Heart failure is a complex disorder characterized by widespread activation of various neurohormonal pathways resulting in increased circulating levels of catacholamines. In the short run, these circulating catacholamines may augment heart rate, blood pressure and myocardial contractility. However, chronic adrenergic stimulation leads to worsening of heart failure by inducing myocardial apoptosis and fibrosis. CirculatBeta-blockers were first used in the management of congestive heart failure in adults more than 30 years ago. Despite et al. in 2007.[Carvedilol is a third-generation beta-blocker, which has an alpha-blocking action as well. Thus, in addition to the beta-blocking action (non-selective), it causes peripheral vasodilatation by the alpha-receptor blockade. CarvedilThe bioavailability after oral administration is 25-35% because of significant first-pass metabolism in the liver. It is meAs with other beta-blockers, carvedilol is not recommended for patients with asthma or bronchospastic disease, diabetes, advanced heart block, sick sinus syndrome, acute heart failure and cardiogenic shock. Dose reduction is required in liver failure. The most11Drug interactions can occur with digoxin, cyclosporine and hepatic enzyme inducers like rifampicin. Concomitant use of digoxin and carvedilol reduces the digoxin clearance from the body and hence it is recommended that the digoxin dose be reduced by 25% when coadministered with carvedilol.Based on the studies performed to date, carvedilol should be initiated in infants and children at a dose of 0.05-0.2 mg/kg/day, given in two divided doses. The doseThe drug is available as 3.125, 6.25, 12.5 and 25 mg tablets. While there are no commercially available oral liquid formulations of carvedilol, a formulation can be prepared from the tablets. The tablets should be crushed and mixed with water and these formulations may be stored at room temperature for up to 12 weeks.Unlike adult patients, very few randomized controlled trials have been performed using f beta-blockers in pediatric patients with heart failure. These studies have analyzed the effect of the addition of beta-blockers (mostly carvedilol) in patients already receiving standard heart failure treatment .–19 Most et al. reported significantly lower plasma concentrations of norepineprine, dopamine and aldosterone after 12 months of therapy with carvedilol.[Most of these studies reported a favorable impact of carvedilol on symptom class and left ventricular functional parameters . Some studies reported survival benefit and reduced need for transplantation.15 Giardirvedilol. Another rvedilol. These inrvedilol.et al. in 2007.[The first and only prospective randomized control on use of carvedilol in children with heart failure was reported by Shaddy The following were the major observations made from this study:No significant difference in the composite end point between the treatment groups based on percentage of patients who improved, worsened or was unchanged.There was a significant interaction between study drug and ventricular morphology, suggesting a beneficial trend for patients with systemic left ventricle versus a non-beneficial trend for those with systemic right or single ventricle.A significant proportion of younger patients (< 24 months) improved compared with those older than 24 months.The hazard ratios for mortality and hospitalization rates showed a trend favoring carvedilol over placebo, although the difference was not statistically significant.Echocardiographic parameters showed a statistically significant improvement in patients with systemic left ventricle, especially in the high-dose carvedilol group.The drug was generally well tolerated in most patients; worsening heart failure leading to drug withdrawal occurred in about 11% of the patients in the carvedilol group.The average trough concentrations of the drug were lower than that observed in adult studies, indicating a more rapid clearance of carvedilol in children.This is the first major trial on beta-blockers in heart failure, which reported a lack of significant benefit on the composite end points studied. The authors postulate that inherent heterogenecity in the etiology of pediatric heart failure, different ventricular morphologies in the study patients and the possible high rate of spontaneous improvement in younger patients as possible reasons to explain the relative lack of benefit of carvedilol in their study. Moreover, the pharmacokinetics of carvedilol is different in children, resulting in more rapid drug clearance and lower trough serum levels of the drug in children, as was observed in this study.et al.[The e-mail survey of expert opinion tried to address some of the issues that emerged after the publication of the study by Shaddy et al. As in thet al. The summMost of the respondents (except one) felt that there is a definite role for carvedilol in the management of pediatric heart failure. Heart failure due to myocardial failure (dilated cardiomyopathy/myocarditis) was agreed upon as the only indication for use of carvedilol (level of evidence A). Although there are some studies reporting a favorable effect of carvedilol in heart failure due to left-right shunts, all the The general consensus among all the respondents and experts who participated in the consensus meeting was to start the standard therapy of digoxin, diuretics and ACE inhibitors first and then initiate carvedilol once the maximum tolerated doses of the other drugs  was achieved.Most experts were reluctant to initiate carvedilol treatment in children who had advanced heart failure .Most of the experts who participated in the e-mail survey felt that carvedilol may not be useful in patients with systemic right ventricle  or single ventricle. In the national consensus meeting, however, the use of carvedilol in patients with systemic right ventricle was considered as optional (level of evidence IIa).All the respondents were in agreement with the standard guidelines for starting carvedilol therapy in a low dose and then titrating the dose once a week toward the maximum tolerated dose. Most experts preferred to start the treatment in the hospital, although the dose titration maybe performed in the clinic setting. Standard methods  should be used to monitor response to treatment.Most of the experts felt that carvedilol is useful in improving symptoms in children with heart failure. Some have observed improvement in ventricular function. However, the respondents were unclear about the more robust end points like mortality and frequency of hospitalizations.Most experts felt that carvedilol is safe and often well tolerated in children with heart failure. One of the experts (Dr. S. S. Kothari) observed that worsening of heart failure may not be that infrequent after initiating carvedilol (up to 20% patients).The protocol suggested for managing patients with worsening of heart failure is to withdraw the drug immediately and then use inotropes like milrinone or dopamine in the intensive care unit or oral enoximone in the ward (Dr. John Simpson). Reinitiation of carvedilol has to be performed very cautiously, at a lower dose with a slower titration.Carvedilol is a useful adjunct in the pharmacotherapy of heart failure in children, especially due to myocardial disease. In children with systemic left ventricle, there is clear evidence that carvedilol therapy improves symptoms and results in improvement in echocardiographic indices of ventricular function. In patients with systemic right ventricle or single ventricle, current data do not support the use of carvedilol for managing heart failure. Long-term prospective randomized controlled studies should address the impact of carvedilol treatment on more robust end points like mortality.


