To analyze the concept of men's health care and identify its essential, antecedent and consequent attributes in the health context. This is a concept analysis structured in the theoretical-methodological framework of the Walker and Avant Model. An integrative review was carried out between May and July 2020, using keywords and descriptors: Men's Care and Health.  The concept of men's health care is structured by 240 attributes, 14 categories, 82 antecedents and 159 consequents, from the selection of 26 published manuscripts. The design was evidenced from the dimensions: Intrapersonal, psychological and behavioral related to masculinities, interpersonal, organizational and structural, ecological, ethnoracial, cross-cultural and transpersonal. The concept of men's health care revealed the male specificities regarding the recognition of the place of health care and the daily exercise in the lived experience. Most of the scientific production is directed to the hegemonic masculinity model, centered on the profile of white and heterosexual men, in which other peripheral models of masculinities that include black, poor men, residents in traditional communities and minority sexual and/or gender groups, are little present.When performing a search in global databases such as the Medical Literature Analysis and Retrieval System Online - MEDLINE/ PubMed, the absence of studies related to the health care of men was identified, as well as the development of defined concepts, in which only the presence of isolated terms and/or uniterms was recognized. In this scenario, the apprehension of the available findings justified the decision to contribute to the development of the concept “men's health care”. Given the above, this study aimed to analyze the concept of health care for men and identify essential, antecedent and consequent attributes in the context of health.This is a concept analysis based on the theoretical-methodological model of Walker and Avant, whose composition is systematized in eight stages, namely: 1. Selection of the concept; 2. Delimitation of the objectives of the analysis; 3. Identification of the use of the concept in the literature; 4. Determination of essential attributes; 5. Identification of the model case; 6. Identification of contrary cases; 7. Identification of the background and consequences of the concept under analysis and 8. Definition of the empirical references of the developed concept.As proposed by Walker and Avant in the first stage, it was defined as a question for the development of the concept: How can men's health care be conceptualized? Thus, we adopted the inclusion criteria of the reviewed studies to achieve development, namely: having been produced in the area of health sciences, social sciences and humanities; presenting health care involving the male public as the centrality of the object/concept and composing relevant findings for the development of the concept in the health field. In the second stage, the objective was defined, followed by the third and fourth stage, which consisted of the theoretical exploration of the conceptual attributes. An integrative review was carried out on the elements that make up men's health care, in order to investigate the existence of theorized concepts, employment, frequency of appearance, adequacy, correlation and the definition of these in the literature. In order to compose the textual corpus of the study, the stages proposed by Mendes, Silveira and Galvão were adopted, namely: 1. Definition of the review question; 2. Search and selection of primary studies; 3. Extraction of data from primary studies; 4. Critical evaluation of primary studies; 5. Summary of the review results; 6. Presentation of the review.The questions adopted for data extraction in the literature were defined through the PICo strategy, whose acronym means: Population/Problem: Man; Interest: Essential, antecedent and consequent attributes; Context: Health care,Three stages were structured for the organization of search strategies. To this end, the search strategy was used: "Men's health" AND "Care" in the Virtual Health Library (VHL) to find uncontrolled descriptors contained in the articles of interest. Then, there were combinations of controlled descriptors, obtained in the Health Sciences Descriptors (DeCS) and uncontrolled, obtained in the initial search, plus the Boolean operators "OR" and "AND". Finally, this strategy was adapted for each database .The search and selection of the studies were carried out from September to December 2021, by two researchers who were authors of the study, independently, and the divergences were resolved by a third researcher. The following databases were used: MEDLINE/PubMed, CINAHL, LILACS, BDENF, Scopus, Web of Science and SciELO. For the management of the collected material, the Endnote was used. The selection of studies followed the recommendations of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) method,For the development of the concept, we extracted from the empirical data: definition, concept, and antecedents, essential and consequent attributes. In this context, the defining essential attributes are configured in words or expressions that are used to structure the essential properties that determine the concept of interest, which makes it individualized from other existing analogous and/or approximate concepts. The antecedents and consequences of this concept are outlined as situations, events and/or incidents, which emerge a priori and a posteriori, in due order, the phenomenon of interest investigated, which results as a consequence, in this case, the health care of men. After this stage, the data were codified and allocated into analytical categories, in which the essential attributes of men's health care were composed of characteristics: Intrapersonal, psychological and behavioral related to