Utilization of health services is the actual attendance by the members of the public at health care facilities to receive care. Utilization, serves as an important tool for oral health policy decision-making. The aim of the present study was to retrospectively gauge and assess the utilization pattern of the dental treatments which was given in hospital for last 10 years.  This retrospective infirmary based study was carried out at Sheri Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India. The yearly outpatient department (OPD) records for the utilization of specific dental treatment of a total of 103963 patients were assessed retrospectively from 2014 to 2003. Trend analysis was used to assess the trend of utilization of each speciality with best fitted linear trend lines.  The pattern of new patients has also shown a constant rise during the study period except for 2008 and 2009. The utilization of oral surgery speciality has shown a tremendous fall from 2003 to 2014 whereas the number of patients coming to periodontics and conservative dentistry has shown an increasing pattern.  Utilization of oral health care has long been used as an indicator of oral health related behaviour of a population. In the present study it can be conclude that the outlook of the population under study has changed from blood and vulcanite dentistry outlook and is moving towards restorative dentistry. . Health has been at the centre of human concern since ancient times. The practice of medicine has come a long way since the time of magic, religion and supernatural thoughts to a modern science following evidence-based practice with a range of services extending from preventive, promotive, curative to rehabilitative offered to the individual and community.  Utilization of health services is the actual attendance by the members of the public at health care facilities to receive care. Utilization, which measures the number of visits per year or the number of people with at least one visit during the previous year, serves as an important tool for oral health policy decision-making   . As des Dental care utilization can be defined as the percentage of the population who access dental services over a specified period of time   . Utiliz Oral treatment seeking behaviour refers to the behaviour of seeking professional help to curb symptoms presenting like pain, bleeding, swelling, bad breath, developmental anomalies, mobile teeth, ulcer, caries, sensitivity and fractured teeth. Dental disease is a serious public health problem with universal distribution and affecting all age groups   . Oral t Barriers to seeking oral health treatment like ignorance, lack of awareness, high cost of treatment, inaccessibility to oral health facility and lack of time also play a significant role. However in recent years it has been observed that the attendance at the health centres have considerably improved. This increase in the utilization of the health services can be attributed to the increase in the level of awareness and education in the masses. Many studies have been conducted on the utilization of the dental health services in various countries including India  , 7 . TheHowever the studies on the pattern of the given treatment have not been performed. It becomes imperative on us to know the felt need of the patients when it comes to their utilization of dental services. Unless it is not assessed that what type of the treatment population is asking for in a health centre we cannot assess the level of education or whether the appropriate knowledge has been imparted to the population or not. Shift from ancient trends of treatments to the modern types of treatments shall be assessed in order to improve the patient education as well as the system which is responsible for the health education. A shift from "blood and vulcanite" dentistry to the modern restorative dentistry if present needs to be assessed and if not present needs to be created   . Thus t In the state of Jammu and Kashmir, India most services are paid entirely by the patients themselves, and most commonly delivered by private practitioners. Thus information on dental conditions, treatment needs and habits have been sparse. The aim of the present study was to retrospectively gauge and assess the utilization pattern of the dental treatment which was given in a SKIMS hospital, Srinagar from 2003 to 2014 with a primary objective to access the change in the trend of utilization of restorative dental procedures as compared to oral surgical procedures.This retrospective infirmary based study was carried out at SK Institute of Medical Sciences, which is located in Srinagar, the summer capital city of Jammu and Kashmir state, 10 km from central business centre. It is the largest hospital in Kashmir and provides treatment of dental conditions. The yearly outpatient department (OPD) records for the utilization of specific dental treatment at the dental wing from 2003 to 2014 were analysed retrospectively. All the patients whose records were present in the hospital database during this period for any type of dental treatment were included.Records of a total of 103963 patients who had visited from 2014 to 2003 were assessed retrospectively. Out of the total number of the patients 45273 patients were revisit cases throughout this time period. The number of the new patients who had visited during this period was 58690. Data was collected in for of hospital records for all these patients.All the patients who had visited the outpatient department (OPD) for the utilization of any kind of dental treatment at the dental wing of SK Institute of Medical Sciences, from 2003 to 2014 were analysed retrospectively.Records of those patients who had been referred to some other department or hospital for specialized treatments as major surgical procedures or patients with oral cancer who were not treated at the dental wing of SK Institute of Medical Sciences were excluded from the study. From the study.Records of a total of 103963 patients who had visited from 2014 to 2003 were assessed retrospectively. All the records which were pertaining to the Dental wing of the hospital were assessed and the data was analysed retrospectively for all these records.The present study assessed the change in the perception in the utilization pattern of the dental treatment in a retrospectively selected population for a period of 12 years.The influx of patients each year was segregated into new and recalls categories. The various dental treatments were classified under specialities i.e. oral surgery, periodontics, conservative dentistry and prosthodontics. This study assessed the change in the utilization pattern of different dental treatments by the population retrospectively.The ethical clearance was taken from the ethical board of the SK Institute of Medical Sciences, Srinagar. The data was analysed in a most professional manner keeping in view the ethics and confidentiality of the patient records.Data were entered into Microsoft excel software and exported to SPSS Version 15 for analysis. Descriptive statistics was used to report the frequency and percentage of independent variables. Trend lines analysis with best fitted linear trend lines was used for judging the difference in the patient referrals with time.The current study was conducted in dental wing of SK Institute of Medical Sciences, Srinagar, India. The patient data records of 12 years, from 2003-2014 were assessed. Dental disease as dental caries and periodontal diseases is a serious public health problem in whole of the world and are prevalent in all age groups. However, despite of their universal distribution only a few people seek dental care or utilize it. There exists a wide gap between the actual dental needs of the population and the demand for dental care which is quite clear from the past cited literature. The barriers in the utilization of the dental care can be removed by motivating people by making them aware about the oral health problems and removing anxiety and fear so that they develop positive attitude towards dental treatment. Previous studies have revealed that the high cost of oral health care and fear of dentists or dental instruments have been major barriers for seeking oral care   .  Increasing Awareness  Though the present study shows an increase in the number of the patients who seek dental treatment in the dental section of the SK Institute of Medical Sciences, there is a clear difference in the influx of the patients from 2003 to 2014. Records of a total of 1, 03,963 patients who were assessed retrospectively comprised of 58690 new patients while 45273 patients were revisit cases throughout this time period. There has been a steady increase in the number of the new patients every year. This trend shows that there has been an increase in the oral health awareness during this time span which has led to the increase in the patient influx. Some earlier studies have also reported an increase in the number of the patients in the dental hospitals [  Change in perception:  Findings from the present study support the assumption that, in developing countries, visits to dental-care services are usually carried out because of agony caused by dental pain. Many previous studies have revealed that the high cost of oral health care have been the major barriers for seeking oral care   . The inPrevious studies have shown that the younger age group visit dentist more regularly in comparison to the older age group which may be due to the fact that the younger age group had more knowledge and fewer barriers in seeking dental care   . Syrjal This development should probably be seen in perspective with modernistic standards and stereotypies as good health, young and slim body, brown face and nice shiny white teeth. The reasons for seeking dental care include several basic wishes of physical, psychological and social origin such as chewing ability, feeling fit dentally and comfortable and overall being good-looking and having a pleasant smile.  Change in Utilization pattern:  However, in present study the trend towards the preventive and restorative dentistry shows an increase with each passing year. People have opted periodontic and conservative procedures more often than the oral surgical procedures as dental extractions. The trend analysis shows that there has been an increase in the procedures as scaling and restorative dentistry from 2003 towards 2014. This trend has been shown in various developed countries in the world   .  Possible reasons for this increase in the demand of the dental health services in the study population can be increase in the education level of the population; increase in the socio economic status or increase in the awareness about oral health. This information can help dentists and planners how to optimally distribute resources viz., manpower and money and produce the greatest amount of additional benefits. This also suggest that Dental surgeons and dental health workers have been playing their role adequately in facilitating public enlightenment and people have appreciated the need for regular dental care by utilizing the services.  Many previous studies have revealed that the high cost of oral health care and fear of dentists or dental tools have been the major barriers for seeking oral health care    . Patie Utilization of oral health care is an indicator of oral health behaviour of a population, with underlying social determinants. Since high costs one of the main barricades to utilization of oral health care, social and economic up-liftment through policies addressing the issues of sickness and rehabilitation benefits, child benefits, healthcare facilities, and women empowerment is crucial for the successful delivery of oral health services.It shall also be highlighted that the impact of health insurance coverage can also drastically help people to go for dental services at an earlier stage. However the dental health insurance is practically not available in this part of the country but it shall be made available as soon as possible to keep the present trend increasing.Utilization of oral health care has long been used as an indicator of oral health related behaviour of a population. In the present study it can be concluded that the outlook of the population under study has changed from blood and vulcanite dentistry outlook and is moving towards restorative dentistry. This can be enough for the planners to focus the resources towards the proper direction or the felt needs of the population.The present study has been a retrospective study where the records of a hospital have been used for making the results. Certain limitations may surface within the records as stratification according to the gender, age and socio economic status could have been more informative as to which group or social class had used the treatment more often. Other limitation is that it may cover only the catchment areas of the hospital and not the whole of the population of the state or the country. The presence of the staff pattern in the dental section of the hospital has almost remained the same all throughout the period of the study thus that could have a little effect on the outcome of the study.Studies regarding the utilization dental services by north.east Indian population are almost non.existent. Therefore it is the responsibility of the health professionals of to gather the data on the utilization of dental services by people residing in this part of the country.The truth that dentistry has changed with passing years is not unknown. There have been changes in the insight of the dentists and similarly the treatments have become much sophisticated and contemporary. It has been witnessed that there has been an increase in the utilization of the dental services in developing countries but the pattern of this utilization has not been investigated in depth.The present study presents the information about the population’s use of dental services. It is both necessary and useful as the dental sector experiences the impact of changing forces which influence the number of people who visit the dentist and the type of services they consume. When such information is available, it can help dentists and planners more toward more optimal distributions of manpower and money