Bifidobacterim longum isolate. The competitiveness against other bacteria is not fully understood yet but may be related to the production of antimicrobial compounds such as bacteriocins. In a previous study, 34 Bifidobacterium isolates have been isolated from baby faeces among which six showed proteinaceous antilisterial activity against Listeria monocytogenes. In this study, one of these isolates, RBL67, was further identified and characterized.Bifidobacteria are found at varying prevalence in human microbiota and seem to play an important role in the human gastrointestinal tract (GIT). Bifidobacteria are highly adapted to the human GIT which is reflected in the genome sequence of a Bifidobacterium isolate RBL67 was classified and characterized using a polyphasic approach. RBL67 was classified as Bifidobacterium thermophilum based on phenotypic and DNA-DNA hybridization characteristics, although 16S rDNA analyses and partial groEL sequences showed higher homology with B. thermacidophilum subsp. porcinum and B. thermacidophilum subsp. thermacidophilum, respectively. RBL67 was moderately oxygen-tolerant and was able to grow at pH 4 and at a temperature of 47°C.Bifidobacterium thermophilum strain. To our knowledge, this is the first report about B. thermophilum isolated from baby faeces since the B. thermophilum strains were related to ruminants and swine faeces before. B. thermophilum was previously only isolated from animal sources and was therefore suggested to be used as differential species between animal and human contamination. Our findings may disapprove this suggestion and further studies are now conducted to determine whether B. thermophilum is distributed broader in human faeces. Furthermore, the postulated differentiation between human and animal strains by growth above 45°C is no longer valid since B. thermophilum is able to grow at 47°C. In our study, 16S rDNA and partial groEL sequence analysis were not able to clearly assign RBL67 to a species and were contradictory. Our study suggests that partial groEL sequences may not be reliable as a single tool for species differentiation.In order to assign RBL67 to a species, a polyphasic approach was used. This resulted in the classification of RBL67 as a  Bifidobacterium spp. in 1899 ) showed the highest homologies to 16S rDNA sequences of other bifidobacteria from the GenBank  of Bifidobacterium RBL67 [GenBank: DQ340558], B. thermacidophilum subsp. thermacidophilum LMG21395T [GenBank: AY004276]  whereas using partial groEL sequences, strain RBL67 is on the same branch as B. thermacidophilum . The comparison of 16S rDNA sequences and partial groEL sequences showed a discrepancy between the classification of strain RBL67 based on those methods. By comparing the partial groEL gene sequences, Bifidobacterium RBL67 is more closely related to B. thermacidophilum subsp. thermacidophilum LMG21395T (98.25% similarity) than to B. thermacidophilum subsp. porcinum LMG21689T . According to the definition of Zhu et al. , the use of the temperature is not reliable anymore for the discrimination of the origin of bifidobacteria. However, since only a few species are able to grow above 45°C, the assignment to a Bifidobacterium sp. can be narrowed. Further studies are now undergoing to determine whether B. thermophilum is more widespread within humans.Another discrimination tool between human and animal bifidobacteria strains was the temperature growth limit of 45°C for strains from human origin ,31. B. tBifidobacterium bifidum DSM20456T was cultivated only on MRS-C agar as it didn't grow on RB-agar. All strains were incubated anaerobically at 37°C overnight in MRS-C broth and agar, or at 40°C for 48 h on RB-agar.A list of strains used in this study is presented in Table B. longum subtype longum DSM 20219T, Bifidobacterium RBL67, B. thermacidophilum subsp. thermacidophilum LMG 21395T or B. thermacidophilum subsp. porcinum LMG 21689T. The flasks were then incubated in a shaker at 160 rpm and 37°C for 12 h. Samples were taken every 2 h and treated for 3 min in a stomacher to remove clumps prior to measurements of the optical density at 600 nm. Each growth curve was carried out twice.Growth under conditions of oxidative stress was measured after a modified method described by Meile et al. . VolumesBifidobacterium RBL67, RBL68 and RBL70, B. thermacidophilum subsp. thermacidophilum LMG 21395T, B. thermacidophilum subsp. porcinum LMG 21689T, B. animalis subsp. lactis DSM 10140T and B. thermophilum DSM 20210T were determined as follows:The temperature and pH extremes of -1 resazurin as redox indicator were anaerobically inoculated with 1% of the tested bifidobacteria cultured overnight. The temperature range was evaluated by incubating the strains for 7 days at 12, 25, 46, 47, 48 and 49°C with an initial pH of 7.0. The pH range was determined using pH 4.0, 4.5, 5.0, 5.5 and 8.0 as initial pH for growth. Samples were incubated at 37°C for 7 days. Aliquots were taken daily, treated in a stomacher for 3 min and the OD was measured at 600 nm. Each growth condition was measured twice. If a strain failed to reach OD600 of 0.4 after 7 days, it was declared as not growing under the tested conditions.25 ml of MRS-C containing 2 mg lBifidobacterium RBL67 and other bifidobacteria was done using a slightly modified PCR protocol established by Schürch [MEGA version 3.1 [Specific amplification of the 16S rDNA of  Schürch  using th Schürch . Phylogesion 3.1 . The seqgroEL gene sequence from Bifidobacterium RBL67 were done using a modified method of Jian et al. [2, 2 μM each of primer H60R and H60F  and subjected to electrophoresis on agarose (0.8%) gels in 1 × TAE buffer. DNA bands were visualized by 2.5 μg ml-1 ethidium bromide under UV light. Corresponding bands (0.59 kb in size) were then cut out and purified as described above.DNA cloning and sequencing of a partial heat shock n et al. . The DNAn et al. . To ampl0F Table  and 2.5 E. coli XL-1 blue cells was done using the electroporation method described by Sambrook and Russel [-1) carrying partial HSP60 encoding gene sequences from Bifidobacterium RBL67 or B. thermacidophilum subsp. thermacidophilum LMG 21395T was then sequenced by Microsynth GmbH and finally aligned to the corresponding sequences from bifidobacteria and Bacillus subtilis W168 (obtained from Genbank entries) using the CLUSTAL W software (version 1.6). Similarities were calculated and converted into a distance matrix with the Jukes-Cantor parameter and rooted with Bacillus subtilis W168 applying a bootstrap value of 1000 using the software MEGA version 3.1 [Purified PCR fragments were ligated into the pGEM-T easy vector using the Promega PCR cloning kit. Ligation and cloning was performed according to the kit manual. Transformation of d Russel . Recombision 3.1 .Bifidobacterium RBL67, B. thermacidophilum subsp. thermacidophilum LMG21395T, B. thermacidophilum subsp. porcinum LMG21689T, B. thermophilum DSM 20210T and B. boum 20432T. Total DNA was isolated using a French pressure cell according to the method described by Cashion et al. [in situ temperature probe.Whole genome DNA-DNA hybridizations were carried out externally at DSMZ Germany. Hybridizations were performed with the genomes of n et al. , DNA-DNAn et al.  in 2 × SCarbohydrate fermentation of strain RBL67 was analyzed using API 50 CHL strips (Biomérieux). The tests were carried out in triplicates according to the manufacturer's instructions with a modification in culture preparation. Briefly, 2 ml of an overnight culture in MRS-C broth were centrifuged . The pellet was then washed and resuspended in 1 ml of autoclaved water. This suspension was then mixed with 5 ml CHL50 medium (Biomérieux) and 0.1 ml of this mixture was applied to each tube of the API test. The test strips were then incubated anaerobically for 72 h at 37°C and evaluated after 24, 48 and 72 h.Bifidobacterium RBL67, RBL68 or RBL70, B. thermacidophilum subsp. thermacidophilum LMG 21395T or B. thermacidophilum subsp. porcinum LMG 21689T were centrifuged . The supernatant was 10 × diluted in HPLC-grade water and filtered (0.45 μm) prior to HPLC analysis. This was carried out using an Aminex HPX-87H (300 × 7.8 mm) column (Bio-Rad) in a Merck LaChrom HPLC system. Sulfuric acid  was used as mobile phase at a flow rate of 0.4 ml min-1. Sugars and acids were detected by a RI detector. Analyses were done in duplicate.Molar ratio of acetic and lactic acid was determined using HPLC. 2 ml of an overnight culture (16 h) of either UVA did the first identification and characterization experiments, carried out the sequence alignments, prepared the DNA-DNA hybridizations, coordinated the study and drafted the manuscripts. VM did the molecular and phenotypic experiments, statistical analysis and participated in sequence alignment and DNA-DNA hybridization preparation. CL conceived the study and participated in the coordination of the study. LM participated in the coordination of the study and the sequence interpretation and helped in the draft of the manuscript. IF and EEK were responsible for the screening and isolation of bifidobacteria strains from baby faeces. All authors read and approved the final manuscript.


