smokers. These likely smokers were prescreened using records of the health care organizations for minimal inclusion criteria  and were sent a study invitation letter. Recruitment information informed the likely smokers that they would receive a free Web-based smoking cessation program and a free 10-week course of nicotine replacement therapy (NRT). Provision of NRT was predicated on eligibility and completion of the baseline assessment, but not continued participation in the program. Individuals who had not opted out of further contact or had not begun enrolling in the program at least 4 weeks after their initial invitation were sent a second ‘reminder’ mailing. Several population-level enrollment strategies were also utilized, including promotion of the study in the HMO newsletter and to HMO staff. Further description of participant recruitment procedures and the results of these procedures are presented in McClure et al .Those invited to participate in the study were given a Web address (URL) and an identification code to enter a personalized website. After logging in, invitees were administered an eligibility survey, online consent, and baseline questionnaire. The intervention delivery system controlled the interaction with the participant by running a software script that collected data from the participant via an assessment and immediately produced appropriate  cessation feedback based on those data. The baseline assessment assessed, and stored in a database, the participant’s smoking history, psychosocial, health, and demographic characteristics relevant to smoking cessation programming. A quit date within 3 weeks of the baseline assessment was also required. Immediately after the assessment, randomization was stratified by the HMO site automatically by the computer, invisible to the participant. Follow-up interviews administered 6 months post quit date were conducted using a computer-assisted telephone interview (CATI).The overall Web-based program and each experimental factor within the program were developed at the University of Michigan’s Center for Health Communications Research (UM-CHCR). The content of the program was based on cognitive-behavioral methods of smoking cessation and relapse prevention, including an appeal to motives for quitting, stimulus control, self-efficacy enhancement, and suggestions for coping with tempting situations and emotions. The intervention components selected for testing within this overall paradigm included outcome expectations, efficacy expectations, use of hypothetical success stories, personalization of the message source, and the timing of message exposure.For 3 of these factors , the depth of tailoring was experimentally manipulated. By the term “tailoring” we refer to a process consisting of: (a) an assessment of individual characteristics relevant to smoking cessation, (b) algorithms that use the assessment data to generate intervention messages relevant to the specific needs of the user, and (c) a feedback protocol that delivers these messages to the smoker in a clear, vivid format. The Web-based program includes integrated cessation messages from multiple assessment responses to develop sentences and paragraphs written specifically for the user. For further description of the UM-CHCR’s tailoring process and examples of tailored feedback, the reader is referred to the UM-CHCR website .Study participants received a variation of each of the 5 two-level intervention factors (1) depth of tailored outcome expectation feedback; (2) depth of efficacy expectations; (3) depth of success stories; (4) personalization of source; and (5) exposure schedule. Each of these factors is described in turn below.In this factor, the depth of tailored outcome expectation feedback was manipulated. Messages included statements tailored to personal and family health history, perceived health status, functional health status, monetary savings, and appearance, among other outcomes. Participants randomized to the high-depth tailored group received feedback and advice related to their specific motives for quitting. In addition, these participants received an overview of the balance between their intrinsic versus their extrinsic reasons for quitting. Participants in the low-depth tailored group received feedback related to their motives for quitting but did not make as many connections with existing health or lifestyle characteristics, nor was feedback regarding the balance between intrinsic and extrinsic motives provided.Tailored efficacy messages addressed relevant barriers to quitting. Responses to high-risk situations, existing skills, and attributions for previous failures in quitting, along with smoking history and current smoking behavior were used to help build self-efficacy feedback. Those with previous cessation attempts, for example, were asked to consider these experiences in developing coping strategies for specific perceived cessation barriers. Participants randomized to the high-depth tailored group received feedback and advice focusing attention on their 2 most problematic individual barriers to quitting . Highly tailored feedback also used information about the participant's home environment, family life, stress and coping levels, coping skills, and level of physical activity, among other unique characteristic traits to provide enhanced advice in dealing with the barriers addressed. Participants in the low-depth tailored group received less tailored content addressing 2 broader barrier topics cited by the smoker .As part of the intervention, participants received a hypothetical story about an individual who successfully quit smoking. Low-depth success stories were tailored only to the participant’s name  and gender. Participants randomized to high-depth success stories received a story that was tailored not only to their name and gender, but also to their age, ethnicity, marital status, smoking status of the spouse, number of cigarettes, biggest barrier to quitting, reason for wanting to quit, degree and type of social support, as well as whether the participant had children in the home, was physically active, and was working outside of the home.In the introductory section welcoming a participant to the program, the highly personalized source condition included a photograph of, and supportive text from, the smoking cessation team of the HMO. It was written in a friendly manner, using words like "we" and "our team", and ended with a signature from the team. The low-personalized version included a photograph of a building representing the HMO institution, was written using words like "this organization", and did not include a closing signature.This manipulation compared the impact of providing the smoking cessation content in a single, large set of materials  to that of breaking the materials into a series of weekly installations. Participants received the efficacy, outcome, success story, and source materials all at one time online or distributed over 5 weeks (efficacy messages were separated into 2 weeks) with email reminders to revisit the site when new content was made available. In both exposures, once content was available, it remained available throughout the study period.This study was designed to identify the most active intervention components or “factors” from a large number of potentially relevant components ,10. A frEngagement was determined through an automated assessment of the number of sections of the Web-based smoking cessation program opened. The sections of the program, described in the previous section, focused on particular treatment components, including outcome expectations, efficacy expectations, success stories, and message source. There were 2 efficacy expectation sections, creating a total of 5 sections that could have been opened by the participant. Program engagement was measured by the cumulative number of Web-based smoking cessation sections opened by the participant.To determine the impact of increasing tailoring depth on engagement, a score was created representing the number of high-depth tailored components received by the participant. Randomization of the 3 tailoring depth factors  allowed participants to receive a range of 0-3 high-depth tailored components.At the 6-month follow-up, a single-item measure, the degree to which the materials were found to be “written personally for me”, was asked. Messages tailored to specific needs and interests of the individual are often evaluated using this measure ,14. In rThe abstinence measure used in this study, collected 6 months following the participant’s self-identified quit date, is 7-day point prevalence abstinence . Abstinence was assessed by self-report during a telephone interview at 6 months post-quit date. Biochemical verification was not collected since it was considered impractical in this population-based study . MoreoveLogistic regression and analysis of variance (ANOVA) procedures were used to address the 3 questions of this study: (a) whether engagement with the program is associated with 6-month cessation, (b) characteristics of participants that predict engagement in the program, and (c) treatment components that predict engagement in the program.The analysis examining engagement by 6-month cessation was conducted in 2 ways: a complete respondent (CR) analysis, and an intent-to-treat (ITT) analysis. The CR analysis focused on participants who answered the smoking cessation-related questions at 6-month follow-up. In the ITT analysis, all participants who were randomized to treatment, including those who failed to provide abstinence data for any reason, were included in the analysis. Non-respondents at follow-up in this case were considered treatment failures . The two remaining research