International Journal of Molecular Sciences will be retracted. An investigation of the peer review process has concluded that it was compromised via the use of fake reviewer email addresses provided by the authors. MDPI takes the integrity of its review process very seriously. Since bringing the management of the peer review process in-house in 2006 ,An internal investigation has concluded that for these two papers the procedures were not correctly followed, for which we apologize to the readers of the journal. The investigation covered all MDPI journals and these were the only problematic cases discovered.We believe that the vast majority of authors submit manuscripts in good will, however we remain vigilant for suspicious activity and strive to have robust procedures in place to ensure that such cases can be discovered prior to publication.


There is not a lot in the literature on disability in Nigeria concerning the role that religion, culture and beliefs play in sustaining discriminatory practices against persons with disabilities.Many of these practices are exclusionary in nature and unfair. They are either embedded in or sustained by religion, culture and beliefs about disability and persons with disabilities.Drawing on various resources and research on disability, this paper looks at these practices in respect of these sustaining factors. Some of the discriminatory practices that constitute the main focus of the paper are the trafficking and killing of people with mental illness, oculocutaneous albinism and angular kyphosis, raping of women with mental illness and the employment of children with disabilities for alms-begging.The examination of these practices lends some significant weight and substance to the social model of disability, which construes disability in the context of oppression and the failure of social environments and structures to adjust to the needs and aspirations of people with disabilities.Given the unfairness and wrongness of these practices they ought to be deplored. Moreover, the Nigerian government needs to push through legislation that targets cultural and religious practices which are discriminatory against persons with disabilities as well as undertake effective and appropriate measures aimed at protecting and advancing the interests of persons with disabilities. In Nigeria, people with disabilities are subjected to numerous types of discrimination  in various cities and communities in Nigeria are kidnapped, trafficked and killed for rituals  disabilities to beg for alms can be seen from the age-old Almajiri system, which is an ancient tradition and cultural practice. The Almajiri is an aspect of the Northern Nigerian Islamic Education System, that is, a ‘semi-formal non-secular education in which children between the ages of 4 and 18 are assigned to wandering Islamic teachers usually referred to as Malams’ to learn the Koran and also to acquire some form of Islamic knowledge  have discussed how religion and culture in the area of the Almajiri system is related to alms-begging. Yakasai , for exaThe Almajiri system is very widespread in Yobe State as in most States of the north which is believed to be a product of the Koranic system into which some parents dump their male children and forget them there. The poor little brats are abandoned to the care of the Koranic teacher who is not earning any salary. The poor teacher simply engages the pupils in part-time begging, the proceeds from which is used to pay the teacher and feed the pupils. In most cases the Almajiri (the Koranic pupil) does not know his parents, his home or any of his relations. He is entirely on his own and ends up on graduation a beggar.One may conclude that the Islamic practice of Almajiri sanctions begging, as do some passages in the Koran.If the above reports and evidence are accurate, then they highlight the point about the role of culture in discriminatory practices against persons with disabilities, which seems consistent with Oliver’s variant of the social model of disability. In his seminal work, Oliver seeks to provide conclusive evidence that disability ‘as a category can only be understood within a framework which suggests that it is culturally produced and socially structured’ Oliver :22. The With regard to religion, Olupona  has noteOne can conclude that both religion and culture exert powerful influence on many Nigerians not only when it comes to negative attitudes towards people with disabilities but also in their engagement in highly discriminatory practices against them.Our discussion has highlighted that religion and culture promote certain beliefs and attitudes about disability and people with disabilities that lead to discriminatory practices. That is, they are sustaining factors in discrimination against people with disabilities. These practices should be wholeheartedly denounced because they result in the invasion of the dignity, personhood and life of persons with disabilities. They trespass the inalienability of human rights, in general, and the rights of persons with disabilities, in particular, as recognised by human rights conventions and laws . To ensure that persons with disabilities are treated fairly and to combat stereotypes, prejudices and harmful practices relating to persons with disabilities, the Nigerian government would have to push through legislation that can target cultural and religious practices which are discriminatory against persons with disabilities. In addition, it has to undertake effective and appropriate measures aimed at raising awareness throughout the society about persons with disabilities.


As psychiatrists, we are often obliged to provide non-consensual treatment. This institute comprises the rights of the patients with mental health disorders. The aim of this paper is to explain the contemporary mental health legislation in our country the Republic of Macedonia and the problems with the implementation of involuntary hospitalisation. This could be overcome with close cooperation between the judicial and health care system. Psychiatrists are often confronted with the problem of non-consensual treatment when patients with severe mental illnesses have to be hospitalised against their will. There is always a controversy as to whether compulsory treatment reduces their right for equality and freedom to decide. We would like to emphasise that if something is compulsory you must do it or accept it because it is the law or because someone in a position of authority says you must. This is important especially in the last several decades with the processes of deinstitutionalization and downsizing of large psychiatric hospitals and establishment of alternative community services .Involuntary treatment is, therefore, the ’last resort’. The second question that arises does this treatment improves the clinical outcome and social functioning of that patient. Given the widespread use of such powers, it is important to assess the effects of this type of legislation . That isBesides the meaning of this institute, taking into practice the involuntary hospital treatment has several disadvantages that are the result of actual law regulations in our county.th, 2005 [After declaring the independence in 1991 the Republic of Macedonia (RM) has adopted an extensive set of legal reforms and many of them were concerned with and address distinct aspects of providing appropriate health care for the population. Also signed and ratified were several international instruments like Convention against torture and other cruel, inhuman or degrading treatments or punishment . The Parth, 2005 . It inclth, 2005 .We need to mention the National Program for the treatment of people with mental disorders with Law on Mental Health  and StraPursuant to the Law on non-litigation procedure when a person is admitted with their consent they should submit a statement in written in front of two adult witnesses who are not employed in the public health institution and are not relatives of the person that is being hospitalised . In caseIn our country, there is a clear legal process in accordance with the international standards that regulates detention and medical treatment without their consent. It is regulated by the provisions of the articles 58 and 59 from the Non-litigation law. Criteria for detention and treatment are the presence of mental illness and aggressive or suicidal behaviour and the Court decides when the mentally ill person should be deprived the right for freedom of movement and contacting the surrounding environment.When mental health organisation is to treat mentally ill patient without their consent or without a Court order the public health organisation is obliged to inform the regional Court in 48 hours. The Court is obliged to appoint two independent doctors one of them specialised in psychiatry, and the examination is performed in the stationary institution in which the treatment is provided. Then after the medical examination and expertise the Court is obliged to examine the circumstances and to provide the decision in the next 72 hours.Post-independence law reforms in R. Macedonia provide substantial and procedural protection of rights of the patients , 12 with