The quaking homolog, KH domain RNA binding (mouse) (QKI) is a candidate gene for schizophrenia. Disturbed QKI mRNA expression is observed in the prefrontal cortex of patients, and some of these changes correlate to treatment with antipsychotic drugs.To test if low doses of antipsychotic drugs can modify QKI mRNA expression, human astrocytoma (U343) and oligodendroglioma (HOG) cell lines were treated with five different antipsychotic drugs including Haloperidol, Aripiprazole, Clozapine, Olanzapine and Risperidone. Messenger RNA expression levels of splice variants QKI-5, QKI-6 and QKI-7 were measured by Real-Time PCR.Haloperidol treatment (0.2 μM) doubled QKI-7 mRNA levels in U343 cells after 6 hours . The effect was dose dependent, and cells treated with ten times higher concentration (2 μM) responded with a five-fold and three-fold increase in QKI-7, 6 and 24 hours after treatment, respectively .The results in U343 cells suggest that QKI-7 mRNA expression in human astrocytes is induced by Haloperidol, at concentrations similar to plasma levels relevant to clinical treatment of schizophrenia. The molecular mechanism of action of antipsychotic drugs after binding to receptors is not well known. We hypothesize that QKI regulation is involved in this mechanism. QKI was recently proposed as a candidate gene for schizophrenia based on linkage, association and mRNA expression studies -3. The aInterestingly, an association between the type of antipsychotic drugs patients received and QKI mRNA expression was shown previously . We hypoin vitro effects on a single cell line. In any case, our current in vitro experiments and the previous analysis of post-mortem brains coincide in the suggestion of alterations in QKI control in both astrocytes and oligodendrocytes after treatment with antypsychotic drugsTo test whether antipsychotic drugs affect QKI mRNA expression in U343 and HOG cells, we treated cell cultures with Aripiprazole, Clozapine, Haloperidol, Olanzapine or Risperidone for 6 and 24 hours. In U343 cells, the most significant change in mRNA expression levels was a 2.1-fold increase of QKI-7  after 6 hour treatment with Haloperidol  and observed a five-fold increase after 6 hours  and a three-fold increase after 24 hours   supplemented with 10% fetal bovine serum  and 1% penicillin-streptomycin solution . Although some of the characteristics typical for oligodendrocytes and astrocytes may be changed in the glioma cells they are used for these experiments since it is not possible today to derive these cell types from a living human brain to perform this experiment. The cells were cultivated to about 30% confluence before treatment with antipsychotic drugs. Medium to treat the cells contained 1 μM Aripiprazole , 2 μM Clozapine , 0.2 μM Haloperidol , 0.25 μM Olanzapine  or 0.15 μM Risperidone , respectively, in DMEM supplemented with 10% FBS and 1% PEST. The concentrations used were in the typical range of blood plasma levels observed in patients treated with the drugs [In the initial experiment, we detected an increase of QKI-7 mRNA expression in Haloperidol treated U343 cells. To test whether the effect was dose dependent we performed an additional treatment with this drug using 10 times higher concentration (2 μM).® ND-1000 Spectrophotometer (NanoDrop Technologies). RNA samples were stored at -70°C prior to use.RNA was isolated according to standard Trizol extraction procedures . The con2 (25 mM), 2 μL dNTPs (10 mM), 0.5 μL oligo dT (10 μg/L), 0.2 μL RNase inhibitor, 0.25 μL reverse transcriptase  and 3.85 μL of sample (about 500 ng of RNA). These reactions were incubated at 25°C for 10 min and 48°C for 1 hour.Reverse transcription reactions included 1 μL RT-buffer (10×), 2.2 μL MgCl® PCR Master mix , 0.3 μM of each primer  and ~10–100 ng of cDNA. The primer for the reference gene  as well as for the QKI splice variants, QKI-5, QKI-6, QKI-7, were uniquely designed using Primer Express , as described previously [Real-time RT-PCR was performed with an ABI PRISM 7000 Sequence Detection System  as follows: 2 minutes at 50°C and 10 minutes at 95°C followed by 40 cycles of 15 seconds at 95°C and 1 minute at 60°C. Each reaction was carried out in a total volume of 25 μL, consisting of 9.8 μL Power SYBRMessenger RNA expression levels of the QKI splice variants were normalized with the expression levels of the endogenous control ACTB. In other words, our target variable for the statistical analysis was the difference between QKI and ACTB expression on a logarithmic scale. To test the effect of antipsychotic treatment on QKI mRNA expression, we analyzed each cell line separately with a two-way ANOVA model, which included the factors treatment, time and the interaction between treatment and time. Comparisons between treated cells and their corresponding controls were carried out with linear contrasts, (i.e. with pre-planned t-test utilizing the pooled estimate of error variance). The statistical analysis was carried out in Proc GLM .The quaking homolog, KH domain RNA binding (mouse); U343: astrocytoma cell line.ACTB: actin beta; D2R: dopamine 2 receptor; D3R: dopamine 3 receptor; FBS: fetal bovine serum; HOG: human oligodendrogial cell line; PEST: penicillin-streptomycin solution; PCR: polymerase chain reaction; QKI: The authors declare that they have no competing interests.LJ carried out cell work and real-time PCR experiments. PS participated in the statistical calculations. EJ participated in the study design and ELC performed cell work, expression studies, was involved in the statistical work and in the study design.Changes of QKI mRNA expression in U343 and HOG cells after treatment with different antipsychotic drugs. The two upper tables show fold-change of QKI expression, standard deviation and p-value for each treatment in U343 and HOG cells. The lower table shows fold-changes of QKI expression, standard deviations and p-values after Haloperidol treatment, with the higher concentration (2 μM), of U343 cells. Changes with p-values < 0.05 are indicated with an asterisk. Two-fold differences are indicated with a box.Click here for filePrimer sequences used for detecting gene expression for ACTB, QKI-5, QKI-6 and QKI-7. Primer sequences used to amplify ACTB-, QKI-5-, QKI-6-, and QKI-7 mRNA.Click here for file


Little information exists about the diffusion of evidence-based interventions, a process that can occur naturally in organized networks with established communication channels. This article describes the diffusion of an effective skin cancer prevention program called Pool Cool through available Web-based program materials.We used self-administered surveys to collect information from program users about access to and use of Web-based program materials. We analyzed the content of e-mails sent to the official Pool Cool Web site to obtain qualitative information about spontaneous diffusion.Leader's Guide (59%) and lesson cards (50%) were the most commonly downloaded materials, and most respondents reported using these core items sometimes, often, or always. Aluminum sun-safety signs were the least frequently used materials. A limited budget was the most commonly noted obstacle to sun-safety efforts at the pool (85%). Factors supporting sun safety at the pool centered around risk management (85%) and health of the pool staff (78%).Program users were dispersed throughout the United States, most often learning about the program through a Web site (32%), publication (26%), or colleague (19%). Most respondents (86%) reported that their pool provided educational activities at swimming lessons. The Diffusion promotes the use of evidence-based health programs and can occur with and without systematic efforts. Strategies such as providing well-packaged, user-friendly program materials at low or no cost and strategic advertisement of the availability of program materials may increase program use and exposure. Furthermore, highlighting the benefits of the program can motivate potential program users. Guide to Community Preventive Services recommends interventions in outdoor recreation settings as effective strategies to reduce exposure to ultraviolet radiation and help prevent skin cancer (rtips.cancer.gov/rtips/index.do). Diffusion of such interventions allows them to broadly affect public health.Skin cancer is a serious, growing, and preventable condition ,2. The Gn cancer ,4. The WAccording to the Diffusion of Innovations model, diffusion is the process by which an innovation is communicated through certain channels over time among members of a social system ,6. DissePool Cool is an environmental and educational sun-safety program designed for use at outdoor swimming pools. The target audience is children aged 5 to 10 years who are enrolled in swimming lessons. A pilot was tested in 1998 and has been evaluated in a randomized, controlled trial (1999), a dissemination pilot study (2000-2002), and a diffusion trial (2003-2006). Pool Cool has had substantial positive effects on child sun protection behaviors and sunburn rates, parent sun protection behaviors, lifeguard sunburn rates, and the sun protection programs, policies, and environments at outdoor pools -16. In aThis article describes the extent and nature of the spontaneous diffusion of the Pool Cool program during a 4-year period. We describe the processes through which spontaneous diffusion has occurred, access to and use of Web-based program materials, levels of program adoption and implementation among Web registrants, and supporting factors and obstacles to program implementation.Leader's Guide to the Pool Cool program. We also provided poolside activities to complement the lessons, including ultraviolet index activity cards, a Play it Safe in the Sun poster, and a sun-safety-themed Jeopardy!-style game board. We also gave pools a Decision Maker's Guide for Sun Safety, a gallon jug of sunscreen, aluminum sun-safety signs, and small incentive items.We conducted the Pool Cool Diffusion Trial  nationalWe made these materials available year-round to nonstudy pools through the Pool Cool and National Recreation and Park Association (NRPA) Web sites. On the Pool Cool Web site, materials could be downloaded as portable document files (PDFs) and reproduced for use at the pool. A Pool Cool e-mail address was provided on the Web site so that incentive items could be requested and purchased. Additional materials identical to those provided to study pools also could be purchased through the NRPA Web site.Before downloading or purchasing materials from the Web sites, people from nonstudy pools were required to register online, provide contact information, and agree to be contacted about how their pool used the program materials. At the end of each summer, we sent registrants a survey about Pool Cool Web-based materials. We used data from the Web-based surveys and surveys from the diffusion study to compare study pools with nonstudy pools that accessed the materials online. We collected additional information about the spontaneous diffusion through e-mails sent to the official Pool Cool e-mail address during the diffusion study. We included only e-mails from people who inquired about the Pool Cool program and who had not participated in a Pool Cool research study. All data collection procedures were approved by the University of Hawaii Committee on Human Studies (CHS no. 11575) and the institutional review board at Emory University (IRB no. 156-2004).The registration form for obtaining Web-based materials asked registrants for their name, organization, contact information, type of organization at which they planned to use the Pool Cool materials, the ages and number of children expected to be exposed to the program, and how they learned about the program. The survey about Web-based materials sent to registrants at the end of the summer included questions about pool characteristics, use of materials, environmental and organizational supports for sun safety at the pool, and obstacles and supporting factors for sun-safety efforts at the pool .Questions about pool characteristics included community description , weekly pool attendance, and number of staff. We included these questions on baseline pool manager surveys as well, allowing for comparison of the diffusion study pools with nonstudy pools that registered for program materials online.2 tests to compare people who completed the survey about Web-based