questions were examined using baseline participant data and engagement data, which were collected from all baseline participants.Exposure schedule, whether the programming was delivered over weekly installments or as a single grouping of sections, was considered a fundamental, structural feature of the Web-based programming. Therefore, in addition to examining this factor as a predictor of engagement, analyses were also stratified by this factor.During an 11-month recruitment period, 3256 people from both HMOs visited the website; 2651 (81% of website visitors) were screened for eligibility; 2011 (62% of website visitors) were eligible; and 1866 enrolled and were randomized to 1 of the 16 study arms (57% of website visitors). The primary reasons for ineligibility to the study were: did not smoke enough (26%), medical contraindications for NRT (23%), already enrolled in another smoking cessation program (16%), lack of adequate Internet/email access (14%), not currently enrolled in the HMO (10%), and currently using pharmacotherapy to quit smoking (8%).P = .75).Of these participants, 1415 (76%) responded to the 6-month follow-up computer-assisted telephone interview (CATI) and were included in the complete respondent (CR) analyses. A chi-square test was used to assess whether the non-response rate to the 6-month follow-up varied among the 16 treatment arms . No significant differences in non-response rates between intervention arms were found (P < .05 level (unadjusted for multiple comparisons) were found only for 2 baseline characteristics, motivation and self-efficacy, which were higher in the low- than in the high-tailored success story condition.Demographic, smoking, and psychosocial characteristics of enrolled participants by HMO are presented in 2 = 16.1; P < .001). Respondent-only analyses found similar, statistically significant effects. Including baseline levels of motivation and self-efficacy in the regression model did not influence the results.Using intent-to-treat criteria (treating 6-month non-respondents as smokers), the cumulative number of Web sections opened was related to subsequent smoking cessation  across the entire 0-5 range of sections opened. Each section opened, on average, contributed to an 18% higher likelihood of quitting smoking . Dichotomizing usage into “heavy” (3-5 sections opened) versus “light” (0-2 sections opened), a significant effect was also found: participants heavily engaged in the Web program had an average 6-month cessation rate of 37.4% while participants lightly engaged had an 27.3% cessation rate  versus a Web program that broke the materials into weekly installments (“multiple”). In the single condition, personalized source and highly tailored efficacy expectation messages were related to a higher number of sections opened. In the weekly exposure condition, no intervention components were related to the number of sections opened.In a related study focused on smoking cessation outcomes , a signi                    In this path model, the tailoring depth influenced perception of message relevance, which in turn, influenced longitudinal engagement in the sequentially delivered Web program. Engagement was related to smoking cessation. Tailoring depth also influenced smoking cessation outside of the hypothesized engagement pathway.This research used a randomized trial to address 3 issues relevant to engagement in Web-based programming for health-related behavior change: (1) the degree to which engagement in program content influences 6-month smoking cessation outcomes; (2) characteristics of participants most likely to disengage with the program; and (3) intervention strategies that enhance engagement. These analyses found an average 18% increase in likelihood of quitting smoking for every Web section opened. The finding that engagement was associated with subsequent smoking cessation may not seem particularly surprising, though a null or even reverse result was possible if smokers who had successfully quit during the course of treatment decided to disengage from the program.Identifying characteristics of participants more likely to disengage from the program offers targets for engagement efforts. Participants who were younger, were male, or had less formal education were more likely to disengage from the Web-based cessation program, particularly when the program sections were delivered sequentially over time. These sub-groups could, in the future, receive programming more specifically related to their needs and interests. In another recent study examining determinants of engagement in a Dutch Web-based weight management and lifestyle program, Verheijden and colleagues  found siParticular components of the intervention influenced engagement with the Web-based programming. Both a more personalized source and highly tailored efficacy expectation messages were related to engagement when the Web program offered all content in a single large package. While message source is a classic focus in communications research, it is rarely examined in smoking cessation research. In this study, the source of the message was the participant’s health maintenance organization. While members of health maintenance organizations may perceive these organizations as untrustworthy due to a lack of openness and accountability , it is pNone of the individual intervention components influenced engagement when the sections of the program were distributed sequentially over a 5-week period. Since many Web-based programs are designed around a longitudinal engagement pattern, we wanted to focus further analysis on this issue, exploring the possibility that higher-depth tailoring might influence extended engagement. In a recent Web-based smoking cessation study, we found that message relevance partially mediated the influence of message tailoring on smoking cessation . In otheIn a path model constructed to explore this issue, perceived message relevance was associated with longitudinal program engagement. Message relevance, in turn, was influenced by greater depth of message tailoring. While other intervention strategies to influence longitudinal engagement exist , tailoring the message to specific needs and interests of the user appears to enhance perceived relevance, which in turn, appears to enhance engagement.This study has a number of limitations. First, our measure of engagement was rudimentary. The number of Web sections opened does not describe the time, quality, or other aspects of engagement . Second,In summary, this study found that: (1) engagement with a Web-based smoking cessation program was associated with subsequent cessation; (2) engagement was lower among younger, male, and less educated participants; and (3) engagement may be improved by including specific components to the intervention, particularly a more personalized source, and highly tailored messaging. Future research, with more detailed measures of engagement  and other engagement strategies  are likely to further our understanding of this issue. We believe that collecting multiple measures of engagement should be a routine part of all online interventions. A clear advantage of online interventions is the ability to measure engagement with relatively little effort, giving us greater insight into the process of program engagement and behavior change.


Chemical injuries of the oesophagus occur worldwide. There is paucity of information on aetiopathological profile of chemical injuries of the oesophagus in Nigeria.The aim of the study was to determine the aetiopathological pattern of chemical injuries of the oesophagus in Nigeria.This is a multi-centre hospital based study in Lagos metropolis spanning a period of 10 years.The patients' bio data, substances ingested, sources of corrosives, reasons for ingesting corrosives and patients' mental state were recorded.In all, there were 78 patients . The offending agents were acids in 55.1% of cases and it was accidental ingestion in 62 patients. The highest incidence of 57.6% was found in the middle 1/3 of the oesophagus.Accidental ingestion of acids is the commonest cause of oesophageal injuries in Nigeria. The incidence of severe strictures necessitating oesophageal substitution could be reduced if early management of corrosive oesophagitis improves in Nigeria. Chemical injuries of the oesophagus are caused by ingestion of corrosives like acids, alkali and some neutral substances. Other causes of oesophagitis include autoimmune diseases, infection, radiation and gastro-oesophageal reflux disease (GERD) -13.Ingested corrosives produce oro-pharyngeal and gastro-oesophageal injuries ranging from minor burns to severe necrosis, depending on the agent, the quantity ingested, concentration and duration of exposure. This may lead to corrosive strictures of the oesophagus .Various aspects of corrosive strictures of the oesophagus have been studied worldwide. A report from Ibadan, in South-Western Nigeria, by Ajao, OG and Solanke, TF  concludeAcids tend to burn the oral cavity, pharynx or larynx at the upper end and the pylorus is often damaged with copious ingestion of acids. Attempt at spiting out the acid may lead to tell-tale signs on the skin of the chest.Alkalis tend to affect the body of the oesophagus, especially at areas of natural constrictions. Powdery substances like calcium carbide do not glide easily in the oesophagus, so they tend to cause local damage which often leads to perforation.The pathology of oesophageal injuries has been studied extensively using animal and human models. The pathology is broadly divided into acute and chronic phases for description.It is important to note that even though acute inflammatory reaction is found in the acute phase irrespective of the causative agent . In animThis histological pattern forms the basis for adoption of Dameron and Wangensteen classification of jejunal injuries  to scoreA score of 1 is for necrosis that is limited to mucosa. Sub-mucosal involvement attracts a score of 2; involvements of muscularis propria, adventitia or outright perforations are scored 3, 4 and 5 respectively.The scoring system for peptic injury of the oesophagus is fairly different. Grading of gastro oesophageal reflux diseases (GERD) is as follow:Grade I: this is a non specific oesophagitis. In addition to neutrophilic infiltration, biopsy shows hyperplasia of basal layers.Grade II: There is breakdown of mucosa and frank ulceration.Grade III: Grade II plus attempts at healing (laying down of granulation tissue).Grade IV: This is reflux-induced oesophageal stricture.Grade IV may also be associated with or preceded by cephalad migration of squamo-columnar junction for more than 3 cm, a situation of Barrett's oesophagus is diagnosed. This is a pre-malignant lesion.This is the phase of established stricture. It develops when the acute phase is not well managed .There is progressive cicatrisation of the offended segment of the oesophagus leading to stricture formation. In a living person, contrast oesophagogram and oesophagoscopy will show the number, length and calibre of the stricture(s).In a 14-year review by Osinowo O and Alonge T [For surgical purposes, it is good to classify strictures as dilatable or non dilatable. Dilatable strictures are single short segment strictures (<2.5 cm) with residual lumina that can take bougie dilators.Non dilatable strictures are the multiple or long segment strictures.Complete loss of lumen falls in this category no matter the length.As their names suggest, dilatable strictures can be opened up by forceful passage of dilators or bougies through them. The undilatable strictures are only amenable to surgery .Short segment non dilatable strictures can be cured by resection and re-anastomosis. Long segment strictures with residual lumina can be treated by patch oesophagoplasty while others are treatable by oesophageal substitution. From the foregoing, it is clear that knowledge of the aetiology and pathology of chemical burns of the oesophagus will ultimately determine the applicable treatment modality. All the methods throw up different treatment challenges in this part of the world.This study was conducted to highlight the aetiopathological pattern of chemical injuries of the oesophagus in Nigeria.This is a prospective study of patients who reported with features suggestive of chemical injuries of the oesophagus from June 1996 - May 2006. It is a multi-centre, hospital based study in Lagos Metropolis in Nigeria. The study was conducted in 4 centres. A protocol was designed and the needed data were carefully entered. The data collected included patients' ages, gender, the corrosives ingested if any, the source(s) and reasons for ingesting the corrosives and patients' mental state. Hypotheses were formulated as follows:Ho: Location of stricture is independent of acid or alkali ingestion. H1: Location of stricture is not independent of acid or alkali ingestion.During the first contact, the time lag from injury to presentation was documented. Patients were asked questions relating to the management of the acute phases of their injuries. Specifically, the mode of treatment was documented vis-à-vis the attempt at inducing emesis before presenting at the hospitals, use of antidotes like oil, water or other specific antidotes .2 blockers, and steroids as part of the initial management at the referring hospital.Endoscopic findings at the acute phase were noted. Questions were asked about specific use of naso-gastric tubes, antacids or HThe patients had barium swallow to determine the segment affected the length, calibre and number of strictures. We relied on history of peptic ulcer disease and/or gastro-oesophageal reflux preceding dysphagia for the diagnosis or peptic strictures.Biopsy samples got at endoscopy or surgical specimens of late cases were sent for histology. The results of which were documented.For descriptive purposes, multiple strictures affecting one segment were taken as one entity. In the same vein, long strictures affecting two oesophageal segments were taken as two. A measure of dispersion of the distribution was carried out.We sought correlation between age and number of strictures using Pearson Correlation Coefficient. We used chi-square to test the significance of acids and alkali's preference for upper 1/3, middle 1/3 and lower 1/3 strictures using two by three contingency tables.We sought correlation between age and incidence of strictures using the Pearson Product Moment Correlation Coefficient and their coefficient of determination was also found.A total of seventy eight patients were studied within the 10-year period. This comprised of 61 males and 17 females giving a M:F ratio of 4:1. Patients in the 20 - 39 year age range were 42, constituting 53.8% of the series while 31 (39.7%) were 10 years and below. (Table The mean age of the patients was 22.56+ 2.89 years at α 0.05 (δ = 13.03 years). The median age was 23.3 years. The distribution enjoyed a Pearson's Skewness of -0.15 and it was leptokurtic.Regression analysis of age (x) against the number of cases (y) brought up a linearity of Y = 22.942 - 0.3314x.The offending substances were acids (battery water) in 43 patients (55.1%) and alkali in 28 patients (35.9%)  cases. There were three pharyngo-oesophageal strictures, three in upper third, 57 in middle third and 29 lower third strictures. The stomach was involved in 7 patients Table . In all,2 calculated χ> 2 table at α 0.01χ) we rejected Ho.All the strictures involving the pharyngo-oesophagus and stomach were caused by acids. In the same vein GERD caused some lower 1/3 strictures. Using chi-square for assessment of the location of strictures caused by acids and alkalis  evaluation showed that only 47.61% of the cases could be explained with this correlation.Oesophagitis, corrosive or non corrosive occur worldwide except for the relative preponderances of causative agents in different localities. The important agents earlier documented in this locality by Odelola and her colleagues , while rMore conclusively, majority of our patients (55.1%) ingested acids (battery water) while 35.9% ingested alkali-mainly caustic soda.The reversal of alkali preponderance in reported paediatric series  could beOn the other hand, battery water is handled mainly by car battery technicians who use sulphuric acid as electrolytes. These electrolytes are usually kept in their workshops where they are not readily available for children to swallow.Another important factor is that acids taste sour; therefore, children who swallow acids may not be able to take enough volume to cause major strictures.It is significant to note that in our series, there was no occupational predisposition to strictures.It is also important to note that only six patients presented early enough for early endoscopy. The corollary here is that most of our patients either presented late in the acute phase or they came with established strictures.The large number of patients who induced emesis before presenting brings to fore, the level of ignorances as to the danger posed by such practice in worsening the pathology of corrosive burns of the oesophagus. The outward passage of the corrosive may have worsened the ensuing strictures in them.Treatment of acute chemical burns of the oesophagus is still less than optimal in Nigeria. In our series, only 12 patients had specific treatment in the acute phase. Many patients still believe the old practice of drinking palm oil to neutralize whatever corrosive agent that is swallowed. It is obvious that most people are not aware of the beneficial effect of drinking water especially in cases of accidental ingestion of corrosives. Water is more readily available at home than specific antidotes. Its use may improve pre-hospital treatment of oesophageal burns in the acute phase.The case of a patient that was forced by armed robbers to drink an unknown substance introduced a new dimension to criminal activities in Nigeria. From our local experience, though not published, robbers usually kill their victims either for lack of cooperation of the victims or when there is risk of disclosure of identity of the robbers by the victims. In our practice, this is the first contact with a patient with this type of experience where the victim was maimed by forceful ingestion of corrosive.We saw an unusual drug induced stricture in a young adult who used a herbal preparation to cure his toothache. The depressed patient who mixed cement with corrosive is another strange case.It is our conclusion that the male patients still maintained their dominance over females in the incidence of corrosive strictures in Nigeria and corrosive ingestion is still mostly accidental among Nigerian adults. The occurrence of severe strictures, necessitating major operations like oesophageal substitution could be reduced if management of corrosive oesophagitis is well carried out at primary and secondary levels of care. The pre-hospital care of such patients may also improve the outlook. It is important to reiterate the call for enforcement of existing laws controlling the use of chemicals in Nigeria. This may reduce the availability of corrosives either for accidental or deliberate consumption.The authors declare that they have no competing interests.MO performed all the procedures as lead surgeon, he designed the study, wrote the manuscript and performed the statistical analysis, EO assisted MO during most of the procedures, and AO assisted MO for the operation of difficult strictures.