A Narghile, one of the names for a water pipe, is an instrument for tobacco smoking that has became a trend among the youth in Israel. The mistaken opinion that smoking a Narghile is not as dangerous as smoking cigarettes makes the youngsters and their parents take it lightly and contributes to the expansion of its use. The objective of this paper was to review the literature on the health risks of Narghile smoking. A literature search of Medline (PubMed) and the Internet on the health hazards of Narghile smoking was conducted. The health hazards that the Narghile smoker is exposed to include interference with oxidation, damage to genetic compounds, increased risk of developing malignancies, infectious diseases, damage to the fetus and newborn, and exposure to commonly abused chemicals. It is concluded that increased awareness of the expanded use of the Narghile is imperative and education programs about the prevention of cigarette smoking and substance abuse should also include Narghile smoking.


The errors and associated corrections described in this document concerning the original manuscript were accountable to the production department handling this manuscript, and thus are no fault of the authors of this paper. Additionally, the online manuscript has now been updated with these corrections accordingly.In the original publication of this article  the inco


The approach developed by Fuhrer in 1995 to estimate wheat yield losses induced by ozone and modulated by the soil water content (SWC) was applied to the data on Catalonian wheat yields. The aim of our work was to apply this approach and adjust it to Mediterranean environmental conditions by means of the necessary corrections. The main objective pursued was to prove the importance of soil water availability in the estimation of relative wheat yield losses as a factor that modifies the effects of tropospheric ozone on wheat, and to develop the algorithms required for the estimation of relative yield losses, adapted to the Mediterranean environmental conditions. The results show that this is an easy way to estimate relative yield losses just using meteorological data, without using ozone fluxes, which are much more difficult to calculate. Soil water availability is very important as a modulating factor of the effects of ozone on wheat; when soil water availability decreases, almost twice the amount of accumulated exposure to ozone is required to induce the same percentage of yield loss as in years when soil water availability is high.


The categorization of neurodegenerative disorders have yet to be undertaken with regards to their mechanistic progression and their characteristic patterns of degeneration (Przedborski et al., The concept of localization of function within regions of the telencephalon and the diencephalon has been a major goal in the neuroscientist community (Stelzer et al., Opposing the category of localized neurodegenerative disorders, and their pathological mechanisms, are systematic neurodegenerative disorders. These are disorders that involve the interaction and breakdown of multiple systems. With these disorders the regeneration of any one region of the brain would not serve as a lasting treatment for the afflicted individuals (Hardy et al., Being able to differentiate between these different types of neurodegenerative disorders allows for simple, explicit, objectives for medical and research professionals in developing treatments for these disorders. Such a paradigm shift is required for the right approach to be taken by medical researchers seeking to find more appropriate treatments for neurodegenerative diseases. In localized neurodegeneration, the regenerative approach can be taken by replacing the damaged region. In systematic degeneration the agent in which causes the degeneration, for instance overtransmission of specific neurotransmitters in the case of schizophrenia, should be addressed and its effects should either be deterred or counteracted using symptom targeted treatments.All authors listed, have made substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


AOJNMB is also included in databank of Geneva Foundation for Medical Education and Research (GFMER) and will continue application for inclusion in all indexing databanks.AOJNMB has a very successful year in 2016 and is indexed in PubMed Central from the first issue. Now AOJNMB could easily be searched in NLM database and full text of articles could freely be downloaded in HTLM or PDF format from PubMed Central. I am deeply grateful to many scientists and physicians who contributed to this success either by publishing their excellent works in AOJNMB or providing critical scientific review of the submitted manuscripts, introduction of the AOJNMB in their countries and sending me their suggestions and comments for improvement of the journal. My special thanks go to our Japanese colleagues who submitted the highest number of manuscripts to AOJNMB in the last few years. Currently we have submissions from more than 20 different countries and I am looking forward to publishing more research works from other countries in the region especially from those who have a solid research system in place. Being indexed in PubMed Central, dramatically improved the visibility of the journal and it is reflected in the increased number of submissions in the last few months. The number of submission to AOJNMB has nearly doubled in the 2Improvement in visibility of the journal may result in increasing number of citation. AOJNMB had 69 citations in Google scholar for 77 citable published articles that is very good for a newly published journal. It is a great honor that AOJNMB has been cited in more than 30 different journals including the most important journals in the field of Nuclear Medicine like; The Journal of Nuclear Medicine, European Journal of Nuclear Medicine and Molecular Imaging Physics, Seminars in Nuclear Medicine, Annuals of Nuclear Medicine, Nuclear Medicine and Biology, and Clinical Nuclear Medicine -6. One oThe future is bright for AOJNMB and we are looking forward to being indexed in ISI web of knowledge. We will do our best to serve as a reliable and valid publication forum for physicians and scientists in the field of nuclear medicine and molecular imaging.It is an immense pleasure for me to take this opportunity for Season’s greetings and wish all of our readers a Merry Christmas and a Happy New Year 2017.