materials with people who completed only the registration form and to compare diffusion study pools with nonstudy pools. We computed frequencies to assess use of program materials, levels of program implementation, and the importance of supporting factors and obstacles to sun safety at the pool. Some respondents returned more than 1 follow-up survey, so we conducted these analyses twice: once using the responses from each respondent's first survey and a second time using each respondent's highest response to each survey item across all returned surveys. Conducting analyses using each respondent's highest response allowed us to determine whether respondents ever used each program component and provided a summary of the highest levels of program use that occurred at all pools.We used SPSS version 16.0  to conduct all quantitative analyses. We used χWe used qualitative methods to analyze e-mail messages related to spontaneous diffusion that were sent to the official Pool Cool e-mail address. We received e-mails related to spontaneous diffusion from 11 people. One researcher reviewed the e-mails for thematic topics and categorized the e-mails into themes. A second researcher then independently categorized the e-mails into the thematic categories, and the study team discussed any discrepancies until consensus was achieved. The thematic categories were not mutually exclusive, and some e-mails were captured by more than 1 theme.Of the 291 Web registrants (representing 291 different pools), most were aquatics or recreation managers, supervisors, coordinators, or directors (88%). A small number were health professionals, researchers or educators (8%), and lifeguards or swimming instructors (5%). Most registrants reported that the materials would be used at a public pool (80%) and expected at least 100 children to be exposed to program materials (70%). Pools were dispersed nationally in states with (n = 28) and without (n = 12) study pools, and 3 pools were in 2 Canadian provinces. All registrants reported that children between the ages of 5 and 10 years would be exposed to the program, and nearly 80% reported that younger and older children also would be exposed. Registrants reported hearing about the program through a Web site (32%), publication (26%), friend or colleague (19%), through NRPA (12%), or at a conference (11%).2 = 8.29, P = .005) and were more likely to anticipate that 100 or more children would be exposed to the materials . No other significant differences were found between Web registrants who completed at least 1 survey and Web registrants who did not complete a survey.Ninety-five Web registrants (33%) returned at least 1 survey about Web-based materials. Twenty-five completed a survey 2 years in a row, and 7 completed a survey 3 years in a row. Survey completers were more likely to report plans to use the materials at a public pool than in other settings  . Most respondents reported that fewer than 2,000 patrons came to the pool each week, but the pools had large staff sizes; more than 60% reported a staff of 23 or more. The only significant difference between diffusion study pools (n = 466) and nonstudy pools that accessed materials online was related to staff size, with nonstudy pools more likely to have a staff of 23 or more .Leader's Guide and lesson cards, which are core program materials, were the most frequently used items. Many respondents reported using multiple items. More than 37% used 3 to 7 Pool Cool items, and nearly 30% accessed 8 or more of the items available online. Only 18% of respondents reported that they did not access any of the items. A higher percentage of respondents who accessed the sunscreen tips poster and the aluminum sun-safety signs reported using each item often, usually, or always compared with other items  reported that their pool provided educational activities in swimming lessons. Most respondents indicated that their pools provided programs and policies for sun safety among the pool staff (92%) and swimmers and patrons (73%).When asked about supporting factors for sun safety at the pool, most respondents rated health concern (79%) and risk management of employees  as very important, and community relations (88%) and community or citizen demand (73%) as at least somewhat important. Overall, respondents rated obstacles to sun safety as slightly less important than supporting factors. Most respondents rated as somewhat or very important limited money, budget, or staff (85%); the design of the pool facility (63%); and lack of information or guidance (59%). Only 47% of respondents reported that sun safety not being a priority or a concern was a somewhat or very important obstacle.Themes of e-mails sent to the Pool Cool e-mail address related to inquiries about program materials, general program information, program evaluation, and speaking engagement and were divided into 2 categories. Most people who contacted the Pool Cool Web site (70%) were interested in obtaining program materials for use in program implementation, a sun-safety event, or for general sun-safety information. A few requested general information about the program; 1 person was interested in the evaluation survey, 1 person wanted to use the program as an example in a graduate class on marketing, and 1 person wanted a speaker to make a presentation about the program.This article describes the extent and nature of program diffusion that occurred at pools in comparison with those participating in the Pool Cool Diffusion study. Most Web registrants were referred to the Pool Cool intervention materials from a Web site, publication, or colleague, and the use of the Pool Cool materials spread to many states other than the states of Pool Cool diffusion study pools. Our results indicate that diffusion of Web-based program materials occurred outside of the active dissemination efforts that were used and evaluated in the Pool Cool Diffusion Trial. Informal linkages and communication channels may have facilitated program diffusion to nonstudy pools.Leader's Guide and lesson cards. These materials are core components of the program and are critical to implementation. An "intervention package" allowed community organizations to implement research-tested interventions (Leader's Guide). The availability of the Pool Cool materials and instructions on the Web site likely facilitated program implementation and use at nonstudy pools. Although respondents may not have used all elements of the program, exposure to the program seems to have increased their usability and use.Respondents downloaded various program materials, and use of downloaded materials was high, especially the use of the ventions ,17. All ventions . AlthougLeader's Guide can be reviewed and referenced on a computer and provide information without being printed.Fewer respondents reported reproducing or purchasing program materials than they did downloading materials. Pools may not have the funds to reproduce or purchase program materials but can still benefit from access to downloadable PDFs online. For example, the The most common supporting factors for sun-safety efforts at the pools were risk management and health of employees and community relations. Highlighting the benefits and the advantage of implementing a new program may be a way to motivate potential program users ,6. FurthWe reported data on spontaneous diffusion e-mails to supplement the information collected from the Web-based materials surveys. Data from both sources suggested that access to program materials does not always result in program implementation. Sometimes program materials were used solely for a specific pool event or adapted to fit the specific needs of the pool, and pools were not typically implementing all components of the program. This fact illustrates that program diffusion does not always occur with high fidelity, and practical use of an innovation may differ from the original intent of the developer. However, if the full program is not adopted, exposure to the health promotional materials may still provide some benefits.This study has several limitations. The information was based on self-report and may be subject to biases, such as inaccurate recall, misrepresentation, and social desirability. Second, many registered users did not complete the survey, which limits the generalizability of the study results. However, our low response rates are similar to those of other Web-based strategies for the diffusion of sun-safety interventions . On the The Pool Cool program was designed to be easy to use and compatible with the sun-safety needs of large pools, and the program can easily be tried before an organization commits to adopt it. Furthermore, we created user-friendly materials and made them available to the public online at no cost. These characteristics were key to program diffusion, and the study results demonstrate that diffusion of the Pool Cool program occurred outside of active dissemination efforts ,6.Both active dissemination and spontaneous diffusion can promote the use of science-based programs in communities -23. Futu


Although physical inactivity is a concern for all adolescents, physical activity levels are especially low among minority adolescents and minimal among girls from low-income families. After-school programs can reduce high-risk behaviors and strengthen schools, families, and communities.We conducted an operational research project that provided free access to a program of regular, organized physical activity combined with health education sessions for adolescent girls in 2 public housing developments in Boston, Massachusetts.From July 2002 through October 2005, at each of 2 public housing sites, the GirlStars program participants met each week for two 2-hour sessions, 1 dedicated to physical activity and 1 dedicated to health education. Sessions were led by the project coordinator and a resident assistant at each development.Participants in the GirlStars program increased their health knowledge, self-confidence, and decision-making skills, but rates of participation were low. Factors that affected participation included safety concerns, lack of community support for the program, interpersonal conflicts, attrition in staff, and conflicts with other activities.Programs in public housing developments that address these barriers to recruitment and retention may be more successful and reach more girls. Racial/ethnic minority adolescents are less active than are white adolescents, and girls from low-income families are particularly inactive -4. The pAfter-school programs can improve adolescents' behavior, performance, and health . These pWe present findings from a program designed to address physical activity and health education needs among inner-city adolescent girls living in public housing developments in Boston, Massachusetts. The GirlStars program was the core research project of the Partners in Health and Housing Prevention Research Center (PHH-PRC). The PHH-PRC is an equal partnership among Boston University School of Public Health, Boston Housing Authority (BHA), Boston Public Health Commission, and the Community Committee for Health Promotion, which is composed of public housing residents and community advocates. The mission of the PHH-PRC is to engage public housing residents in community-centered research programs and activities that improve their health and well-being.BHA is a public agency that provides subsidized housing to low- and moderate-income people. BHA is the largest landlord in Boston and the largest public housing authority in New England. The agency houses approximately 10% of the city's residents. Approximately 80% of these households have annual incomes less than $15,000. Among the residents, 36% are Hispanic, 31% are non-Hispanic black, 22% are non-Hispanic white, and 8% are Asian. Nearly 40% of residents are children. The agency's housing developments are concentrated in neighborhoods of Boston with the highest incidence of indicators of poor health, including injuries and environment-related illnesses such as asthma, lead poisoning, and smoking.We designed the GirlStars program to provide adolescent girls aged 9 to 13 years who live in Boston public housing developments regular, organized physical activity combined with health education. The goal of the intervention was to promote a lifetime of physical activity and positive health behaviors. This