Trisha Greenhalgh and Jill Russell discuss the relative merits of “scientific” and “social practice” approaches to evaluation and argue that eHealth evaluation is in need of a paradigm shift. We argue that the assumptions, methods, and study designs of experimental science, whilst useful in many contexts, may be ill-suited to the particular challenges of evaluating eHealth programs, especially in politicised situations where goals and success criteria are contested.We offer an alternative set of guiding principles for eHealth evaluation based on traditions that view evaluation as social practice rather than as scientific testing, and illustrate these with the example of England's controversial Summary Care Record program.PLoS Medicine readers to join a debate on the relative merits of “scientific” and “social practice” approaches to evaluation and consider the extent to which eHealth evaluation is in need of a paradigm shift.We invite evaluations of such initiatives fail to deliver the insights expected of them. PLoS Medicine has published three papers offering a “robust” and “scientific” approach to eHealth evaluation Much has been written about why electronic health  initiatives fail PLoS Medicine series rests on a set of assumptions that philosophers of science call “positivist” The approach to evaluation presented in the previous Alternative approaches to eHealth evaluation are based on very different philosophical assumptions “interpretivist” approaches assume a socially constructed reality —hence, reality is never objectively or unproblematically knowable—and that the identity and values of the researcher are inevitably implicated in the research process “critical” approaches assume that critical questioning can generate insights about power relationships and interests and that one purpose of evaluation is to ask such questions on behalf of less powerful and potentially vulnerable groups (such as patients) Catwell and Sheikh argue that “health information systems should be evaluated with the same rigor as a new drug or treatment program, otherwise decisions about future deployments of ICT in the health sector may be determined by social, economic, and/or political circumstances, rather than by robust scientific evidence” , page 1.social practice—that is, as actively engaging with a social situation and considering how that situation is framed and enacted by participants reflexivity—consciously thinking about issues such as values, perspectives, relationships, and trust. These traditions reject the assumption that a rigorous evaluation can be exclusively scientific. Rather, they hold that as well as the scientific agenda of factors, variables, and causal relationships, the evaluation must also embrace the emotions, values, and conflicts associated with a program In contrast to this view of evaluation as scientific testing, scholars in critical-interpretivist traditions view evaluation as Kushner observes that “The [positivist evaluation] model is elegant in its simplicity, appealing for its rationality, reasonable in asking little more than that people do what they say they will do, and efficient in its economical definition of what data count” , page 16The first problem with scientific evaluation, suggests Kushner, is that programs typically have multiple and contested goals; hence, no single set of goals can serve as a fixed referent for comparison. An early finding of our evaluation was that the SCR program had numerous goals  Second, outcomes are not stable; they erode and change over time and across contexts. In the SCR program, it was originally planned that patients would access their electronic record from home via linked software called HealthSpace, thereby becoming “empowered”. But HealthSpace was subsequently uncoupled from the SCR program because it was deemed “high risk” by civil servants Third, Kushner suggests, the causal link between process and outcome is typically interrupted by so many intervening variables as to make it unreliable. In the SCR evaluation, we documented 56 such variables—including training, permissions, physical space, technical interoperability, local policies and protocols, professional sanction, and point-of-care consent Fourth, key characteristics of program success may not be articulated in the vocabulary of outcomes and may not yield to measurement. One such dimension of the SCR program was the variable culture of e-governance across different organisations .Finally, program learning that leads away from initial objectives threatens failure against outcome criteria. In the SCR program, an early finding was that predefined milestones  were sometimes counterproductive since implementation teams were required to push forward in the absence of full clinical and patient engagement, which sometimes led to strong local resistance. We recommended that these milestones be made locally negotiable. But because critics of the program interpreted missed milestones as evidence of “failure”, policymakers took little heed of this advice.explaining the phenomenon under study. Controlled, feature-at-a-time comparisons are vulnerable to repeated decomposition: there are features within features, contingencies within contingencies, and tasks within tasks “Scientific” evaluation aims to produce statistical statements about the relationship between abstracted variables such as “IT response times”, “resource use”, and “morbidity/mortality” Expressing findings as statistical relationships between variables may draw attention away from people taking action “Substance”  and “verisimilitude” (something that rings true) are linked to the narrative process, which Karl Weick called “sensemaking” PLoS Medicine series MacDonald and Kushner identify three forms of evaluation of government-sponsored programs: bureaucratic, autocratic, and democratic, which represent different levels of independence from the state In sum, critical-interpretivist approaches to evaluation have different quality criteria and generate different kinds of knowledge than “scientific”  approaches. These differences are summarised in Lilford et al. identify four “tricky questions” in eHealth evaluation  and resolve these by recommending mixed-method, patient-and-system studies in which internal evaluations (undertaken by practitioners and policymakers) are formative and external ones  are summative We offer below an alternative  set of principles, initially developed to guide our evaluation of the SCR program First, think about your own role in the evaluation. Try to strike a balance between critical distance on the one hand and immersion and engagement on the other. Ask questions such as What am I investigating—and on whose behalf? How do I balance my obligations to the various institutions and individuals involved? Who owns the data I collect? Second, put in place a governance process (including a broad-based advisory group with an independent chair) that formally recognises that there are multiple stakeholders and that power is unevenly distributed between them. Map out everyone's expectations of the program and the evaluation. Be clear that simply because a sponsor pays for an evaluation it does not have special claim on its services or exemption from its focus Third, provide the interpersonal and analytic space for effective dialogue . Conversation and debate is not simply a means to an end, it can be an end in itself. Learning happens more through the processes of evaluation than from the final product of an evaluation report Fourth, take an emergent approach. An evaluation cannot be designed at the outset and pursued relentlessly to its conclusions; it must grow and adapt in response to findings and practical issues which arise in fieldwork. Build theory from emerging data, not the other way round .Fifth, consider the dynamic macro-level context  in which the eHealth innovation is being introduced Sixth, consider the different meso-level contexts , how action plays out in these settings  and how this changes over time. Include reflections on the research process  in this dataset.Seventh, consider the individuals  through whom the eHealth innovation(s) will be adopted, deployed, and used. Explore their backgrounds, identities and capabilities; what the technology means to them and what they think will happen if and when they use it.Eighth, consider the eHealth technologies, the expectations and constraints inscribed in them  and how they “work” or not in particular conditions of use. Expose conflicts and ambiguities .Ninth, use narrative as an analytic tool and to synthesise findings. Analyse a sample of small-scale incidents in detail to unpack the complex ways in which macro- and meso-level influences impact on technology use at the front line. When writing up the case study, the story form will allow you to engage with the messiness and unpredictability of the program; make sense of complex interlocking events; treat conflicting findings  as higher-order data; and open up space for further interpretation and deliberation.Finally, consider critical events in relation to the evaluation itself. Document systematically stakeholders' efforts to re-draw the boundaries of the evaluation, influence the methods, contest the findings, amend the language, modify the conclusions, and delay or suppress publication.eHealth initiatives often occur in a complex and fast-moving socio-political arena. The tasks of generating, authorising, and disseminating evidence on the success of these initiatives do not occur in a separate asocial and apolitical bubble. They are often produced by, and in turn feed back into, the political process of deciding priorities and allocating resources to pursue them Differences in underlying philosophical position may lead to opposing quality criteria for “robust” evaluations. Some eHealth initiatives will lend themselves to scientific evaluation based mainly or even entirely on positivist assumptions, but others, particularly those that are large-scale, complex, politically driven, and differently framed by different stakeholders, may require evaluators to reject these assumptions and apply alternative criteria for rigour


One of its four central areas of work is climate protection as described at This gateway page provides recent highlights of activities including WRI analyses and statements to congressional and other federal bodies. Various sections detail international and U.S. action on climate protection, as well as WRI’s numerous programs and publications related to this topic. Other sections focus on the themes of technology options, green power and renewable energy use, and information and analysis tools.The WRI has 17 climate protection programs. These range from the GHG [greenhouse gas] Protocol Initiative to the Vulnerability and Adaptation program, which seeks to reduce environmental and human impacts of climate change. Each program page describes the program’s aims and strategies, provides background and contact information, and links to publications and materials including press releases, reports, and workshop documents.Two of the technology areas addressed by the WRI are carbon capture and sequestration (CCS) and sustainable transportation. The CCS program works to foster acceptance of these technologies among policy makers and the public, deploy a regulatory framework for CCS activities, and focus research on the most cost-effective methods. Currently 75 stakeholder organizations are involved in this initiative. The WRI Center for Sustainable Transport, known as EMBARQ, works mainly on urban issues. One of its successes has been the introduction of cleaner, more efficient buses in Mexico City, resulting in yearly carbon emission reductions there of almost 50,000 tons. On the basis of this outcome, a dozen more cities including Hanoi and Istanbul plan to duplicate this project.