Parenting capacity assessment in court evaluations is a particularly complex task, given that it is necessary to consider the vast array of distinct and interrelated aspects and abilities which represent parenting, as well as the elevated number of contextual levels that influence parenting quality. The perspective we want to introduce regards the potentiality of the multifamily group as the elective observational setting in parenting capacity assessment. Assessing parenting capacity constitutes a crucial task both in the process of child protection in cases of alleged or substantiated parent mistreatment and also regarding decisions relative to child placement in cases of highly conflictual marital separation. According to Budd , severalThe first source of difficulty regards the lack of universally accepted standards relative to the minimum level for attributing sufficient parenting capacity. The absence of shared references exposes the evaluators to the use of vague and subjective criteria, based on their own experiences and personal assumptions.The second source of difficulty concerns the typically obligatory nature of the assessment context (in which the parenting capacity assessment takes place), which places parents under high levels of stress linked to the involvement of the courts and to eventual consequences resulting from a negative evaluation. This causes defensive behavior in parents as well as the tendency to alter their usual ways of thinking and their personal conduct for reasons of social acceptability, with inevitable repercussions on the reliability and validity of the gathered information.The third source of difficulty is related to the shortage of instruments specifically designed to measure parenting capacity, instruments that can't be replaced validly by traditional methods of assessment of psychological functioning .Several authors Reder, , have giEven though the models cited above retain their own specific properties, they all reflect the affirmation of the primary goal of observation of parental behavior and of the parent-child relationship over the most usual practices that favor the use of traditional methods and traditional tools of investigation, for example administering cognitive tests, personality tests etc. to the parents. These tools have less validity and reliability regarding such assessment  and with methods traditionally employed to assess parent capacity. To be optimally carried out, assessments would require prolonged observation of the different aspects of parenting in multiple relational contexts that can affect it, such as the presence of the other parent and/or other children, the pressure produced by stimuli and concurrent environmental demands.From a few field studies , as well as characterized by the alternation and synergic combination of activities that are practical and experiential in nature -which partially evoke Minuchin's structural approach  as well as the way he or she interacts with other adults, with particular reference to his or her peer collaboration skills in structured group work. The first element allows us to assess the parent's potentiality of interaction with several children who aren't his or her own, an important aspect in understanding to what extent the eventual parent's dysfunctions are specifically conditioned by the nature of the established relationship between parent and child. The second element provides ecologically valid indications about the single parent's and single families' ability to establish relationships based on respect, listening, cooperation and solidarity with other adults. This constitutes an important indicator of parental social skills and, in particular, of parental ability to draw upon and mobilize forms of mutual help and social support, elements representing a crucial protective buffer for maintaining adequate parenting abilities in the presence of a variety of stressors.The third feature linked to the use of the multifamily setting in parenting capacity assessment is related to the nature and the typical but obviously not exclusive way of organizing activities. In fact, it's based on the alternation and synergistic combination of practical-experimental activities  and reflective activities . This kind of organization of activities is particularly appropriate for stimulating and assessing a parent's ability to reflect on his or her interaction with the child and on the underlying mental experience, even with the help of feedback provided form other parents. Such a reflective process is also favored by the fact that each parent can be given the role to observe the interactive behavior of other participants - including his or her own child with other parents. Such a decentralized position is useful to the parent in order to understand experiences and emotional states that would be more difficult to understand if directly involved in the interaction.Moreover, as we mentioned before, a sufficient degree of understanding of the emotional experience inside the parent-child relationship is considered a crucial requirement for adequate parenting in parenting capacity assessment models.The use of the multifamily setting, though it seems to require substantial use of professional and organizational resources, can be a particularly effective method to carefully carry out a crucial task such as parenting capacity assessment, a task according to which decisions with remarkable impact on families and community will be made.RD and AR contributed equally to the conception ad drafting of the work.The reviewer DP declared a shared affiliation, though no other collaboration, with one of the authors RD to the handling Editor, who ensured that the process nevertheless met the standards of a fair and objective review. The other authors declare that the study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Serum prolactin concentrations were measured by radioimmunoassays in 98 patients with established carcinoma of breast, 12 patients with cystic mastitis and 10 patients with gynaecomastia and compared with that of age matched normal control women. The serum prolactin levels in the patients with breast cancer, gynaecomastia or cystic mastitis were observed to be similar to that in normal women. It was interesting to note that the levels of prolactin in the luteal phase of the cycle were higher than that in the early follicular phase in normal women.


We present autopsy data from a patient that illustrates the anatomical factors that allow the esophagus to be a mobile structure, especially with respect to the posterior left atrial wall. Esophageal injury and the development of an atrio-esophageal fistula is a devastating complication of percutaneous and surgical ablation therapy for atrial fibrillation . The potA 60 year old male patient who died of noncardiac causes underwent an autopsy. He had no history of heart or esophageal disease and there was no prior history of cardiac or mediastinal surgery. A dorsal view of the lungs and mediastinum is shown in These figures are shown to illustrate the anatomical basis for the marked mobility of the esophagus that can be seen during left atrial ablation procedures. It appears that there is loose fatty areolar tissue that connects the esophagus to the pericardium overlying the posterior atrial wall and the laxity of this tissue accounts for the marked mobility of the esophagus. Understanding the basis for esophageal mobility may hold the key to developing methods to displace the structure during catheter ablation on the posterior left atrial wall and thus prevent esophageal injury.