study was approved by the institutional review board at Boston University Medical Center.From July 2002 through October 2005, the intervention was conducted at 2 housing developments in Boston. Group meetings were held in a community meeting space at each housing development for 2 hours after school, twice per week; meetings were often held outside, weather permitting. One meeting session was dedicated to health education and the other focused on physical activity. Both sessions were led by the GirlStars project coordinator and program assistants. Girls provided input for health education and physical activity sessions at the beginning of the program, and many of their suggestions were incorporated into the curriculum.Health education sessions focused on improving knowledge of risk behavior and increasing self-efficacy, resilience, and self-confidence. Discussion topics included body image, goal setting, self-esteem, development, nutrition, and healthy eating. All sessions included practical activities and group work that involved the girls.Girls completed a physical activity and behavior questionnaire at enrollment and at the end of the program. Height and weight were also measured at these times.The program recruitment goal was 80 girls, 40 from each of 2 housing developments, with an intervention and comparison group. Because of low rates of participation, however, all the girls were enrolled in the intervention group. Sites were selected on the basis of the number of eligible girls living there and presence of experienced on-site youth workers who would assist with recruitment and programming. When the program was planned, BHA employed youth workers who conducted youth programming at each housing development.GirlStars program staff used recruitment tools and approaches at both sites, including flyers, open houses, mailings, attending community events, knocking on the doors of all households with eligible girls, and face-to-face contact. BHA staff also assisted with targeted mailings to appropriate girls.During the 3 years of the program, 60 girls enrolled. Some girls enrolled at baseline and continued throughout the study; others attended periodically, moved from the development, dropped out, or aged out of the program. Of the 33 participants enrolled at baseline, 31 agreed to be measured. At baseline, 6 of 14 (43%) girls at site A were overweight, compared with 4 of 17 (24%) girls at site B. All 33 girls completed the physical activity questionnaire. Responses indicated that girls at site A were less likely than girls at site B to have participated in physical activity for at least 20 minutes per day in the week before the questionnaire. By the end of the program, girls at both sites increased their physical activity level and improved their knowledge of nutrition and healthy eating.At the end of the program, 10 girls at site B participated in individual, semistructured, open-ended interviews, during which the girls were asked about their reasons for joining the program, reasons for attending group sessions, benefits of participation, and recommendations for future programs. Responses reinforced the need for after-school programming. Being bored and having "nothing to do" were common reasons for participating in the program. Girls reported that they learned about personal health and had increased self-confidence in decision making. They also reported that the supportive environment, which was fostered by the program leader's ability to connect with girls and make them feel comfortable talking freely, contributed to the positive outcomes of the program.A number of challenges affected recruitment and participation, including program location and safety, interpersonal conflicts, reluctance to participate in physical activity, lack of community support, lack of continuity in staffing, and conflicts with other activities.Recruiting girls to the program was the biggest challenge. When the program began, BHA lost funding for its youth workers. This change in staffing directly affected the program, since GirlStars program staff had to devote more of their time to recruitment. GirlStars staff, unfamiliar with the housing developments and residents and often considered "outsiders," had difficulty identifying and recruiting participants. After the youth workers left, we saw that to build community interest in the program, we needed someone from the development or known by residents. We intensified efforts to recruit program assistants who were residents of the development to help lead group sessions and with recruitment and retention.At site A, a local community center referred girls to the program, but because the community center was close to site A, community center activities competed with GirlStars activities, which resulted in irregular attendance. At site B, a BHA staff member was a resident services coordinator, and she identified and recruited potential participants and program assistants. She worked as a liaison with parents and property management in the absence of a program assistant.At each development, the program was located at former youth centers. Although these centers were centrally located, feedback indicated that parents were concerned about their daughters' traveling to other parts of the development to attend the program.At site A, the meeting space was vandalized several times, and other youths at the development harassed and threatened program participants, which decreased participation. The program was relocated to another space in the development, but the harassment continued. To address this problem, a uniformed officer was present during group meetings for a time. Additionally, the program coordinator and the BHA resident services coordinator defined rules of behavior and consequences to reestablish control over the group. Some girls were expelled from the group until they could demonstrate the ability to behave and conform to group expectations.In addition to the safety of the girls, personal conflicts directly affected participation. Dynamics among girls and cliques prevented some girls from feeling comfortable attending meetings. At site A, several participants were suspended for physically fighting. Some parents did not want their daughters to participate because of other participants.Girls' reluctance to participate in the physical activity portion of the program was a challenge that required creativity in gaining the girls' interest. Other research on adolescent girls and physical activity found that participants associate physical activity with exercise and sports and do not see it as fun . DispellFor community involvement to be successful, researchers and the community must be partners in decision making . ElicitiAt both sites, difficulties hiring and retaining resident assistants resulted in frequent turnover, which compromised program stability. Reasons for not remaining in the position included the need for full-time employment, lack of experience, and medical issues. At both sites, a program assistant was eventually hired and remained with the program until its conclusion. The program assistant provided continuity for the girls, provided ongoing support, and was integral to involving parents with the program. Because the program assistant was a resident of the development, she offered insight into the concerns of participants' parents and other residents and was a connection to the program outside group meetings.As in other studies , the mosAlthough we did not meet our recruitment goals and the small number of participants prevents us from drawing firm conclusions, we believe that the GirlStars Program was beneficial to the girls who participated. The girls were involved in the planning of health education and physical activity sessions, which may have encouraged their participation. They also reported that their relationships with other girls and with the program staff motivated them to remain in the program. Program sessions focused on increasing self-efficacy, resilience, and self-confidence, and participants had increased health knowledge, self-confidence, and decision-making skills and became more physically active. The length of time needed for such a program to become established might vary in different contexts. The positive reinforcements from the program encouraged participation, but time is needed to nurture the personal relationships that lead to bonding between participants and staff. For a program to be successful in public housing developments, broad community support is essential. In addition, awareness of underlying factors that may affect participation and the ability to design programs that address those needs are vital for any program in public housing. A number of lessons from this program may be applicable to other organizations seeking to enroll girls in a program in public housing developments or other urban, multicultural, low-income populations.Sites should be selected after a comprehensive evaluation process. For future programs, the Prevention Research Center developed criteria on the basis of a review and assessment of the first 2 years of GirlStars. The Prevention Research Center has created a document that will be distributed among all public housing developments in Boston to engage tenant organizations, property managers, and community agencies for future programs. An organizational stipend will be available to tenant organizations for the assistance they provide to the program. The document also assesses types of programming the target population would be interested in and level of community support for the program.Local tenant organizations, resident assistants, and managers at the developments must be involved in recruiting participants. Buy-in from the community is needed for program success. The local tenant organization must be used in outreach to households and in identifying girls. The development should also partner with other youth-serving agencies to attract girls from the development.To maximize participation in programs, tenant organizations should also be involved in decisions regarding the schedule of the program. Participants enrolling in the program should be consulted about activities and topics to be discussed in meetings. Group leaders should try to incorporate the desires of participants into program curricula.Physical safety was a major concern of our participants and their parents. The level of violence in these housing developments and their surrounding neighborhoods is high, and safety concerns must be mitigated by careful choice of program location, hours, and supervision.A resident assistant must be hired at each development to assist in program activities and in recruiting and retaining participants. Resident assistants must also receive training to build their skills in working with the target population. They should maintain a close working relationship with the tenant organization and management staff of the housing development.A program-specific advisory board must also be established at each development; this board should consist of interested parents and other residents, the tenant organization, management staff of the housing development, and members of other community organizations. The advisory board should provide oversight for the program and advise program staff about the curriculum and program activities. The advisory board must also communicate with program staff the needs and issues in the developments as they relate to the program and its participants.Attaining the support of management from each housing development, beginning at program inception, is essential to success. Managers and other staff can help with problems and build support for the program among residents. Management at each development must become familiar with the program and its components to provide information to new residents and help identify and recruit participants.Participants in the GirlStars program increased their knowledge of personal health, self-confidence, and decision-making skills; however, the program did not reach many girls. The major barriers to participation were safety concerns, interpersonal conflicts, reluctance to participate in physical activity, lack of community support, lack of continuity in staffing, and conflicts with other activities. Future programs that address these barriers may be more successful and reach more girls.