Cystic adventitial disease of the popliteal artery is a rare cause of non-atheromatous claudication. It usually requires surgery to improve the distance walked by patients.We report the case of a 44-year-old Caucasian man with unilateral symptomatic popliteal cysts extending to his genicular branches and associated with multilevel stenosis of his anterior tibial artery. A surgical evacuation of the cysts successfully restored his arterial patency and led to an objective haemodynamic improvement but was associated with early recurrence of symptoms.We suggest that the involvement of the genicular branches in cystic adventitial disease of the popliteal artery is a possible indicator of extensive adventitial degeneration and unfavourable clinical prognosis. Cystic adventitial disease (CAD) of the popliteal artery (PA) is a rare but well-recognized non-atheromatous cause of claudication. Since it was first described in 1954 [Histopathological features of the disease are cystic collections of mucinous material containing varying combinations of mucopolysaccharides and mucoproteins within the adventitial layer of the artery. The cysts exert extrinsic pressure on the arterial lumen, which accounts for the clinical manifestations of chronic lower limb ischemia, mainly intermittent claudication, and limb pain with absent distal pulses. Its aetiology is uncertain, with theories arguing about the possible degenerative, embryonic or ganglionic nature of the disease .Diagnosis is usually achieved with duplex ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI). Various approaches of treatment have been described, including percutaneous cyst aspiration, open incision and cyst enucleation, endovascular stenting, excision of the cyst with autologous vein graft reconstruction, and bypass surgery .We report the case of a patient with unilateral claudication secondary to multiple adventitial cysts of the popliteal artery with additional involvement of the genicular arteries.A 44-year-old Caucasian man who works as a personal trainer presented with a four week history of unilateral (right) leg claudication occurring at a distance of 150 meters and exacerbated by running. He had no significant personal medical history, smoked five cigarettes per day, and engaged in extreme sports and vigorous exercise. His body mass index (BMI) was normal, although he had been morbidly obese ten years prior to presentation.On examination, all of our patient's lower limb pulses were palpable beside the dorsalis pedis on both his feet. His Doppler ankle-brachial pressure index (ABPI) was 1.09 on the affected side, with a 40 mmHg post-exercise pressure drop. Duplex ultrasound revealed three adventitial popliteal cysts, the largest measuring 3.4 cm (length) by 0.8 cm (diameter). A magnetic resonance angiogram confirmed a high-grade stenosis in his symptomatic proximal popliteal artery, as well as multiple stenoses in both his anterior tibial arteries but with a three-vessel bilateral run-off. An MRI scan of the affected popliteal fossa, performed to accurately assess the relations of the cysts to the surrounding structures and to exclude any other pathology, additionally showed involvement of his genicular arteries  limb occurring at a distance of more than half a mile and after exercise. A repeat Duplex scan demonstrated that his popliteal artery was widely patent with no evidence of recurrent stenoses. His ABPI was 1.36 with no pressure fall after exercise. In the absence of radiological evidence of popliteal artery stenosis, our patient was advised to avoid strenuous exercise, with a view to proceed to further imaging if symptoms recurred.et al. [Although CAD of the popliteal artery was first described more than five decades ago, there is a growing published interest in the diagnosis and management of this rare condition -7. Our cet al.  that focMultiple treatment options have been employed in the management of the disease. Despite reports of spontaneous resolution of symptoms , the majBecause of the rarity of the disease and the lack of large studies involving long follow-up examinations, the recurrence rate of previously treated CAD of the popliteal artery, or any associated risk factors, are not precisely known; it is, however, presumed to vary between six percent and ten percent, irrespective of the treatment method, with onset of recurrent symptoms between one and 21 months -15.The proposed mechanism for an adventitial cyst to become symptomatic involves a sufficient increase of the pressure within the fluid-filled cyst during muscle exertion, thus resulting in haemodynamically significant endoluminal stenosis . CommuniCAD of the popliteal artery, although uncommon, should be considered in the differential diagnosis in young patients presenting with claudication, particularly if there are no risk factors for peripheral vascular disease. Our report raises the possibility that the extension of CAD to the genicular arteries could be a predictor of higher risk of recurrence, either as an indicator of cysts communicating with the knee synovium or as a marker of the involvement of smaller vessels elsewhere. Vascular surgeons should thus be encouraged to report similar cases in order to better identify risk factors of unsuccessful outcome based on larger series. Also, patients should be warned that they may not experience complete resolution of their symptoms despite objective evidence of surgical patency.The authors declare that they have no competing interests.EY performed the literature search and compiled data presented in this report. PT undertook the management of our patient from the time of his initial presentation to his surgery and follow-up examination. He also revised the manuscript draft. Both authors read and approved the final manuscript.Written informed consent was obtained from our patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


In 2005, the Centers for Disease Control and Prevention (CDC) started a 3-year colorectal cancer screening demonstration project and funded five programs to explore the feasibility of a colorectal cancer program for the underserved U.S. population. CDC is evaluating the five programs to estimate implementation cost, identify best practices, and determine the most cost-effective approach. The objectives are to calculate start-up costs and estimate funding requirements for widespread implementation of colorectal cancer screening programs.An instrument was developed to collect data on resource use and related costs. Costs were estimated for start-up activities, including program management, database development, creation of partnerships, public education and outreach, quality assurance and professional development, and patient support. Monetary value of in-kind contributions to start-up programs was also estimated.Start-up time ranged from 9 to 11 months for the five programs; costs ranged from $60,602 to $337,715. CDC funding and in-kind contributions were key resources for the program start-up activities. The budget category with the largest expenditure was labor, which on average accounted for 67% of start-up costs. The largest cost categories by activities were management (28%), database development (17%), administrative (17%), and quality assurance (12%). Other significant expenditures included public education and outreach (9%) and patient support (8%).To our knowledge, no previous reports detail the costs to begin a colorectal cancer screening program for the underserved population. Start-up costs were significant, an important consideration in planning and budgeting. In-kind contributions were also critical in overall program funding. Start-up costs varied by the infrastructure available and the unique design of programs. These findings can inform development of organized colorectal cancer programs. Screening for colorectal cancer (CRC) reduces mortality and improves quality of life through earlier detection of precancerous polyps and thus more effective treatment of cancers . Less thCRC screening has been shown to be cost-effective in numerous studies using decision analytic models to assess the benefits and the cost of screening . The modThe Centers for Disease Control and Prevention (CDC) established the Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 to explore the feasibility of establishing a CRC screening program for the underserved U.S. population. Data from the five program sites funded through this effort provide a unique opportunity to understand the costs associated with offering screening through organized programs. Each program is described in detail elsewhere in this issue ,10.CDC is undertaking a detailed evaluation of CRCSDP to estimate the cost of implementation (start-up and maintenance), describe implementation processes, assess patient outcomes, and determine the relative cost-effectiveness of screening modalities. We report here on the start-up costs of establishing CRC screening programs, which include all expenditures before delivery of the service. This information is essential for the estimation of the funding required to plan and start a CRC screening program. Subsequent reports will include costs incurred during the service delivery phase of the program.We developed an instrument to collect data on use of resources and costs related to the start-up of CRCSDP. The start-up period was defined as the time between the date of the funding award  and the start of delivery of the screening service in each program. We knew that the times required to complete start-up activities for each program might differ, which would lead to an inconsistent duration of the start-up period for programs. Nevertheless, we adopted this definition to ensure that start-up activities and their costs were fully captured at each program site.Well-established methods for collecting cost data for program evaluation, such as the "ingredient approach," were considered in designing the questionnaire -14 S. S, and actThe cost instrument was designed to ensure collection of accurate data despite variations among the five programs. The programs differed in structure, provider network, selection of the screening test, and size of the service delivery area, and all of these factors affected costs. One of the five programs is implemented statewide, two are restricted to large urban areas (one city each), and two others serve clients throughout one to three counties. Two programs provide colonoscopy as the primary screening test, and the other three provide guaiac-based fecal occult blood tests. The structure for service delivery was more decentralized in some programs than in others. Decentralized programs, for example, contracted with providers to perform recruitment, screening, and patient follow-up activities, whereas centralized programs did not outsource these activities. Provider networks varied by site and included hospitals, specialty care