Governments are increasingly introducing performance management systems to improve the quality and outcomes of health care. Two types of approaches have been described: assurance systems that use summative information for external accountability and internally driven systems that use formative information for continuous quality improvement. Australia recently introduced a National Quality and Performance System (NQPS) for Divisions of General Practice that has the dual purposes of increasing accountability and improving performance. In this article, we ask whether the framework can deliver on its objectives for achieving accountability and fostering performance improvement. We examine the system in terms of four factors identified in a recent systematic review of indicator systems known to improve their use. These are: involving stakeholders in development; having clear objectives; approach to data collection and analysis including using 'soft data' to aid interpretation; and feeding back information.We found that early consultative processes influenced system development. The system promotes the collection of performance information against defined program objectives. Data includes a mix of qualitative and quantitative indicators that are fitted to a conceptual framework that facilitates an approach to performance assessment that could underpin continuous quality improvement at the Division level. Feedback of information to support the development of quality improvement activities has not been fully developed.The system currently has elements that, with further development, could support a more continuous quality improvement or assurance based approach. Careful consideration needs to be given to the development of methods for analysis and review of performance indicators, performance assessment and engagement with consumers. The partnership arrangement that supported early development could be expected to serve as an important vehicle for further development. Performance management systems are increasingly being introduced to improve the quality and performance of healthcare. They are the latest innovation in a raft of technologies that seek to improve the accountability of healthcare providers in ways that stimulate improvements in the delivery of care . In the Introduction of these systems into the public sector marks a policy shift toward greater management of primary care and a move away from more traditional command and control approaches that monitor service cost, activity and output data to more indirect and hands off regulatory approaches that measure performance against specified targets . In thisTwo types of performance systems have been described: those that use summative mechanisms for the purpose of achieving external accountability such as to funding bodies and more internally driven systems that use formative mechanisms for the purpose of achieving continuous quality improvement . Both syConsiderable debate exists about the value of performance systems and evidence of their effectiveness in improving the quality and outcomes of care is scant, particularly in primary care settings . That whThe Australian Government introduced a National Quality and Performance System for Divisions of General Practice in March 2005. It is an ambitious performance management framework that has the dual purposes of increasing accountability and improving performance, the latter explicitly based on the ideal of CQI. NQPS stated aims are to establish "a process to reward high performance, promote best practice, support under performance and sharpen the focus of the network in order to ensure all communities can have similarly high expectations of Divisions network members" (pp2.9) . The sysThe study has two components – a review of published theoretical and empirical studies of the use of performance management systems that examined the evidence relating to the role, function and effectiveness of primary care performance management systems; and analysis of NQPS development and implementation processes. The latter was facilitated by our involvement in key aspects of development of the system, including development of the underpinning conceptual framework  and leadDivisions of General Practice are local networks of general practitioners operating in defined geographical areas to improve health. They were established by the Australian Government in 1992 to encourage GPs to work together and form links with other health professionals to upgrade the quality of health service delivery at the local level. There are now 119 Divisions across Australia, their state based organisations (SBOs) and a national peak body, the Australian General Practice Network (AGPN) which together comprise the Divisions network. Divisions receive core funding from the Australian Government Department of Health and Ageing (DoHA) and are governed by elected boards whose members are predominantly GPs. They are a diverse group, both in terms of their numbers of constituent GPs which range from eight to over 300, and in terms of the characteristics and size of the communities and populations they serve which range from under 17,000 people in some rural and remote regions to almost 600, 000 in metropolitan areas. Ninety-five percent of Australian GPs are now members of Divisions [The NQPS is a key component of the Australian Government's response to a 2003 Review of the Role of Divisions of General Practice. It found a lack of clarity regarding government expectations of the network's performance, variability in performance and little capacity in the program to demonstrate achievements and value for money. The Review recommended that Divisions should have clearer goals, clarity of roles, increased accountability for outcomes and taxpayers' funding, improved consistency of performance and governance across the network, greater alignment with territory and state boundaries and an increased focus on the delivery of services [The NQPS comprises three key mechanisms for achieving accountability and quality improvement. These are a set of national performance indicators, a requirement for accreditation and a process of performance assessment that is linked to a system of rewards and sanctions. Table As shown, fifty-two national performance indicators (NPIs) capture government expectations for performance in relation to governance, prevention and early intervention, access, integration and chronic disease management. Divisions are required to report against a compulsory subset of these indicators. There was choice in the number and level of indicators to be reported in the first year, as well as scope for reporting achievements against locally conducted programs although this was not compulsory. Once Divisions are accredited by an approved provider, they will no longer be required to report against the majority of the governance indicators. The first full year of reporting was completed in September 2006.The NPIs are underpinned by a conceptual framework  that is Assessment of performance will be conducted at two levels: at the network level, where benchmarking can facilitate comparison between Divisions and at the Division level, where individual achievement against NPIs will attract a score that feeds into a process of overall performance appraisal. This latter process includes consideration of achievement relating to contractual obligations, local programs, links within the network and organisational capacity. Assessment against NPIs may be augmented in future with the determination of targets.Performance was initially intended to link to a set of rewards and sanctions . Those mPublication of performance data did not feature in early documentation about the system. Australia does not currently publish primary health care system performance information but the Australian Commission on Safety and Quality in Health Care  has signaled its intention to do so . It is uDevelopment and implementation of the NQPS was overseen by a Review Implementation Committee (RIC) established by the Australian Government Department of Health and Ageing. It comprised representatives from Government and the Divisions network who operated through working groups to oversee the development of the key system components as well as the administrative processes that were needed to support them. This included development of the NPIs, a strategy to support accreditation and development of the system for performance assessment. While much of this early work was conducted within extremely tight timeframes, it was also accompanied by processes of consultation which appeared to achieve the endorsement of key members of the Divisions network . DespiteAt the outset, development of National Performance Indicators was contracted to two experts: a legal expert on governance who developed governance indicators in consultation with the network through a series of key meetings, and to a primary health care research organisation who engaged a group of national and international clinicians, consumers and academics to develop the clinical and other performance indicators which were then subject to processes of consultation with Divisions members and other stakeholders. A related working group was also established to drive the development of an automated reporting system for NPIs.In a series of interviews we conducted in early 2006 with a representative sample of Division CEOs, cautious support for the concept of performance indicators was expressed but this was accompanied by widespread concern that clinical indicator data that would have to come from General Practice to report on some indicators would be difficult to obtain, both because many GPs would not support reporting of data to government and because of the capacity of existing data sources to provide the quality required. Some Division CEOs saw this as a major impediment that could not be addressed in the absence of formal agreements between Divisions, general practice and Government . Other CA consultant was also engaged to develop the strategic directions for the National Information Strategy which was to support the collection, analysis and feedback of data to Divisions . A serieAn accreditation working group was also established under the auspices of the RIC to assist Divisions to become accredited. Acting on the recommendations of the Working Group, the Department provided incentive payments to support Divisions to become accredited and all Divisions subsequently applied for and received the early adopter accreditation incentive payment . By NoveDivision engagement in the development of the performance assessment system was through a Performance Working Group. While considerable work was undertaken to develop the specifications for assessing performance at the Division level and the detailed conceptual work relating to the reward system, which at that time was the Funding and Performance Pool and "earned autonomy", those concepts were later abandoned. More recently a decision has been taken to engage an AGPN/SBO Coalition to explore more "effective alternatives for encouraging high performance and supporting Divisions to raise their performance standard"  but concFrom the outset, key government documents outlined clear objectives for the operation of the NQPS system. These were captured in the broad system aims referred to in early documents (see above) and the development of the key system components, which together reflected aspirations for improving accountability and fostering quality improvement. Indicators themselves have clear objectives but further articulation of the key objectives for analysing baseline data and identifying the processes for feeding back performance information to the sector are needed to operationalise the system as a whole and to achieve a shared understanding of the parameters and requirements for performance. Despite early involvement of the stakeholders in development, these further steps appear not to have occurred. Over time, this has amounted to a stagnation of the system and resulted in a drift away from the early emphasis on fostering quality improvement.In relation to NPIs, clear objectives for performance are embedded in each of the domain areas for which indicator data is collected. Each major program area has a number of indicators that measure performance against defined program objectives. These were defined during the process of developing the indicators. In relation to diabetes for example, the objective is "Divisions will support general practices/GPs to provide optimal care and contribute to the achievement of the best possible health outcomes for patients with diabetes". Nine indicators across process and intermediate outcome domains measure performance based on best practice approaches to diabetes care . This haAt the network level, analysis of performance indicators is intended to provide a national picture of performance but the exact objectives and questions to be asked of baseline data have not been clearly articulated, at least in the public domain. This far, analysis of NPIs has been undertaken as part of the Government's processes of accountability to parliament for public money, as part of its program evaluation processes. A lack of clarity regarding the way in which data will be analysed and used to support a process of continuous quality improvement remains, despite early objectives for fostering continuous improvement.While Governments use performance indicators to verify processes of quality improvement, providers need to be able to use the data to inform strategies for improving the quality of care. This requires achieving a balance between obtaining data that is of high enough quality and precision to ensure accuracy in measurement and capturing data that is relevant and of use in complex real world settings to underpin the development of strategies for improving care. Well derived performance indicators are not only markers of outcomes or processes that can be influenced by organisations but they should also act as a catalyst for change within organisations . The NQPNPIs include a mix of qualitative and quantitative indicators. These are fitted to a coherent conceptual framework  that expCapture of contextual information to support interpretation of quantitative NPIs is a critical feature of the framework. This allows a Division to provide supporting information in relation to its performance in a particular area. This might include information relating to population characteristics or geographic location for example, where this may impact on the capacity of a Division to deliver programs or affect the likely uptake. This feature of the framework is designed to address difficulties associated with measurement where there is potential that confounding factors such as socio-economic variation, case mix, comorbidity and severity at the local level  may be rAvailability and reliability of data are fundamental to any performance system, particularly when the key objective is to establish differences between groups . The danSystems that emphasise verification of performance tend to rely on ranking processes, using data in a summative fashion to establish certainty, linking results to rewards and sanctions. Systems emphasising quality improvement use data in a more formative way with a focus on providing information that can facilitate opportunities for reflection and learning. Early work on the development of the performance assessment system demonstrated a desire to capture the best of both systems – precision, rewards and sanctions and a capacity to use information to stimulate quality improvement. Further development of the system needs to build on this early work and clearly identify the purpose and processes of performance assessment.Firstly, an early discussion in relation to performance assessment involved consideration of the appropriateness of ranking based on some summary score or rating. There were concerns that ranking would result in competitiveness within the network which would undermine the goal of strengthening the network as a whole, a stated priority in key Government documents. This is consistent with findings from studies of assurance systems which suggest that when providers are in competition to get good results, a range of perverse incentives and unintended consequences that undermine the conditions required to support quality improvement result . In addiOther discussions around elements of the proposed performance assessment process signalled concern with the promotion of overall performance and development, rather than with simply verifying, rewarding and/or penalizing individual performance. Linking performance to rewards that seek to spread innovation across the sector, such as through a performance and development pool is one such example. Other discussions related to supporting individual improvement through setting targets for performance that would be negotiated by individual Divisions with their contract managers. At that time the Department intended to provide its project managers with training on continuous quality improvement approaches to ensure its performance assessment processes were underpinned by a continuous quality improvement philosophy .When interviewed in 2006, CEOs expressed the view that performance assessment needed to be nationally consistent, a concern borne out of the fact that Divisions are managed by Commonwealth officers residing in different state offices and that consistency in management hitherto had not been evident. The introduction of a national system for measuring, comparing and monitoring performance alters the focus of attention to the national level and achieving consistency across the state offices assumes a greater level of importance. Other concerns related to the need for timely provision of performance feedback and an incremental approach to the development of targets for performance. Neither of these issues has since been resolved. In any case, they are elements only of a broader process that first needs to establish the key purpose for performance assessment. If a key purpose is to promote and foster quality improvement, then organisations need to be provided with the data so that it can inform the development of quality initiatives. To this end, there is evidence that multidisciplinary performance improvement teams are ideal for discussing and acting on identified problems .The NQPS is an ambitious framework that aims to promote both quality improvement and accountability. Government has inscribed its expectations for performance in the sector into its choice of performance indicators and these will provide the data against which a national picture of the network's achievements will be measured and individual performance assessed and compared. For the first time, a nationally consistent assessment of Divisions' capacity to improve health outcomes will be available. It's approach to linking the collection of Division level data to standardised program objectives, offers a capacity for supporting quality improvement that appears to be unique among comparator country frameworks.The system currently contains something of a mix of summative and formative mechanisms that with further development could support a more CQI or assurance based approach. How the system refines and operationalises these components in relation to its priority questions and choice of methods for analyzing performance data, its approach to feeding back data to Divisions and putting into place a structure that supports the interpretation of data and identification of priorities for action  will determine its success as a performance framework. International evidence suggests that a focus on CQI is more likely to produce fewer technical indicator problems, greater levels of engagement with stakeholders and information that may provide a prompt and starting point for dialogue about improving quality.The partnership arrangement that engaged the stakeholders and underpinned early development could be expected to serve as an important vehicle for further implementation, development and review. Three key areas need to be addressed. Firstly, the methods to be used for analysis, benchmarking, review and further development of the NPIs needs to be determined with a clear purpose in mind. This may best rest with a consortium of stakeholders who have the relevant sector, clinical and epidemiological knowledge to engage in a process of reflection that can identify national issues of concern and conduct review activities that will ensure that maximum use of performance information is made in relation to supporting quality improvement activities. Ongoing support for a national information strategy is critical to addressing current concerns in general practice and delivering data that can underpin this system.Secondly, the partnership needs to work with the AGPN/SBO coalition to determine the purpose and parameters that will operate in the performance assessment process, the philosophy that will underpin it and the developmental supports that will be required to build capacity across the entire sector.Thirdly, there is increasing recognition internationally of the need for consumers, as well as funders and providers, to have access to information about system performance and it seems timely for Australia to examine how this might best be done. Bringing consumers into the partnership arrangement at a high level may provide scope for further examination of how consumers might best be served by health performance management systems in the Australian context.As it currently stands the NQPS has not realised its potential for achieving accountability and fostering quality improvement. Over time, its implementation has become more reminiscent of the traditional command and control approach to monitoring cost, activity and output data that has dominated contract management in recent years. As a regulatory framework that seeks to measure performance in terms of client outcomes and health improvement by linking accountability requirements with quality improvement processes, it still has some way to go.Two authors BS and KG developed the conceptual framework for performance assessment in primary health care that underpins the NQPS. BS was supported by DL in leading the team that was commissioned to develop the National Performance Indicators. KG worked in the Australian Government Department of Health and Ageing on aspects of development of the NQPS.KG developed the idea for the article and prepared early drafts, BS contributed to defining and shaping the arguments and added additional material for subsequent drafts, DL conducted literature searches associated with the article. All three authors read and approved the final draft.