At 2:28 p.m. on 12 May, 2008, a devastating earthquake measuring 8.0 on the Richter scale hit Wenchuan County, Sichuan Province in southwest China, and resulted in the deaths of thousands of people. To date, few epidemiological studies have been conducted on the determinants of the mortality of patients hospitalised after an earthquake. This paper is aimed at identifying the contributing factors of mortality and providing a clinical reference for the management of those injured in earthquakes.A hospital-based case-control study was conducted. Cases included all deaths (n = 36) due to earthquake injuries in the West China Hospital. Controls were the quake survivors from the same hospital by at a ratio of four survivors to one death matched for sex and age. Data sources included death certificates and medical records. A conditional logistic regression was performed to assess the odds ratio (OR) of variables used in the study. A chi-squared test for trend was performed to reveal the possible relations between risk factor (variable) number and case fatality.People with a severe traumatic brain injury (TBI) had the greatest risk of death  = 8.9 to 7208.6), followed by patients with multiple system organ failure . Prior major disease and infection significantly increased the risk of earthquake-related death . The number of fatal cases increased as the risk factor numbers also increased.Severe TBI, infection, MSOF and prior major disease are the significant determinants of earthquake-related inpatient death in the 2008 Wenchuan earthquake. Future research with a large sample size including macro- and micro-level factors is needed. At 2:28 p.m. on 12 May, 2008, a devastating earthquake hit Wenchuan County in southwest China's Sichuan Province. Measuring 8.0 on the Richter scale, the earthquake had a maximum intensity of φ  and a depth of 33 km. It led to 69,197 deaths, 374,176 injuries and 18,222 people being reported missing by 12:00 noon on 20 July. The severity and scale of this disaster has rarely been seen before, either in China or internationally.The earthquake occurred in a rural and mountainous region in western Sichuan Province, about 50 miles (80 km) west-northwest of Chengdu . West China Hospital of Sichuan University, as the only large-scale, state-level and general teaching hospital in the earthquake-affected area, received the largest number of injured people, treating a total of 2728 cases (872 were treated in the emergency department and 1856 were admitted) [Understanding risk factors related to earthquake inpatient death is essential for effective patient management. Some previous studies have exposed the factors affecting casualties -4 and thThe Institutional Review Board (IRB) of the West China Hospital in Sichuan University approved this study. No informed consent was necessary as this study used existing data, which was obtained with IRB approval and informed consent from IRB.A hospital-based case-control study was conducted. Cases included all deaths (n = 36) in West China Hospital due to earthquake injuries for the five months after the date of the earthquake. Controls were selected from quake-related and hospitalised survivors (i.e. cases flagged on admission) in a ratio of four survivors to death matched for sex and age. Thus, the number of controls was 144. Data sources include death certificates and medical records.Using the information from patient medical records, we collected data on 13 dichotomous variables: local hospital treatment; severe traumatic brain injury (TBI); crush syndrome; acute renal failure (ARF); thoracic organ injury; celiac organ injury; amputation; cranium fracture; trunk fracture; extremity fracture; infection; multiple system organ failure (MSOF); and prior major disease.We define the above variables as follows. Local hospital treatment means the earthquake patient received primary treatment before being transferred to the West China Hospital. Severe TBI was judged as damage to the brain resulting from external mechanical force, along with a Glasgow Coma Score of 8 or below ,7. CrushA conditional logistic regression was conducted to assess the odds ratio (OR) of the variables used in the case-control study. To determine the precision of the estimates, 95% confidence intervals (CI) of ORs were calculated. To reveal the possible relation between risk factor (variable) number and case fatality, a chi-squared test for trend was performed. This analytic process was performed using Stata software .The male to female ratio for both groups ws 1 to 1.1. The mean (standard deviation (SD)) age and days before admission were 65.8 (21.0) years and 7.3 (5.9) days for cases, and 64.3 (20.9) years and 7.2 (6.0) days for controls. Less than 20% of patients were transferred to the West China Hospital within 72 hours after the earthquake for both cases and controls.Table Table In univariate analysis, local hospital treatment lowered the risk of earthquake-related death . Patients with crush syndrome, ARF and celiac organ injury had higher risk of death . After adjustment for other variables, however, all four variables demonstrated no statistical significance.x2 = 21.864, p = 0.000).Table The magnitude 8.0 earthquake that struck Sichuan Province on 12 May, 2008, was the strongest earthquake China has experienced in over 50 years. It caused the largest loss of life since the Tangshan earthquake in 1976. Identification of determinants for earthquake-related death is critical to triage, transfer, nursing and treatment, as well as for treating patients in shock. This paper revealed that severe TBI, infection, MSOF and prior major disease were the significant risk factors associated with earthquake-related inpatient death in the 2008 Wenchuan earthquake.Over 60% of the dead were older than 60 years of age. Similar findings were published elsewhere ,10-13. DPeople with severe TBI have a high risk of death. Bouras and colleagues  reportedUnivariate analysis revealed that local hospital treatment, crush syndrome, ARF and celiac organ injury were related to patient death. Although the four factors failed to be recognised as influential to mortality in multivariate analysis, they should be carefully managed when considering their clinical importance. The fact that local hospital treatment might reduce the risk of death suggests that rapid medical rescue plays an essential role in saving lives. One drawback of this study is that the information of patients' staying in a local hospital before transferring to our hospital was not available. It should be remembered that delay to definitive care is one of the most important predictors of outcome after trauma. Two previous papers ,16 reporWhatever the main risk factors for earthquake inpatient death are, the fact that those multi-factors  co-existed might indeed increase the risk of patient death. The result of chi-squared tests for trend provided meaningful evidence that patients who were recorded with more risk factors were more vulnerable to death, which will benefit the earthquake patient management.To the best of our knowledge, this paper is the first hospital-based case-control study on risk factors pertaining to earthquake inpatient death; however, there are some limitations to this study. To begin with, we failed to analyse the impact of age and sex on death because of matching. Secondly, we did not calculate sample size because this was an emergent natural disaster study, and nobody knows how many injured people will die in the hospital. This might lead to insufficient statistical power to disclose risk factors. Thirdly, the authors failed to consider the seismic and structural factors, along with time under the rubble, which could be associated with earthquake-related death. Nevertheless, compared with population-based case-control studies, this paper has provided information which directly relates to medical relief and earthquake inpatient management. Finally, a selection bias (e.g. admission rate bias or Berkson bias) should be noted. One of the most important exclusions from hospital-series case-control studies are at-scene deaths. As most earthquake deaths do occur outside the hospital, it is a critical exclusion for trauma death numbers. Therefore, the causes of death for hospitalised patients may dramatically differ from at-scene deaths. Moreover, although the discharged earthquake patients were at low risk of death, we failed to follow up with them and the post-discharge deaths (if any) were excluded. This might restrict the general applicability of our study results. However, what this paper demonstrated can be used when managing earthquake inpatients.Based on the results of this case-control study along with the treatment experience in our hospital, some suggestions might be helpful when managing future earthquake patients as follows: older patients with earthquake trauma  are the population at highest risk and more attention should be paid to them; an evidence-based system of triage should be drawn up to distinguish patients with different severities of injury; screening, treating and following up infections are vital to the patients' survival and once patients are infected, they should be isolated; and a team of multidisciplinary doctors should be organised as soon as possible to monitor, diagnose and treat critical cases, especially those in the intensive care unit.The cause of earthquake-related death is multi-factoral and complicated. Better identification of the risk factors for death and their relation with each other can help medical providers identify vulnerable populations and take corresponding measures to reduce mortality. Future research with a large sample size, including macro- and micro-level factors, is needed.Severe TBI, infection, MSOF and prior major disease were the significant risk factors associated with earthquake-related inpatient death, and should be given more attention when managing patients after an earthquake.• Understanding risk factors related to earthquake inpatient death is essential for effective patient management.• Few epidemiological studies have been conducted on the determinants of mortality of patient hospitalised after an earthquake.• This case-control study revealed that severe TBI, infection, MSOF and prior major disease were the significant risk factors associated with earthquake-related inpatient death.ARF: acute renal failure; CI: confidence interval; CT: computed tomography; IRB: Institutional Review Board; MRI: magnetic resonance imaging; MSOF: multiple system organ failure; OR: odds ratio; SD: standard deviation; TBI: traumatic brain injury.The authors declare that they have no competing interests.WJ, SY and LY participated in the study design, data analysis and interpretation. WJ drafted the manuscript. SY is the guarantor and critically revised the manuscript. WJ, CL, GZ and LL performed the data abstraction from medical records and interpretation. WL participated in data analysis, interpretation and critical revisions of the manuscript. All authors read and approved the final manuscript.