centers, state health departments, and community health centers.All data were collected in Microsoft Excel . Program staff entered the data prospectively into the Excel work sheets to ensure accuracy of the information and avoid issues related to recall bias. For example, program staff maintained a log of the activities performed that was updated on a weekly or monthly basis. Programs were also provided with a user guide giving detailed definitions of each activity captured for the start-up period. This guide assisted with data reporting and helped to ensure consistent reporting among all programs so that meaningful comparisons could be made. Evaluators conducted a series of conference calls with each site to provide additional guidance for data collection.www.bls.gov) or the average salary from a similar job category provided by the programs. On the basis of this information, we computed the hourly rate for labor and the proportion of in-kind labor cost — labor hours expended but not covered by CDC funds. The labor costs were then aggregated for each activity in each program.We analyzed costs according to CRCSDP program activities during the start-up period. In estimating the true labor costs, we used the information collected on 1) the number of hours worked by staff per month on various activities, 2) the proportion of salary paid through CRCSDP funds, 3) data on the percentage of time staff members worked, and 4) staff salary. The staff salary information was requested as either a range or the actual base salary in addition to the fringe benefit rate. We used the average of the lower and upper bounds of the salary range when necessary. When salary information was not provided, we used national average compensation for a specific job category from the Bureau of Labor Statistics  and supplies such as computers. Labor was a major component of in-kind donations.Distribution of start-up costs among budget categories is shown in For all programs combined, the largest cost categories by activity were management ; data collection and tracking, which were mainly for database development ; administrative costs ; and quality assurance  . Other aCost allocations among activities for each of the five programs are shown in To our knowledge, no previous evaluation has provided details on the costs to begin a CRC screening program for the underserved population. The important contributions of this paper include 1) the imputation of market value to in-kind contributions (voluntary and donated services and products), which can help other programs explicitly account for in-kind contributions in their budgets in cases when these resources might not be freely available; 2) the categorization of cost components , which pOne of the largest cost components was overall program management, which involved a wide range of activities. Necessary resources included expenditures to develop fiscal systems, recruit and train staff, establish policies and procedures, and negotiate contracts with providers. Another significant cost component was developing a database system to monitor and track patient services. Labor required to perform these activities was the most significant budget category; materials and supplies accounted for a much smaller proportion of the total cost. Most of these activities represent fixed costs and therefore will not vary in relation to the volume of screens performed.In this CRC screening demonstration, in-kind contributions were critical in providing the resources required for the start-up program activities. Therefore, total cost of start-up activities should include the monetary value of these contributions, which are generally related to donation of labor hours. This in-kind labor was mainly provided by senior management staff members, who were vital for the overall success of the program, and by physicians and other key individuals who participated in the medical advisory board to ensure that the program was designed to include pertinent clinical care partners and that quality care was provided to program participants. In future planning for resource allocation for a similar program, these critical categories should not be overlooked.Start-up costs varied substantially across the five programs in this screening demonstration. The infrastructure available before the start of this effort accounts for some of the difference. For example, programs that could easily manipulate existing data-collection tools did not have to incur large expenses to create new data systems. Therefore, we can expect programs that plan to build on a well-established infrastructure to incur smaller start-up costs than programs with limited infrastructure. Other sources of variation could include the type of screening tests offered, the geographic area covered, the setting in which the program was created , and individual program contributions to administrative costs, which were a significant proportion of total costs. Although we provided a user's guide to minimize inconsistencies in reporting data, programs may have differed in the allocation of expenses to the various activity-based categories. Systematic quantitative assessment of these variations in start-up cost was not possible because of the small number of pilot sites available. Finally, we did not assess the cost incurred in the start-up period in relation to the effectiveness of the services provided by the programs. An evaluation of the cost-effectiveness of the programs is planned, and results based on intermediate outcomes (cost per screen performed and cost per polyp/cancer detected) will be reported in future publications. However, such a study cannot be conducted in the start-up phase of a program when no screening has occurred.The information provided in this assessment on the magnitude of cost related to specific start-up activities can serve as a guide to estimation of start-up costs for funding agencies and organizations implementing screening programs. The detailed list of start-up activities developed for this study can also assist program staff to develop budget estimates, and the real-world cost values reported in this analysis can serve as a benchmark for evaluation of these estimates. Thus, our work should provide essential information for the successful start of CRC screening programs. Furthermore, details on implementation costs are expected to provide in-depth assessment of the costs associated with recommended screening tests and realistic estimates of the cost of diagnosis and complications.


Popliteal pterygium syndrome is a rare congenital disorder that consists of popliteal webs and craniofacial, genitourinary and extremity anomalies. Only moderate successful surgical excision of the fibrotic band within the popliteal web has been reported because the nerves and vessels in the affected site are short and displaced into the web and they are attached to adjacent tissues. We performed hamstring tenotomy on the ischial tuberosity, tenotomy of the flexor hallucis longus and Z-lengthening of the Achilles tendon on the ankle in our patient, and this was followed by gradual correction using an Ilizarov external fixator. Full extension of the knee joint was achieved at the ninth postoperative week. However, some recurrence of flexion contracture was noted at two years follow-up. Gradual soft tissue lengthening with an Ilizarov external fixator can be one of the optimal procedures when excision of a fibrous band and Z-plasty are not possible due to severe adhesion of the nerves and vessels into a fibrotic band. However, a cautious approach is recommended when considering the high risk of recurrence. Popliteal pterygium syndrome (PPS) is a rare disorder that's characterized by flexion contractures of the knee and popliteal webbing. The cause of the PPS has not yet been firmly established. This disorder sometimes affect other joints and it is often combined with craniofacial, oral cavity and genitourinary anomalies.A 7-year-old male was admitted to our hospital for flexion contracture of the right knee and popliteal pterygium. The combined anomalies included cleft lip, cleft palate, congenital lip sinus, mucus membrane adhesion , atrophy of the scrotal wall, small testes and a small penis. Bilateral popliteal pterygium was found at the 2nd postnatal month. Lengthening of the skin and soft tissues by excising the fibrous band and Z-plasty were performed for the left pterygium. However, only Z-plasty was done for the skin and soft tissue lengthening for the right pterygium because excision of the fibrous band was not possible due to severe adhesion of the sciatic nerve to the fibrotic band to the sciatic nerve. Thereafter, soft tissue lengthening was attempted in another hospital at the age of 5 because the flexion contracture and popliteal pterygium of the right knee relapsed, but the adhesion to the sciatic nerve also caused a failure. On the physical examination, 45° of knee flexion contracture and 30° of plantar flexion contracture were observed . FemoralWe performed hamstring tenotomy on the ischial tuberosity, tenotomy of the flexor hallucis longus and Z-lengthening of the Achilles tendon on the ankle, and this was followed by the application of an Ilizarov external fixator . The patPPS is a rare genetic condition that's characterized by popliteal webbing, craniofacial anomalies, genitourinary anomalies and skeletal anomalies. The same as for Van der Woude syndrome, mutation in the interferon regulatory factor 6 gene is presumed to be responsible for the disorder.PPS can be diagnosed based on the presence of cleft lip, cleft palate, genital hypoplasia and popliteal webbing, but care should be taken to differentiate it from multiple pterygium syndrome, arthrogryposis multiplex congenita, sacral agenesis and myelomenigocele. Multiple pterygium syndrome is characterized by pterygia of several joints such as the axilla, the volar side of the elbow and the interphalangeal areas, and patients with multiple pterygium present with other various deformities.There are various treatment methods for PPS. Surgical treatment is preferred because the results of conservative treatment, including serial casting or traction, have been unsatisfactory. Among these surgical treatments, lengthening of the soft tissues such as the skin, muscles and ligaments using resection of fibrous bands and Z-plasty was the most preferred technique.An Ilizarov external fixator is commonly used for correction of shortening or deformity, and it is also employed for the treatment of joint contractures. According to Gillen et al.,Gradual soft tissue lengthening with an Ilizarov external fixator can be one of the optimal procedures when excision of fibrous band and Z-plasty are not possible due to adhesion to the nerves or blood vessels in the popliteal pterygium. However, a cautious approach is recommended when considering the high risk of recurrence.