The United Nations (UN) System's agencies have been criticized for not adequately assessing the impact of their training and fellowship programmes. Critics point out that beyond documentation of the number of fellows that underwent training, and their immediate reaction to the experience, it is necessary to ascertain that fellows are using what they have learned, and most importantly that their institution and country are benefiting from the significant investments made in the fellowship programmes.This paper presents an evaluation framework that was adopted by the 17th Meeting of the UN System Senior Fellowship Officers convened in London in 2008 in response to this challenge. It is arranged in three sections. First, the assumptions and constraints concerning impact evaluation of training are presented. Second, a framework for evaluating the impact of training in the context of UN System programmes is proposed. Third, necessary conditions and supportive measures to enable implementation of the impact evaluation framework are identified.The critical message emerging from this review is the importance of constructing a 'performance story' based on key milestones associated with the design and implementation of fellowship programmes as a way of assessing the contribution of different components of the fellowship programmes to institutional outcomes. The United Nations (UN) System's agencies have been criticized for not adequately assessing the impact of their training and fellowship programmes . Criticsth Meeting of the UN System Senior Fellowship Officers  mandated the design of a generic evaluation framework that defines the scope, dimensions and core indicators for evaluating the impact of UN Fellowship programmes [In response to these concerns, the 16This paper presents an evaluation framework that was adopted by the 17th Meeting of the UN System Senior Fellowship Officers . It is arranged in three major sections. First, the assumptions and constraints concerning impact evaluation of training are presented. Second, a framework for evaluating the impact of training in the context of UN System programmes is proposed. Third, necessary conditions and supportive measures to enable implementation of the impact evaluation framework are identified.In its detailed and well received 1998 report on "Fellowships in the United Nations System" the Joint Inspection Unit (JIU) proposed the following definition;"...a fellowship in the United Nations system is a specially tailored or selected training activity that provides a monetary grant to a qualified individual or group of qualified individuals for the purpose of fulfilling special learning objectives; such training may be of short or long duration and may take place in an appropriate training institution or in the field inside or outside the fellow's country; should be in response to nationally-approved human resources policies and plans and should aim at impact and relevance for all stakeholders involved .It should be noted that the JIU definition has not been accepted by all UN agencies. Some agencies exclude study tours, while others actually include seminars and workshops. Moreover, the financial commitment of fellowships has not been accepted by all. Some bilateral and multilateral institutions outside the UN system put the emphasis on the extent to which any fellowships modality contributes to the achievement of clearly defined organizational objectives rather than on the definition of fellowships. Such a determination can only be ventured on the basis of evaluation of the effectiveness of fellowships in all its modalities. Noting that evaluation is the Achilles heel in most UN organizations, the JIU report acknowledge that effectiveness of fellowship in all its modalities is fundamentally linked to assessing its benefits to individuals and institutions.Classification of different type of measures abound. In the context of training, none is more influential than Kirkpatrick ,5, who pa) Reaction - a measure of satisfaction (what the trainees/fellows thought and felt about the training);b) Learning - a measure of learning (the resulting increase in knowledge or capability as reflected in end of course assessment);c) Behaviour - a measure of behaviour change (extent of behaviour and capability improvement as reflected in on the job performance);d) Results - a measure of results .Kirkpatrick followers have suggested additional levels including, for example the introduction of a fifth level concerning estimation of the Return on Investment (ROI) . Other uBasing an impact evaluation framework on the strength of Kirkpatrick work mandates two important observations. First, it is necessary to note that most of Kirkpatrick's and his followers work were undertaken in the context of corporate training, whereby the trainees were also employees trained for well defined purposes. In these circumstances it has been possible to assess the training outcomes in relation to institutional key results areas and to estimate the returns on training investments. UN System fellows, on the other hand, return to different organisations and the impact of their learning on their home institutions is infinitely more difficult to assess due to limited control over their deployment and support once the fellowship is completed.The second observation is even more pertinent. Although Kirkpatrick's 4 step approach has been widely discussed in the literature, it is evident that most organisations have not evaluated all four levels. Training interventions have been typically evaluated at the reaction and learning levels. Only a few studies have paid attention to behavioural outcomes, and very few assessed the benefit to organisations. The reliance on fellows' reaction and learning measures may reflect the difficulty and cost associated with measuring performance and organizational benefits and may underpin the limitation of current approaches .Key constraints associated with the assessment of the impact of training include:(a) Methodological constraints associated with the attribution of any impact or change in the performance of individuals or systems to the participation in fellowship programmes. Reporting results and 'proving' attribution are two different things. Attribution involves drawing causal links and explanatory conclusions between observed changes and specific interventions . If we w(b) Conceptual constraints associated with the expectation that training on its own would have a sustainable impact on the system evaluated. Change in performance is commonly based on a multi prong intervention of which "people development" is only one of the elements. Conceptually there is no basis to expect that training alone would influence the performance of complex systems in the absence of contributing factors such as appropriate technology, resources, leadership, favourable internal and external conditions, conducive formal structure and most importantly supportive organizational culture.(c) The challenge of programme me fidelity. Experience with some UN System programmes have shown that fellowships are not always linked to well articulated objectives, that the selection process may be skewed, that the host institutions and programmes often lack understanding of the training needs, that fellows return to settings that fail to support and utilize them properly, and other such deficiencies. Furthermore, there is a great variability in the design and implementation of fellowship programmes in terms of duration, mode of training, recipient instruction resources and capacity and other variables. The fidelity of the fellowship programme as reflected in the presence of these critical determinants should arguably be demonstrated before major investments are made in the measurement of impact.Whilst it is not possible to completely eliminate these constraints, it may be possible to mitigate their effect. The mapping of the entire pathway, from the initial identification of training needs and selection of fellows to the assessment of the support for and utilization of fellows in the home institution provides what Brinkerhoff and Gill  called aIn turn, the mapping of the fellowship programme pathway will improve our understanding of the added contribution of each component of the fellowship programme, helping us to attribute their contribution to the overall impact and improving our understanding of the role of training in the context of a broader capacity building effort. Most importantly, it should help us to verify that fellowship programmes have clear and well understood objectives in line with recipient institutions' priorities, that the programmes were well designed and funded, that the right people were selected and participated, that the training they received was consistent with their work settings requirements, that they gained the skill and knowledge they required, that they returned home and were posted in relevant positions, that they were given necessary support and opportunity, that they were able to apply their newly acquired competencies in practice, that their performance lead to improvement in programmes and institutional performance and ultimately that the programmes benefited particular customers or communities. In theory each step is a logical necessary condition for the success of subsequent steps. We could view these steps as a 'hierarchy of outcomes' we wish to achieve and hence need to monitor and evaluate.The notion of mapping the pathway towards higher level goals is consistent with Mayne's Contribution Analyses approach . AccordiThus, as Mayne  suggesteWhilst most UN System agencies have monitored some of the key milestones related to the result chain of a fellowship programme, it appears that the link between these steps as a pathway leading to impact has not been explored systematically. The Logframe approach which is used by many agencies in project design and monitoring, points in the right direction. By linking higher level goals to specific objectives, activities and inputs, the framework enables clarity about the pathway. The inclusion of indicators for verification of progress and attainment of goals provides a blue print for monitoring and evaluation and the identification of barriers along the way.The World Bank evaluation indicators  which weThe critical message emerging from these assumptions and assertions is the importance of constructing a 'performance story' based on key milestones associated with the design and implementation of fellowship programmes, as a way of assessing the contribution of different components of the fellowship programmes to institutional outcomes ,15.The proposed framework for evaluating the impact of UN System fellowships is based on an attempt to analyse the contribution of different events and experiences to the attainment of particular results. The emerging performance story enables 'reasonable' observers to determine the plausibility that particular interventions led to certain results. The performance story describes the journey from the inception of a fellowship programme to the attainment of its immediate and long term goals. The important events and experiences along the way are identified as milestones (performance indicators) that are monitored in order to ascertain that the programme is moving in the right direction and ultimately it has reached its destination.  and reduces uncertainties associated with alternative explanations. In addition, the proposed analysis aims to explore the fidelity of the fellowship programme by ascertaining the fulfilment of necessary steps that lead us to expect that the fellowship intervention produce benefits to the recipient institutions.The proposed evaluation framework focuses on both qualitative and quantitative evidence concerning the attainment of milestones implied in the extended Kirkpatrick classification of training evaluation measures. In addition to the four domains suggested by Kirkpatrick  we include the domains of planning, design and implementation and the long term impact ('mega-impact') of the fellowship programme.The data collection methods are varied to provide a triangulation that may increase our confidence in the emerging findings. We stress the benefit of using existing information through secondary analysis of records and reports. Information routinely kept by institutions and fellowship authorities, is more economical to obtain and less likely to be biased. Accessing existing data, however, requires close collaboration with recipient institutions, fellowship authorities and other relevant stakeholders. Engagement of stakeholders in the elicitation of information and the interpretation of what it means is an essential component of this approach, as we rely on a deeper understanding of contextual issues and conditions which may affect the results. Furthermore, the involvement of stakeholders supports the emergence of ownership, an essential condition for capacity building and lasting improvement.Figure Key indicators include:• Clear objectives:- aligned with national priorities and UN Agencies' mandates.