masculinities, interpersonal, organizational and structural, ecological, ethnoracial, cross-cultural and transpersonal.The analysis of the results of the review evidenced in the literature was descriptive, in which the synthesis of each study included in the review was presented, as well as comparisons between the studies. In addition, a thorough and exhaustive analysis of the direct relationship between the elements and the phenomenon investigated was carried out. The structuring of the development of the concept of health care for men is organized in the presentation of the scientific productions selected for the composition of the corpus of analysis, followed by the exposure of the use of terms related in the literature in different areas of knowledge, the delineation of the derivation/development of the concept from its essential attributes, the definition of the concept, the antecedents and consequences, the model case and the otherwise.The identification of the use of terms related to the concept of health care of men present in the literature was organized by the appearance in the areas of knowledge, expressed in When based on the survey, selection and dissection of the literature on the subject, submitting it to the derivation for the development of the concept, the essential attributes related to the health care of men were apprehended, represented in model case was developed, described below: [...] "Adult man has observed his body, his mind and spirit daily, which made it possible to recognize a drop in his income at work. When experiencing pain and changes in sexual dynamics, he talks to his partner; he seeks to consume foods that he believes can increase potency, indicated by friends. He reflects on what occurs to him and seeks to recognize the place of this pain, and the reasons for its occurrence, later, he tries to change the pace of his activities, adopts physical exercises and relaxation; he tries to think of positive situations. He uses the references of care experienced in the past, seeks guidance from significant people, family, friends, co-workers and neighbors; he adopts integrative and complementary practices, seeks assistance in traditional spaces and in health services. He recognizes himself as vulnerable, external to his desires, fears, and concerns and expresses his feelings and emotions. He reveals the tensions between his state and the pressures of hegemonic masculinities. When feeling afraid of becoming ill, he resorts to his socio-affective, environmental, bioenergetic, ethnic/racial, cultural, spiritual and/or religious network, and allows himself to be cared for by others to face the adverse situation and reintegrate into his daily activities that make up his sociohistory”. In order to illustrate the operability of the applicability of the concept of men's health care, a is presented, as follows: [...] “Adult man realized that he has not been yielding at work as before, he feels constant pain but takes medication on his own or drinks a beer. He believes that this discomfort will pass, because he thinks he is strong enough to overcome this situation and continue working in the same way. When he realizes that tiredness affects his sexual activity, he avoids intimate encounters and touching this aspect with his partner. Sometimes he is afraid of getting sick, he feels irritated and he feels confident not to cry, he thinks about seeking help, but soon gives up thinking about it he can solve this situation alone and goes back to work”.As a way to illustrate the non-operability of the concept of men's health care, the opposite The structuring of antecedents and consequences for the health care of men are represented from the qualification as harmonious and disharmonious, when considering their characteristics in relation to health care. The antecedents of the concept were structured in dimensions: intrapersonal , interpersonal, macrosocial, ecological, ethnic-racial, cross-cultural and transpersonal, which relate to the interactions described below: Intrapersonal : Illness; autonomy and independence; cycles and/or phases of life; personal beliefs; male beliefs; food and body culture; diseases; male identity; normative models; intelligible practices; performances; subsistence; male universe; force vectors; experiences.Interpersonal (socio-affective interaction): Discursive fields; affective determinants; medical discourses; femininity; female historical-cultural reference; medical guidance; therapeutic plans; marital, family, maternal, paternal and socio-affective relations; references of care; sexualities; female universe.status; urbanization.Macrosocial (interaction with structures of society): Accesses - diagnostic tests, internet, health services; social environment; provided by institutions; conjuncture; daily life; contexts - social and life; social constructions - gender - masculinities; social class; culture; social determinants; city dynamics; factors - generational, historical, political, risk; communication - cellular telephony; social imaginary; social metaphors; health care models; world of work - conditions, locations, value; organization of health services; social organization; health plan; family provision; racial relations; wealth; economic situation; social Ecological (interaction with the environment): Animal and plant coexistence; emigration and migratory flows; territorial and regional insertion; geographical location; nationality; agricultural, environmental, ecological and ethnic relations.Ethnic-racial: Ethnic-centered experiences; ethnic teachings; ethnic acculturation.Cross-cultural (interaction with culture): Adoption and influence of local customs and popular knowledge.Transpersonal: Adoption of beliefs and philosophies; desires around personal fulfillment; ancestral, spatial, spiritual, faith and religious influences; ways of existing, seeing care, health and living