The Centers for Disease Control and Prevention's (CDC's) Prevention Research Centers (PRC) Program underwent a 2-year evaluation planning project using a participatory process that allowed perspectives from the national community of PRC partners to be expressed and reflected in a national logic model.The PRC Program recognized the challenge in developing a feasible, useable, and relevant evaluation process for a large, diverse program. To address the challenge, participatory and utilization-focused evaluation models were used.Four tactics guided the evaluation planning process: 1) assessing stakeholders' communication needs and existing communication mechanisms and infrastructure; 2) using existing mechanisms and establishing others as needed to inform, educate, and request feedback; 3) listening to and using feedback received; and 4) obtaining adequate resources and building flexibility into the project plan to support multifaceted mechanisms for data collection.Participatory methods resulted in buy-in from stakeholders and the development of a national logic model. Benefits included CDC's use of the logic model for program planning and development of a national evaluation protocol and increased expectations among PRC partners for involvement. Challenges included the time, effort, and investment of program resources required for the participatory approach and the identification of whom to engage and when to engage them for feedback on project decisions.By using a participatory and utilization-focused model, program partners positively influenced how CDC developed an evaluation plan. The tactics we used can guide the involvement of program stakeholders and help with decisions on appropriate methods and approaches for engaging partners. Established by a Congressional mandate in 1984, the Prevention Research Centers (PRC) Program comprises 33 university-based research centers that address the most important chronic disease and health promotion issues facing public health today. With funding from the Centers for Disease Control and Prevention (CDC), the PRCs conduct prevention research and training as well as disseminate and translate research into practice and policy . The PRCFramework for Program Evaluation in Public Health , a 2-year evaluation planning project. Guided by the six-step framework (hereafter referred to as the CDC framework) outlined in c Health , the PRCInitially, the task seemed enormous. The CDC framework , howeverCDC staff recognized that a participatory approach could benefit the evaluation planning process and the PRC Program overall. Previous evaluations of CDC-funded and other programs show that engaging stakeholders and using participatory methods result in increased use of findings, increased relevance to stakeholders' needs, evaluation capacity building at the grantee level, decreased anxiety about the evaluation process, and support for future evaluation activities -8. In adCDC staff in the PRC Program implemented the evaluation planning project through a contract that stipulated, on the basis of recommendations in the evaluation literature -8, that The evaluation planning process formally began when the contract was awarded in 2001. The core evaluation work group comprised evaluation contractors and PRC Program staff. One of the first activities of the work group was to form an advisory committee, named the Collaborative Evaluation Design Team (CEDT). The core evaluation work group and CEDT worked closely throughout the project and learned several lessons as a result of the collaborative project activities. Realizing that these lessons could be helpful to other programs and responding to the support of reflective practice in the evaluation field , we the. The firWhen initiating Project DEFINE, CDC communicated with PRC partners through the existing standing committees: an overall steering committee and five topic-specific committees. These committees, whose members are PRC representatives and provide input and guidance to CDC's PRC Program staff, were key to communicating with and seeking input on the evaluation design from PRC directors and other PRC leaders. Involving these committees had two benefits. First, because the PRCs elected the committee members, a committee stamp of approval on evaluation activities offered a form of peer endorsement. Second, one of the committees, the National Community Committee (NCC), included leaders from the PRCs' partnering communities, thereby ensuring the incorporation of community perspectives into the deliberations of the core evaluation work group as well as relaying important information on Project DEFINE to other community leaders involved with each PRC.Because no PRC committee was devoted to an evaluation planning process, the CEDT was created to help guide the project and create additional avenues for stakeholder input. Consistent with the CDC framework , the CEDThe CEDT helped to ensure project relevance, feasibility, and utility and to facilitate input from stakeholders. The CEDT's involvement in decision making and project oversight enabled stakeholders to trust that the project would represent their perspectives and not just those of the core evaluation work group. Finally, the CEDT and core evaluation work group reflected on the lessons learned and made adjustments as the project unfolded.The contract's scope of work outlined a series of participatory methods that were used during Project DEFINE. These methods led to the development of a program description in the form of a logic model that reflected input from all PRC Program partners. Concept mapping was the primary method used to develop the basic constructs of the logic model . Other mThrough these activities, stakeholders shared diverse perspectives, values, and priorities. The approach encouraged partners to work through challenges, such as the differences among stakeholders in program understanding, project expectations, and power differentials that are common in community–academic partnerships ,13.Because a transparent decision-making process, information sharing, and feedback for project changes are essential in partnerships and participatory projects ,8,12,13,A participatory project often has a more fluid process than a nonparticipatory project, and therefore funding organizations, researchers, or evaluators must be able to adjust project plans as needed ,13. On tFlexibility in the use of project resources was also an important factor in Project DEFINE. When the core evaluation work group modified plans, resources were also reallocated across tasks. CDC supported the project year by year. CDC's up-front commitment of both staff and funding ensured that the project was participatory, even though this approach to evaluation planning has higher costs and takes more time to complete ,13. ForeThe four tactics described allowed us to continually listen and provide feedback to our national community of researchers and others with a vested interest in prevention research. The processes also led to lessons learned, which we describe below.Using participatory methods and having a utilization-focused approach for Project DEFINE resulted in several benefits. First, CDC's PRC Program office increased its abilities to strategically manage the program. The PRC Program's national logic model, a tangible product of the participatory process and available on the PRC Program Web site , was useSecond, individual PRCs have increased their evaluation activities over the years. During the project, the involvement of PRC partners increased as they understood that CDC would use the logic model for planning and that their input could influence future program decisions. Since then, each PRC has been required to develop its own logic model and a related evaluation plan for the 5-year cooperative agreement application. Several PRCs have used these logic models for strategic planning and evaluation or have created logic models for specific research projects.Third, academic, community, and state partners of the PRCs now expect to be engaged in PRC planning and research activities. The focus on community-based research has intensified during the 20-year history of the PRC program and is now explicit in the national program's requirements. Community partners have stated that they appreciate having their role more formally defined.Fourth, unexpected benefits beyond the PRC program have also resulted, including adaptation of the PRC logic model by CDC's National Academic Centers of Excellence (ACE) on Youth Violence Prevention . The conA primary challenge of the participatory process was the time and effort required for Project DEFINE. The work described here extended over 2 years. This time was necessary to engage the network of diverse program partners and address the complex issues involved in developing the logic model. A second challenge was the investment in program resources. The type of planning required for Project DEFINE can be costly, although methods can be tailored for various budgets and data requirements. A third challenge was identifying the critical project decision points for each step and the people to engage in feedback and decision-making processes. For example, when should program partners be consulted? When should CDC bring draft documents to the CEDT for comment? The best way to answer these questions was to communicate openly with members of the CEDT, asking for their perspective on the methods to use and the decisions in which they should be involved.  Having the infrastructure and processes in place to ensure routine and repeated communication with, and engagement of, stakeholders throughout the project was extremely valuable. By using a participatory model and staying attentive to the project's practical use, we were motivated to use a variety of methods to involve all partner groups throughout the process, all of which influenced the development of the national logic model. Consistent communication and commitment to bringing in diverse viewpoints from the PRCs and their partnering communities led to stakeholder support of, and involvement in, Project DEFINE. Ongoing feedback also served as a periodic touchstone to ensure that the project remained pertinent and responsive to the needs of all partners. The project established the groundwork that the PRC Program needed to prepare for national evaluation and created momentum to continually engage partners in these activities.The CDC framework and its program evaluation standards offer a structure for planning a public health evaluation project and principles to follow as the project progresses . Partici