- based on training needs analysis.- articulated in an achievable and cost effective education and training plan.• Fair and transparent selection of fellows based on established selection criteria• Relevant and appropriate placement of fellows using host institution with relevant expertise and adequate resources to provide an effective and efficient programme• Successful and timely completion of fellows' programme:- accomplished education and training objectives and certification of competence, where applicable (Evidence of learning gained through the fellowship).- resulting in positive feedback from fellows and other stakeholders .• Return home to relevant position with adequate support:- percentage of fellows who are employed in relevant positions following various intervals of time.- level and appropriateness of support provided to returning fellows (mentoring).• Evidence of positive contribution to work:- self and others' reports about enhanced capacity and contribution with concrete and verifiable examples (changes in behaviour or performance that could be reasonably attributed to the learning experience offered by the fellowship).- continuing professional and personal development, and contribution to others' learning (dissemination).- increasing productivity.• Evidence of positive development in performance:- examples of new programmes or innovative ways of working (including new technologies) that led to more effective performance.- bridging operational gaps.- strengthened professional networks.• Improved performance leading to enhanced services and benefits provided to community:- evidence concerning benefits to the target community.- contribution to attainment of development goals including MDGs.The third objective of this paper is to identify necessary conditions and supportive measures to enable implementation of the impact evaluation framework in the context of the UN System fellowships programmes. Our comments and recommendations here are made with reference to the application of contribution analysis presented in the previous section. Underpinning this approach is the capacity to map and monitor the key steps (milestones) that constitute a pathway towards impact. This task requires a high level of cooperation among the main stakeholders in accessing, collecting and interpreting information that supports their ability to make a judgment about the plausibility of the emerging performance story. Ascertaining the attainment of the selected milestones calls attention to the fidelity of the programme as we do not have reason to expect long term impact unless we implement the fellowship programme properly.The development of a clear pathway implies clear direction. Fellowship programmes that are intended to have impact on the recipient institution should be based on clear analysis of what needs to be developed or strengthened and how training could contribute. Without such direction it is not clear what the fellowship is expected to achieve and to assess its contribution. This information provides a baseline against which progress can be measured and impact determined. If we don't know the situation at the starting point we could not argue that we have added value, nor can we take credit for an improved state of affairs. The initial analysis of training needs provides an assessment of the level of competence before training and enables verification of learning gains. Identification of institutional performance gaps as justification for the fellowship provides a yardstick against which we can measure progress.Clarity about the recipient system requirements and training needs is essential to guide all aspects of the fellowship programme design, from selection of fellows who are most likely to succeed and contribute, to the design of appropriate training programmes and the preparation of plans for placement and utilisation of fellows on completion of the programme. To be useful, this information must be made available to the host institutions and used to monitor the relevance of the training programme provided. Lack of adequate follow up and support to returning fellows is among the greatest risks to the attainment of the higher level institutional goals, as frequently observed fellows are not given sufficient opportunity to contribute in the areas of expertise they may have acquired. In this way the effectiveness and contribution of the fellowship to the institution is diminished. The contribution analysis may help to identify the disjointed pathway, but beyond a certain timeframe the damage may be irreversible.To achieve a meaningful progression from analysis and identification of needs to appropriate intervention and subsequent utilisation that leads to sustainable benefits and impact requires a solid partnership between the recipients, the providers and the sponsors of the fellowship programme. As mentioned earlier, one of the key weaknesses of the UN fellowship programme is that most of the important steps are outside the term of reference of the sponsoring agency and thus beyond its control. This weakness needs to be remedied through stronger collaboration and contractual arrangements concerning the execution of the fellowship programme. The active involvement of relevant stakeholder is a cornerstone of the contribution analysis approach. Partnership is required at all steps.Approaches based on stakeholder participation are built on the principle that stakeholders should be involved in all stages of evaluation, including determining objectives and impacts, identifying and selecting indicators, and participating in data collection and analysis. The stakeholders are essential participants in assessing the contributions towards impact based on the emerging performance story. Their involvement and subsequent ownership of the findings increases the chance that deficiencies would be addressed and opportunities taken up.Beyond the high level of commitment and resources required to undertake impact evaluation, it is necessary to recognize three major limitations in evaluating the impact of fellowship programmes:• Attribution: what would have happened without the intervention?• Conceptual logic: why is impact expected?• Fidelity: based on the way the programme was implemented is it justified to expect impact?Monitoring key milestones from conception to fruition of a fellowship programme mitigates these limitations by assessing the importance and contribution of each step on the logical pathway towards training impact and ascertaining that the fellowship programme has been implemented properly within a logical conceptual framework. Whilst the contribution analysis approach may not be able to provide the casual relations among variables leading to an impact, it could establish a 'plausible association' whereby a 'reasonable person, knowing what has occurred in the programme and that the intended outcomes actually occurred, agrees that the programme contributed to particular outcomes.The performance story which emerges from this analysis enables 'reasonable' observers to determine the plausibility that particular interventions have led to certain results. The performance story describes the journey from the inception of a fellowship programme to the attainment of its immediate and long term goals. The important events and experiences along the way are identified as milestones that could be monitored in order to ascertain that the programme is leading in the right direction and ultimately that it reached its ultimate goals. The verification that certain milestones have been reached strengthens the confidence that particular contributions helped to attain particular results (attribution) and reduces the uncertainties associated with alternative explanations. In addition, the proposed analysis aims to explore the fidelity of the fellowship programme by ascertaining the fulfillment of necessary steps that justify the expectation of the fellowship producing benefits to the recipient institutions.The proposed evaluation framework focuses on both qualitative and quantitative evidence concerning the attainment of milestones implied in the extended Kirkpatrick classification of training measures. In addition to the four domains suggested by Kirkpatrick  are the pre-training domain of planning, design and implementation, and the long term impact ('mega-impact') following the training programme.A major advantage of the contribution analysis approach is that it can be based on assessment of any plausible evidence regardless of the design, method or source used to obtain it. Thus, it allows use of information obtained through current monitoring and evaluation approaches and techniques. The use of varied data collection methods provides triangulation of findings.Accessing existing data sources requires close collaboration with recipient institutions, fellowship authorities and other relevant stakeholders. The task requires a high level of cooperation among the main stakeholders in accessing, collecting and interpreting information that supports their ability to make a judgment about the plausibility of the emerging performance story. Engagement of stakeholders in the elicitation of information and the interpretation of what it means is an essential component of this approach, as we rely on their deeper understanding of contextual issues and conditions which may affect the results. Furthermore, their involvement supports the emergence of ownership, an essential condition for capacity building and lasting improvement.Effective use of evaluation towards improvement of programmes and determining their merit requires a supportive evaluation culture. Evaluation culture values evidence as a basis for decision making and supports monitoring of outcomes obtained at different stages. Evaluation is viewed as an integral part of planning and managing programmes, from identification of needs, design and implementation of strategies and programmes, to assessing outputs and outcomes towards impacts. At each stage, important decisions are made and information is required. The process is based on partnership and continuing dialogue with key stakeholders about the contributions made by different interventions towards higher level goals.The recommended approach requires major efforts and investments not undertaken to date. Evaluation does cost but "spending whatever limited funds are made available for a fellowship programme without having any reasonable indication of impact is a waste of much needed resources" .th meeting of the UN Senior Fellowship Officers gave the following verdict on the framework:The 17th Senior Fellowship Meeting, and following the deliberations on the resulting findings, the Meeting has found particular merits in the Contribution Analysis approach and therefore adopts this specific modality, with the elaborated milestones pathway as the platform for future implementation and evaluation of Training and Fellowship Capacity Development activities within the UN system" ["Having considered the various possible evaluation approaches for impact assessment presented during the meeting, by the Task Force experts, led by WHO pursuant to the mandate received during the 16The authors declare that they have no competing interests.AR was primarily responsible for the formulation of the evaluation framework and for drafting the paper. MZ was primarily responsible for the literature review and AG contributed to the formulation of the outline of this review. All three authors contributed to the identification of supportive conditions for implementation of the framework and the formulation of the conclusions. All authors read and approved the final manuscript.Indicators and methods for evaluation of the six stages of fellowship.Click here for file