Technical development in last two decades has made it possible for pulmonologists to do endobronchial ultrasound (EBUS). With EBUS mini-probe, the multilayered structure of the tracheobronchial wall can be analyzed better than any other imaging modality. Instead of fluoroscopic guided biopsy, EBUS can be used to biopsy peripheral lesions. EBUS-transbronchial needle aspiration has proved valuable for mediastinal lymph node staging of lung cancer. Studies have shown that EBUS is cost-effective as it reduces the need for more morbid and costly invasive procedure like mediastinoscopy or thoracotomy. Prospective studies are needed in India to see how EBUS will help in populations with high prevalence of tuberculosis. Bronchoscopy has become the most commonly performed invasive procedure by pulmonologists. In India fiberoptic bronchoscopy has been performed since 1980s.Computerised Tomography (CT) scan was and continues to be the imaging modality of choice for diagnosis and staging of lung cancer. However CT proved unsuccessful in evaluation of lymph node involvement and for diagnosis of air wall infiltration. Positron Emission Tomography-CT (PET-CT) to a certain extent improved the mediastinal lymph node staging. However to obtain tissue for histopathology, mediastinoscopy or thoracotomy is needed. A better imaging modality was increasingly felt necessary for lung cancer staging. In the late 1980s endoscopic ultrasound (EUS) was introduced in gastroenterology.4However in the past decade increasing number of researchers have found EBUS immensely useful in numerous conditions. EBUS has become a hot topic in all major conferences and is becoming an essential bronchoscopic tool. With the recent introduction of dedicated ultrasonic bronchoscope with real time guidance for needle aspiration there is widespread acceptance of this novel method leading to a ‘new dawn for respiratory physician’.5There are two forms of EBUS, radial and linear (convex). The major differences are given in The view of the bronchoscopist is limited to the lumen and the bronchial mucosa. EBUS has extended the vision beyond the tracheobronchial wall. One of the first indications to use EBUS was for preoperative assessment of airway wall in patients with centrally localized lung tumor. CT scan often cannot predict the extent of tumor invasion into the airway wall. For planning Endobronchial treatment modalities it is important to know if the tumor is extending into or beyond the cartilage or just limited inside the submucosal layers . This isIn advanced tumors the longitudinal extent and patency of distal airways can be assessed by passing the radial probe beyond high-grade stenosis.91011Fluoroscopy is generally used during bronchoscopy to guide sampling peripheral pulmonary lesions. CT guidance for peripheral lesions can be considered in prior unsuccessful bronchoscopy but is expensive and has significant radiation exposure.Assessment of mediastinal lymph nodes is important for lung cancer staging and planning appropriate treatment strategy. Current imaging modalities like CT and PET can indicate size and metabolic activity, respectively but their accuracy is far from satisfactory. American College of Chest Physicians (ACCP) guidelines of 2007 concluded that for mediastinal lymph node metastasis sensitivity and specificity are 51 & 85% for CT and 75% & 85% for PET.181920Radial probe EBUS can be used to localize the mediastinal lymph nodes. Once target lymph node is identified, the probe is removed and a needle is inserted for sampling through the working channel of bronchoscope without real-time needle monitoring. A randomized trial between conventional TBNA and TBNA after EBUS localization, for mediastinal staging demonstrated that EBUS guidance significantly increased the yield of TBNA in all stations (84 versus 58%), except for the subcarinal region,et al. real time EBUS-TBNA for enlarged mediastinal nodes on chest CT in suspected lung cancer patients, 572 lymph nodes were punctured and 535 (94%) resulted in diagnosis. Biopsies could be taken from all reachable lymph node stations  and had a mean diameter of 1.6 cm. A sensitivity of 94%, a specificity of 100% and accuracy of 94% could be achieved. Similar results was found in other series also.22et al. evaluated 100 lung cancer patients without enlarged lymph nodes.615Recently linear probe EBUS has been developed which allows real-time ultrasonic guidance during needle insertion . In a laet al. concluded that both transesophageal and transbronchial ultrasound-guided FNAC have similar diagnostic yields, although transbronchial approach is superior for right-sided lymph nodes.28EUS is also useful in assessing mediastinal lymphadenopathy. It has the added advantage of allowing to evaluate and do real time FNA of lymph node stations 8, 9, celiac axis lymph nodes and left adrenals which cannot be reached by EBUS and are occasional sites of lung cancer metastasis.EBUS-TBNA can be used in the evaluation of mediastinal adenopathy due to other etiologies. EBUS-TBNA has a sensitivity of 85–91% for the primary diagnosis of sarcoidosis.2932et al. after comparing the actual costs of 5 different strategies of mediastinal lymph node staging of lung cancer concluded that combined EBUS real time TBNA and conventional TBNA are the most cost-effective strategies.Although very useful in a variety of pulmonary diseases the question one needs to consider is whether EBUS is cost effective especially in a developing country like India. EBUS linear bronchoscope, processor, dedicated needles and radial probe add significantly to the cost of the procedure. But it has been found that EBUS-TBNA has significant cost savings.Limited resources make the choice of decision between radial EBUS and linear EBUS difficult. Linear EBUS is an attractive option if one considers sampling mediastinal adenopathy since real-time guidance of needle is possible. However it is costlier and cannot be used for other indications of EBUS like assessing airway infiltration and localizing intrapulmonary lesions. There are no studies directly comparing the yield of radial EBUS and linear real time EBUS for mediastinal lesions. However for esophageal cancer a prospective trial has shown that there was no clinically relevant difference between curved array and radial echoendoscopy in the staging.Endobronchial ultrasound, which has been introduced about a decade ago, is becoming more and more popular. It is accurate, safe and is being used for an increasing number of indications. Radial probe EBUS can be used to evaluate airway invasion by tumors and analysis of peripheral pulmonary lesions. Linear EBUS provides real-time guidance for sampling mediastinal lesions. Although EBUS is very costly so far all the studies have shown that it is cost-effective. EBUS-TBNA and EUS-FNA can effectively replace mediastinoscopy as the preferred staging procedure for mediastinal lymph nodes in lung cancer patients. In India where tuberculosis is so prevalent it needs to be seen whether EBUS will mirror the high accuracy found in studies from developed countries.