We describe popliteal arterial adventitial cystic disease which causes intermittent claudication in a young athletic man, with atypical manifestation, without loss of foot pulses on knee flexion nor murmur in the popliteal fossa. The findings obtained from Magnetic Resonance Imaging were non-diagnostic. The diagnosis resulted from Echo-Doppler ultrasonography along with peak exercise testing. Ultrasonography also provided useful physiopathological informations suggesting that a popliteal artery adventitial cyst can become symptomatic if muscle exertion increases fluid pressure within the cyst, enough to cause hemodynamically significant endoluminal stenosis. Rapid diagnosis is essential to prevent progressive claudication threatening limb viability. To guarantee this professional sportsman a reliable and durable outcome, instead of less aggressive management, we resected the involved arterial segment and interposed an autologous saphenous-vein graft. Popliteal arterial adventitial cystic disease is a rare disorder causing intermittent claudication that is well described in young adults, and was first reported by Atkins and Key  in a 40-In patients with advanced disease, the diagnosis generally rests on evidence of segmental popliteal artery stenosis or occlusion without other popliteal artery disease. Traditional angiography or more recently gadolinium-enhanced magnetic resonance imaging (MRI) angiographic scans disclose an eccentric popliteal artery narrowing known as the "scimitar" sign. In some cases, stenosis is visible only on images obtained during knee hyperflexion.Although the precise etiology remains unknown, now the most accepted mechanism involves cystic degeneration causing vessel stenosis or occlusion without superimposed thrombosis. Increased pressure from the liquid within the cyst is thought to cause popliteal stenosis through an "intermittent" mechanism induced by physical exercise.In the 34-year-old man we report here, since MRI angiography failed to visualize the cyst clearly, the definitive diagnosis of popliteal arterial adventitial cystic disease came from the ECHO-Doppler ultrasound examination.We describe here the case of a 34-year-old man, a professional football player in excellent physical conditions, with no clinical history of importance except traumatic rupture of the anterior cruciate ligament, the right in 1985 and the left in 1995, treated with reconstruction using the central third of the patellar tendon. The patient presented with the abrupt onset of intermittent claudication in the right calf after walking on the flat for 300–400 meters.An Echo-Doppler ultrasound examination disclosed a suspected "small aneurysm" or "popliteal adventitial cyst" but no popliteal artery disease was seen on MRI angiography even on images obtained during forced knee flexion.On the patient's admission to our vascular service, an Echo-Doppler ultrasound examination, obtained during hyperflexion, disclosed no peripheral perfusion deficit. On treadmill exercise testing, after 500 mt. the incline was increased from 10% to 15% and the speed from 6 km/h to 8.6 km/h. About 19 minutes later (about 1900 mt.) the patient began to experience pain in the right foot and, after exercising for a further 250 mt. with the incline at 12% and the speed at 7 km/h, he complained of cramp-like pain in the right calf. At peak force, and during cramp, the Echo-Doppler ultrasonogram showed an accentuated stenosis that involved the lumen of the right popliteal artery and corresponded to an increase in cystic volume. These changes were not discernible during baseline testing.   and the Particularly remarkable features in this report are the Echo-Doppler ultrasonographic findings clearly documenting the pathophysiological mechanism through which the popliteal artery adventitial cyst became symptomatic. Although previous investigators -8 descriIn cases like this reported here, ultrasounds examination can be more accurate than imaging techniques such as CT scan or MRI; Moreover ultrasounds are less expensive, widely available and free of ionsiong radiations.This possible mechanism is supported from observations, unlike the case we report, describing cysts communicating with the synovial structures in the knee. Numerous reports describing treated Baker's cysts, that ultimately recurred, underline the need for meticulous surgical dissection of the cyst away from the adjacent joint structures in these cases and, also, in similar cases of cysts developing contiguously with the hip joint . ArguingOur decision to manage our patient's cyst by resecting the involved arterial segment and interposing an autologous saphenous vein graft, rather than undertaking CT- or ultrasound-guided drainage or surgical evacuation, depended primarily on the need to guarantee a young adult with a professional sports career a reliable and durable outcome.In spite of their rare occurrence, popliteal artery adventitial cysts are a disabling disease especially because they typically affect young otherwise healthy athletic adults. The diagnosis is usually reached by MRI angiography at rest. Even though arterial stenosis can become symptomatic and therefore visible on ultrasonography only after maximal prolonged exercise testing, ultrasonography is diagnostically far more reliable than more traditional imaging modalities. Popliteal arterial adventitial cystic disease should be managed surgically without delay, before the artery occludes, and radical surgery is essential to avoid the known risks of recurrence.The authors declare that they have no competing interests.MT and NS permormed the surgery and participated in the design of the study, LR and MM conceived the study and wrote the manuscript, FC gave orthopaedic contribution to the operation, CM performed the ultrasound test with VF.Written informed consent was obtained from the 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


We tested for dengue seroconversion among 104 Israeli young adults who traveled to tropical countries for at least 3 months. Seven (6. 7%) seroconverted during travel; four (3.8%) had immunoglobulin (Ig) M antibodies; one was symptomatic with borderline IgM and a rise in IgG; two others (1.9%) had a rise in IgG titers, without detectable IgM. All four IgM-positive patients had traveled to Southeast Asia.


Starting a residency program is a huge endeavor that requires both program organization and widespread support from various groups. The Oman Medical Specialty Board (OMSB), with a mission of developing and maintaining postgraduate medical specialty education in the country and setting the professional and educational standards for the training and certification of Medical and Healthcare Professionals, set to the task of establishing an Ophthalmology Residency Program in 2006. OMSB deemed it necessary to form the Ophthalmology Residency Training Program to train personnel in this challenging surgical specialty.A task force committee was constituted in 2007 to formulate requirements and design guidelines for the residency program. The Scientific Committee for the Ophthalmology Training Program was formed in April 2009. Internal reviewers and external reviewers from USA and Saudi Arabia then evaluated the proposed residency program and the available infrastructure and manpower. To the utmost happiness of all concerned, they were very positive about the possibility of commencing the program through the involvement of two tertiary ophthalmology health care centers in Oman . However, they proposed incorporating a few major changes in the existing system to facilitate resident training. With the departments of the training centers initiating steps to make those changes, the two centers were accredited by the OMSB. It was not until August 29, 2009, when four residents started for the first time their Ophthalmology Residency Training under the umbrella of OMSB, paving the way for a new era in specialty training in the country.[The Ophthalmology Residency Training Program will incorporate the six general competencies for residents, as endorsed by the Accreditation Council for Graduate Medical Education, considered relevant to the practice of ophthalmology: Patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. The program aims to produce competent general ophthalmologists that will have knowledge both in general ophthalmology and in subspecialties. They will have excellent clinical and surgical skills, awareness of medical ethics, professional values and attitudes, and will have the capability of conducting teaching and research activities. We believe the graduates of this program will acquire the skills to be utilized for the benefit of patients and the education of the next generation of ophthalmologists in the country.There will be many obstacles, but I’m quite confident that the new generation of qualified ophthalmologists, who have received their training outside the country, will be able to carry the flame and pass it on successfully.


Coalescent simulations have proven very useful in many population genetics studies. In order to arrive to meaningful conclusions, it is important that these simulations resemble the process of molecular evolution as much as possible. To date, no single coalescent program is able to simulate codon sequences sampled from populations with recombination, migration and growth.Recodon, which is able to simulate samples of coding DNA sequences under complex scenarios in which several evolutionary forces can interact simultaneously . The basic codon model implemented is an extension to the general time-reversible model of nucleotide substitution with a proportion of invariable sites and among-site rate variation. In addition, the program implements non-reversible processes and mixtures of different codon models.We introduce a new coalescent program, called Recodon is a flexible tool for the simulation of coding DNA sequences under realistic evolutionary models. These simulations can be used to build parameter distributions for testing evolutionary hypotheses using experimental data. Recodon is written in C, can run in parallel, and is freely available from . Recodon, to fill this gap.Coalescent theory  providesRecodon is accomplished in two main steps. First, the genealogy of the sample is simulated under the coalescent framework with recombination, migration and demographics. Second, codon sequences are evolved along this genealogy according to a nucleotide or codon substitution model.The simulation of data in N), recombination, migration and growth rates. Time is scaled in units of 2N generations. Recombination occurs with the same probability between different sites (either nucleotides or codons). A finite island model [For each replicate, genealogies are simulated according to thecoalescent under a neutral Wright-Fisher model ,16. Waitnd model  is assumRecodon implements several nucleotide and codon models that include different parameters  compartmentalization. Simulated data can also be used to obtain numerical estimates of population genetic parameter using approximate Bayesian computation [One potential application of ng genes . For exaputation ,27-30. ERecodon. In particular, we studied the effect of population structure on the footprint of molecular adaptation. Results suggest that population subdivision tends to increase both dN and dS divergences, as a result of longer times to the most recent common ancestor (Figure dN/dS ratio is not affected by different migration rates when the simulated value is below one or one, but there seems to be a slight increase when the simulated dN/dS is 10.In addition, we carried out a very simple experiment to illustrate another possible use of r Figure . This inIn the future we plan to relax some of the current assumptions, like an homogeneous recombination rate .Recodon is a versatile program for the simulation of codon alignments under complex population models. This program fills a gap in the current array of coalescent programs for the simulation of DNA sequences, as no single program is able to simulate codon sequences sampled from populations with recombination, migration and growth. Data simulated with this program can be used to study both theoretical and empirical properties of DNA samples under biologically realistic scenarios.Recodon is written in ANSI C, and it has been compiled without problems in Mac OS X, Linux Debian and Windows. It can run in parallel using the MPI libraries in architectures with several processors. The program is freely available at , including executables, source code and documentation. The program is distributed under the GNU GPL license.Recodon is an extension of a coalescent program written by DP, who conceived the idea and supervised its development. MA wrote and validated the program. Both authors drafted the manuscript, and both read and approved its final version.