We investigated in the rat the role of the Apc gene, which is mutated in familial adenomatous polyposis and sporadic colon cancer in the process leading from normal colonic mucosa to aberrant crypt foci (ACF) and finally to adenomas and adenocarcinomas. We analysed mutations in exon 15 of the rat Apc gene using in vitro synthesized protein assay in 66 ACF and in 28 colon tumours induced by azoxymethane. No Apc mutations were found in ACF, whereas five mutations were found in the tumours. The data suggest that mutations of the Apc gene are associated with the transition from ACF to adenoma and adenocarcinoma and not from normal mucosa to ACF.


Guideline for Internal Quality Control for Quantitative Measurements in Clinical Laboratories of China. The primary aim of this pilot study was to investigate the approximate incidence of invasive pulmonary aspergillosis in patients with acute exacerbation of COPD and the diagnostic value of combined serological tests, so further analysis on cost-effectiveness and diagnostic protocol is limited by the relatively small number of confirmed cases. We think that the possible solution to this problem is large multicenter clinical trial conducted in high-risk population.We appreciate the comments of Dr. Wiwanitkit on our article. All procedures for the serological test in this study were performed according to the


Tuberculosis is the cause of unaccountable human sufferings and economic loss and is one of the earliest human afflictions. Genitourinary tuberculosis (GUTB) term was coined by wildbolz in 1937 and comprises 20% of all extra pulmonary tuberculosis. It was considered that we have conquered this disease, but due to HIV infections and drug resistance, there is a resurgence of tuberculosis. Though the incidence has decreased in the developed countries, it is still highly prevalent in the developing and underdeveloped nations.In text books of urology written in the USA and Europe, the description of this disease is shrinking. The Editorial based on IJU is to be complimented for publishing the supplement on GUTB. I am grateful to them for entrusting me to edit this supplement. The topics were carefully selected to cover this disease in all perspectives. I am grateful to all my authors who worked hard and had written the chapters after reviewing the existing published literature. I am hopeful that this supplement of the Indian Journal of Urology will fill the void in this subject and will be useful for the postgraduates and urologists for better management of these unfortunate patients afflicted by GUTB.


Four experiments in which SPF Wistar rats were inoculated intrapleurally with asbestos or other materials are described. Mesotheliomata were observed in a considerable proportion of animals with all the samples of asbestos used and with a sample of brucite. A few were produced with synthetic aluminium silicate fibres and single ones with barium sulphate, glass powder and aluminium oxide. The risk of developing a mesothelioma at a given time after injection was approximately proportional to the dose. Of the UICC standard reference samples, crocidolite was the most carcinogenic and removal of the oils by benzene extraction did not alter the carcinogenicity of these samples. Chemical properties also seem unlikely to be the main factor producing mesotheliomata but the results support the hypothesis that the finer fibres are the more carcinogenic, and this is additional to the known aerodynamic advantage which the finer fibres have in penetrating to the periphery of the lung.


Drug discovery today requires the focused use of laboratory automation and other resources in combinatorial chemistry and high-throughput screening (HTS). The ultimate value of both combinatorial chemistry and HTS technologies and the lasting impact they will have on the drug discovery process is a chapter that remains to be written. Central to their success and impact is how well they are integrated with each other and with the rest of the drug discovery processes-informatics is key to this success. This presentation focuses on informatics and the integration of the disciplines of combinatorial chemistry and HTS in modern drug discovery. Examples from experiences at Neurogen from the last five years are described.