life; ritual practices.The consequent of the concept were structured in dimensions: intrapersonal , interpersonal, macrosocial, ecological, ethnic-racial, cross-cultural and transpersonal, described below:Intrapersonal: Healthy and balanced eating; abandonment of habits harmful to health and/or addictions; adoption and directing efforts to promote a healthy lifestyle and habits, preventive care with physical and mental health, aesthetics, relaxation, leisure, daily measures to control diseases, improvement of sleep pattern; learning, perception and concern with health care; self-examination; evaluation of signs and symptoms; knowledge of the body; control in food consumption, weight, metabolic levels, blood perfusion; moderate consumption of alcoholic beverages; dedication to work and the family; decrease in exposure to the risks of greater health problems, the emergence of diseases and aggravation of others already existing; elaboration of individualized forms of care; adequate coping with the effects and treatments of diseases; emission of healthy behaviors; positive coping with the disease and/or health problems; hydration; hygiene; independence for self-care; management of intrapersonal barriers to care; manifestation of emotions and feelings; maintenance of the practice of positive attitudes towards oneself, life, health status, good functioning of the body and continuity of care and healthy longevity; changes in health behaviors; objectification of care, health and life; personal organization and care routines; health promotion, physical, psychosocial and spiritual well-being and health prudence; recognition of the importance of health care; rest; subversion; personal and symbolic appreciation; zeal.Interpersonal: Adherence and regular monitoring of consultations and/or interventions and/or prescriptions and/or treatments and/or health-disease-aggravation therapies, implemented by professionals in health services; Adherence to available family support; Adoption of care with the home environment; Support received and provided to loved ones/family members; Care of the other; Care for sexual and reproductive health; Child and/or child care; Being with the other; Establishing relationships with and between people; Affective involvement and/or manifestation of affection; Establishment and strengthening of trust and family and socio-affective bond; Interaction with health professionals; Immunization; Modeling of good behavior with others; Practice of physical activity and/or physical exercises; Obtaining referrals from health services; Participation in activities offered in the health service ; Preservation of marriage and harmony of the home and health habits arising from conjugality; Medical search for diagnosis; Conducting diagnostic tests; Recreation and/or socialization with friends; Overcoming weaknesses caused by widowhood; Use of medications according to medical prescription and/or safe recommendation; Use of primary health services.Macrosocial: Access to attractions in the community; support received in the workplace; search for help from others; search for improvement in quality of life; sharing with the social other; collective coexistence; work performance; willingness to obtain social support; engagement in intellectual activities; involvement in social projects; exercise of good coexistence and company; strengthening with the social network; engagement in labor and union activities; structuring of modes for care, health and life; establishment of levels of care and health care; management of responsibilities towards the family; management of barriers imposed by daily, by work, by the health system and by economic/financial difficulties; maintenance of functional and work capacity; improvement of social skills; motivation to attend public spaces; participation of group activities in the community and/or educational groups; promotion of future reduction of spending on health; promotion of social and work well-being; provision of material resources for care to occur; preservation of the workforce; reduction of the pace of daily activities and work; overcoming patriarchal values and gender barriers, masculinities and other social character; use of informational support in access to guidance and instruments arising from social incentive; healthy life.Ecological: Agricultural cultivation; ecosophy; establishment and/or closer ties with the environment/earth; environmental preservation.Ethnic-racial: Racial self-affirmation; good ethnic coexistence; establishment of mechanisms for overcoming and combating racism and racial discrimination; strengthening of ethnic relationships; valuing knowledge, cultures and ethnic traditions.Transcultural (interaction with culture): Ancient knowledge transmitted from generation to generation; search for traditional knowledge; preservation of family traditions; overcoming cultural barriers; use of teas and products and/or natural and/or home remedies from traditional and/or ancestral popular knowledge.Transpersonal: Achievement of happiness; accumulation and/or acquisition of life experiences; well-being; search for help, assistance and/or spiritual and life healing; search for balance; going to church; participating in religious groups; promotion of spiritual well-being."The health care of men is a set of conceptions, attitudes and practices, which is structured individually and/or collectively in the intrapersonal, behavioral, interpersonal, macrosocial, ecological, cross-cultural, ethnocultural and transpersonal dimensions in a given socio-cultural and territorial inscription. This care is directed both individually and collectively to men and by themselves, based on the beliefs and expectations about the male being in the world. In the individual sphere and experience, care is manifested anchored in the notions of the productive and sexual body, in an intersubjective