The benefits of community-based health programs are widely recognized. However, research examining factors related to community leaders' characteristics and roles in implementation is limited.The purpose of this cross-sectional study was to use a social ecological framework of variables to explore and describe the relationships between socioeconomic, personal/behavioral, programmatic, leadership, and community-level social and demographic characteristics as they relate to the implementation of an evidence-based strength training program by community leaders. Eight-hundred fifty-four trained program leaders in 43 states were invited to participate in either an online or mail survey. Corresponding community-level characteristics were also collected. Programmatic details were obtained from those who implemented. Four-hundred eighty-seven program leaders responded to the survey (response rate = 57%), 78% online and 22% by mail.t-tests as appropriate. Implementers reported higher levels of strength training participation, current and lifetime physical activity, perceived support, and leadership competence . Logistic regression analysis revealed a positive association between implementation and fitness credentials/certification (p = 0.003), program-specific self-efficacy (p = 0.002), and support-focused leadership (p = 0.006), and a negative association between implementation and educational attainment (p = 0.002).Of the 487 respondents, 270 implemented the program (55%). One or more factors from each category – professional, socioeconomic, personal/behavioral, and leadership characteristics – were significantly different between implementers and non-implementers, determined by chi square or student's Among this sample of trained leaders, several factors within the professional, socioeconomic, personal/behavioral, and leadership categories were related to whether they implemented a community-based exercise program. It may benefit future community-based physical activity program disseminations to consider these factors when selecting and training leaders. An essential component of community-based physical activity programs are the leaders who implement them -4. CommuLeaders often possess a wide variety of backgrounds and skills, which inevitably influence the programs they implement and the participants who receive them. In community-based public health program evaluations, there are varying types and degrees of success ; it is likely that the characteristics of the leaders and communities contribute to this variability – independently and collectively -12.Currently, there is a gap within the public health literature by which a comprehensive model could be developed and utilized to identify, select, and strategically train community-based leaders to maximize their skills and capacity. General literature on leadership, however, lends insight to factors and characteristics worthy of exploration. For example, it has been proposed that leadership is influenced by the leader's personal characteristics. Research suggests that such characteristics can be defined on a variety of levels, such as age, education level, or in a capacity that is more descriptive of life experiences and personal habits, such as eating habits or exercise practices. In this context, a study may seek to determine which factor is important to program implementation: formal training or prior program implementation experience? Perhaps neither; perhaps both. Also, does it matter whether the leaders themselves model the behavior they are trying to encourage? Personal commitment and/or experience may affect the execution of implementation ,13-20.Other theories on leadership suggest that while personal characteristics are important, situational factors such as support, the organization, or environment may interact with individual factors and modify effectiveness accordingly ,17,21-23What is commonly agreed upon in this area is that appropriate leadership is important to bring about change within a group, and that greater levels of change require leadership that is more dynamic. It has been suggested that the most effective leaders are those who rely on not one but multiple leadership styles and those who are able to adapt depending on the situation ,26.Considered succinctly, optimizing leadership is likely a function of both personal and environmental factors that facilitate program implementation and sustainability through separate and collective action ,15,17,21There is emerging popularity and demand for evidence-based health promotion programs. Despite the recognized importance of community program leadership and an extensive body of literature related to the leadership for the business sector ,16,22,32The purpose of this study was to explore and describe the relationships between socioeconomic, personal/behavioral, programmatic, leadership, and community-level social and demographic characteristics as they relate to the implementation of an evidence-based strength training program by community leaders. This was a cross-sectional design that utilized a convenience sample of leaders from the StrongWomen Program (SWP) – a nationally disseminated community strength training program targeted to midlife and older women . The priThe SWP was designed as a community-based program to be implemented as twice weekly group strength training classes lasting eight to twelve weeks in community settings. At the time of survey administration June 2006), thirty-nine day-long workshops had been conducted from May 2003–June 2006 – training 854 community leaders from forty-three states to lead the SWP. Program leaders are most commonly from nonprofit organizations such as the USDA Cooperative State Research, Extension, and Education Service, hospital-based wellness centers, and community/recreation centers  to implement the program, and that support-focused leadership style and greater levels of program-related self-efficacy (as measured by the scores previously described) increase the likelihood of implementation . Additionally, higher educational attainment was negatively associated with program implementation (p = 0.002). Results are shown in Table To examine the impact of these measures on program implementation, a logistic regression model was estimated. The logistic equation presented in Tables It is important to note here that the construction of alternative models informed by the univariate results occurred during the analyses of these data. The process involved a phased approach testing for collinearity among variables and using step-wise logistic regression. The variables were first tested for collinearity within their respective categories . For example, within the socioeconomic and professional category, education and income were highly correlated and thus could not be included in any regression models together. Using separate step-wise logistic regression tests, educational attainment remained in the model while income did not; thus, education was chosen over income for inclusion. This also occurred with three variables in the leadership category. Program-related self-efficacy, leader self-identification, and leadership comfort were all correlated, and were subsequently tested in models separately; program-related self-efficacy was chosen for inclusion based upon the model's Cox & Snell R-squared value. The final phase involved testing the remaining variables for potential collinearity followed by step-wise logistic regression. The final model presented Table  is signiThe mission of public health is to prevent disease and promote health in the greater population through the ongoing collection of health-related data; providing sound health information, resources, and recommendations; and supporting the implementation and dissemination of public health initiatives and programming. While we understand the importance of physical activity participation and have data to support the feasibility and benefits of community-based programming ,29,45-52Of approximately forty distinct factors examined – including a range of socioeconomic, professional, personal/behavioral, leadership, and community variables – these data revealed that fitness credentials, support-focused leadership style, and greater levels of program-related self-efficacy were positively associated with program implementation, while higher levels of educational attainment were negatively associated with implementation in a logistic regression analysis. Additionally, in chi square group-level comparisons, physical activity level, perceived support, comfort leading groups, and leader self-identification were higher among implementers compared to non-implementers.The social ecological model provided a valuable framework to categorize variables related to leader implementation. These findings demonstrated that both individual and interpersonal levels of influence were important. Fitness credentials/certification is an individual leadership characteristic specific to the implementation of this program. For example, leaders in this sample have a variety of professional expertise – from physical and occupation therapy to nursing, dietetics, and chiropractics . In the The self-efficacy score was derived from three questions in which leaders rated their confidence to overcome social, logistical, and physical challenges related to program implementation. Program-related self-efficacy was significantly higher among implementers, which is consistent with previous findings ,31,53, aThe leadership assessment was asked separately from programmatic questions, and this category of questions was asked in a general context. Respondents were asked to identify potential leadership strengths and weaknesses of their own leadership characteristics in terms of organization, communications, conflict resolution, and providing support, which are commonly examined factors in determining leadership style ,22,27,40In this study, educational attainment was inversely associated with program implementation. This was an interesting finding and counterintuitive to other findings . HoweverThe primary limitation of this study is the convenience sample and cross-sectional design. This design and sampling structure dictate that all findings are associations in which causality cannot be inferred or implied, and that results cannot be extrapolated to other populations or programs. In future survey research of a similar nature, it would be optimal to administer the survey prior to and following a potential implementation timeframe. Specifically with regard to the sample: they were predominantly women who were mostly white and of relatively high socioeconomic status (SES). Despite this, there is a range within SES. Additionally, the national representation of leaders with varying personal and educational degrees is beneficial for understanding common factors across professions, geographical regions, and urban/rural locations. An additional limitation of this study is response bias. Response bias is a consideration for survey research, although the response rate was 57%. It is helpful that response rate does not appear biased by implementation, as it is similar among implementers and non-implementers.Although these data provide valuable insights into initial program implementation, there are a number of questions related to program adoption and sustained delivery (i.e. utilization of the RE-AIM Framework) that would provide a fruitful area of further investigation ,55. The Studies on other social change issues have identified a number of factors that are associated with sustained change. These include policy changes, strategic collaborations, and effective leadership at the community level. Without leadership to initiate, motivate, and sustain physical activity programs, the causal pathway to behavior change among community members is interrupted, minimizing the efficacy of programs and reducing the likelihood of community and individual change ,32,56,57Implementation is an important step to increasing access to community programs, and ultimately, to increasing participation. Thus, optimizing implementation rates through leader recruitment and training are viable strategies to achieve that goal. These findings may also help administrators to improve criteria for leader selection, as good leaders are difficult to recruit and maintain.This study's theoretical model offers a contextual framework of factors related to leader implementation, and contributes knowledge to advance research related to future community-based programs. Utilizing lessons learned from this study, future research – particularly prospective studies – examining a similar social ecological framework that includes personal/behavioral, socioeconomic, professional, leadership, and community factors in other programs and in other populations are clearly warranted. Studies including men and individuals with greater socioeconomic and racial diversity (e.g. low income and non-white populations) would be beneficial to the literature and for applications in a variety of public health programs and settings.Strong Women series. In addition, she is a shareholder in LLuminari, Inc, a women's health media company.Authors RA Seguin, R Palombo, CD Economos, R Hyatt and J Kuder declare no competing financial or non-financial interests. Author ME Nelson declares that she is author of eight trade books in the Authors RAS, RP, CDE, RH, and MEN contributed to the concept, design, data analysis, and data interpretation; manuscript development and revisions; and final manuscript approval. JK contributed to data analysis and interpretation; manuscript revisions; and final manuscript approval.