and psycho-emotional way, which involves values, self-recognition of the need to take care of oneself, singular experiences, search for personal fulfillment, ethnic agreement and transcendence. In the collective sphere, interpersonally care is manifested in interactions with its socio-affective network; community, environmental and culturally emerges and is expressed under the influence of the social construction of masculinities and femininities, of ecosystemic and socio-historical experiences”.From the identification of the attributes of the concept of “men's health care”, the stage of conceptual definition was carried out. The concept developed showed that the health care of men is based on previous references and is structured in male and female learning of gender, which outline attitudes, behaviors, stereotypes and practices that demarcate impressions of the place of man in the ways of being, of seeing himself, health, care, environment and life: [...] -When raising the essential attributes of the concept of men's health care, the expressiveness of existing phenomena was observed, which had different ramifications and origins, which led us to outline structures that were based on the dimensions of men's being and existence in a given socio-historical, cultural, gender and masculinities context, sexual identities, territory, schooling, age and generation, race/color/ethnicity, the world of work, daily and complex life and social class.-To develop the concept from the identification of essential attributes, it was noted in the material that there was a greater centrality and frequency of appearance of findings related to men's health care with regard to the set of actions, attitudes, characteristics, conceptions, components, state, motivations, orientations, perceptions, positions, feelings and experiences arising from the identity constructions of men. In addition, they were also linked to the principles, values, subjectivities, imaginary and intelligibilities that strongly guided the construction of habits and lifestyle in relation to health care.The health care of men reserves great centrality in the individual sphere of the subjects, which has a significant approximation with the hegemonic aspects of masculinities, when gender norms based on patriarchy and machismo are printed. Such findings may result in harm to the self-care of health by influencing the adoption of isolated, unsafe care measures, as seen in the context of male self-medicalization, the removal of this public from health services, resistance to adherence to health therapies and prevention strategies. ,-,,-,-,,,,,Although the studies were developed between the 1990s and 2000s, men of different ages were investigated, and even the most current studies, there was a marked nuance for the exercise of biophysiological care, corporeality.-,,-,,,-Regarding the dimension of interpersonal essential attributes, we observe the presence of communication phenomena, the relationship that men establish with and among people who are in their cycle and/or socio-affective network.-locus of social and political inscription.,-status and responsibilities required and the way these elements influence the health care of men-The essential macrosocial attributes are related to phenomena arising from occupation, family, socioeconomic level, culture, values and social ideologies and evolutionary relationships of intra and interpersonal character of society. Men's health care is closely linked to the dynamics of the world of work, social class, mobility, exchanges, social conflicts, as well as emerging from ways of life, everyday life and complexity. In this sense, the attributes reveal the emergence of processes such as assemblages, cultural influences, representations, life stories, objectification, organization, daily life, ethics, the health-disease process, health promotion, quality of life, social responses, routines, experiences and vulnerabilities.,,,,When trying to identify essential attributes and frame them in ecological dimensions, in which the presence of a health care interconnected to the habitat, the ecological niche and the intimacy of men with the maintenance of the ecosystem was observed, specific phenomena were glimpsed. In this way, the preservation of local customs, the position of being in community, ecosophy, the relationship with the physical and social, animal and vegetable environment, as well as the presence of the interrelationship with space, the world, nature, organisms and the earth, were identified.,(-),,,-,,-(53)It was also noted the incorporation of attributes related to ethnic and cross-cultural dimensions, seized in studies whose male population investigated was permeated by the influence of structural markers of age and generation - elderly men, territory - rural, riverside and peasant men and race/color - black men.The concept of men's health care involved the following dimensions/aspects: intrapersonal, psychological and behavioral related to masculinities, interpersonal, macro-social, ecological, ethnic-racial, cross-cultural and transpersonal. In addition, the impact of this study is based on the advancement of scientific knowledge on the subject and the potential for feasibility in generating contributions to health science and practice, whether from an epistemological and conceptual perspective, or to practice from the reformulation of public policies, orientation of the service and health care and construction of care technologies. The concept analyzed can be useful to support the practice directed to the health care of men in the various scenarios of action, in the field of nursing and health, strengthening the structuring of instruments for clinical care, teaching, research and development of public policies for men, considering the antecedents, attributes and consequences of the care of this population.


MEFV mutations. Up to now, however, no nationwide research of autoinflammatory diseases with standardized contents which can integrate with data of other international studies has been performed in Japan.In recent years, responsible genes for autoinflammatory diseases have been increasingly known and clinical phenotype-genotype correlations of these diseases have been explored through international clinical databases such as EUROFEVER project. However, clinical features of genetic disorders could be affected by countries and races of the patients. Actually, patients with Familial Mediterranean fever in Japan show the different distribution of both clinical features and We have established autoinflammatory diseases database in Japan. In this research, we designed this database for integration with that of EUROFEVER project in cooperation with Pediatric Rheumatology international trials organization. This integration will enable us to evaluate clinical features and genotypes of autoinflammatory diseases patients in Japan in comparison with the European patients, which will provide further evidences of these diseases, leading to appropriate diagnosis and treatment for the affected patients.Most of diagnoses of the patients with autoinflammatory diseases in Japan have been performed in the central specialized hospitals. In this research, we have collaborated all these hospitals and will collect the patients diagnosed as autoinflammatory diseases through these hospitals. In addition to the diseases devoted to EUROFEVER project, other candidate diseases such as Nakajo-Nishimura like syndromes are included. Inclusion criteria and database contents of the patients are designed by reference to that of EUROFEVER project. Patients’ information will be obtained from collaborated hospitals and the hospitals which actually will treat the patients. Before participation of this study, each collaborated hospital conformed to institutional review board of each hospital and the Declaration of Helsinki.Pilot study using paper-based registrations and questionnaires has been closed, and this analysis is ongoing. Now this research is in the transition to web-based system. We hope to show these results in Autoinflammation 2013.We have established autoinflammatory diseases database in Japan. This research is ongoing now.T. Kawai Grant / Research Support from: the Japanese Ministry of Health, Labor and Welfare, R. Nishikomori Grant / Research Support from: the Japanese Ministry of Health, Labor and Welfare, M. Awaya: None declared, K. Nakagawa Grant / Research Support from: the Japanese Ministry of Health, Labor and Welfare, K. Izawa Grant / Research Support from: the Japanese Ministry of Health, Labor and Welfare, T. Yasumi Grant / Research Support from: the Japanese Ministry of Health, Labor and Welfare, O. Ohara Grant / Research Support from: the Japanese Ministry of Health, Labor and Welfare, T. Heike Grant / Research Support from: the Japanese Ministry of Health, Labor and Welfare


Aquatic Biosystems. We welcome submission of original research manuscripts, reviews, and commentaries to the journal.Aquatic biological systems are a critical part of the structure and function of earth's biosphere. While attention of the scientific community is often focused on the reaction of biological systems to changes in the environment, these systems also have profound effects, or actions, on the environment. Throughout the evolutionary history of earth, the rise and/or fall of different aquatic biosystems has impacted the character of the biosphere. At no time have environmental changes been more important to all life on earth than in the modern era, which underscores the need for the new journal,  While the nature of the last common ancestor of all life remains enigmatic, geological evidence indicates the evolution of diverse prokaryotic microorganisms early in the earth's history. Around 3 billion years ago, the concerted metabolic activities of oxygen-evolving aquatic photosynthetic bacteria led to an oxygen-enriched atmosphere, and the development of a UV-protective ozone blanket, both of which provided the antecedents for an explosion of biological diversity and biomass. Two billion years later, the rise of larger and structurally more complex algae and aquatic plants provided new habitats and energy sources for the expansion of aquatic animal populations, which in turn formed the basis of new food webs.Subsequent shifts in the dominance structure of aquatic biological communities, driven in part by continental drift and sea level changes, influenced the chemical and geological character of the biosphere. A primary example of such a shift in dominance was the proliferation of planktonic coccolithiphores in the early cretaceous, leading to vast calcium carbonate deposits on the ocean floor and alterations in ocean chemistry. Modern studies of the ocean floor are leading to discoveries of complex communities, such as near hydrothermal vents and submarine brines, which may represent a snapshot of the early history of planet earth.Most recently, during the past few ticks of the evolutionary clock, the rapid surge in human population and development has reached a scale and dimension that can significantly alter the structure and function of aquatic biosystems, even on a global scale. The increasing and widening threats posed by the actions of human biosystems to the integrity and sustainability of aquatic biosystems highlight the importance of understanding how these systems function, and their resilience to environmental change. Understanding the aquatic microbial community and its effects on plants and animals is key to choosing a sustainable future. It is also important to place the reactions of aquatic biosystems to human actions within the context of non-anthropogenically-driven changes in the environment, such as climatic cycles.st century. Success will require open access to information and the concerted and long-term commitment of scientists, managers and policy makers. This commitment must extend to exploring innovative ways to prevent, minimize or reverse damage to aquatic biosystems, including the development of engineered biosystems aimed at renewable production of essential resources and mitigation of harmful waste materials, such as greenhouse gases, excess nutrients and pollutants. In other words, countering the consequences of negative actions with positive actions, in order to avoid negative reactions by critical aquatic biosystems.The complexity of this task will require the use of all available resources, including the wide range of technological capabilities driving basic and applied research in the 21Aquatic Biosystems. The scope of the journal ranges from the molecular and organismic levels to global systems and processes, reflecting the wide range of research in aquatic biological systems. The journal encourages reports on a wide array of environments, including lakes, rivers, marshes, springs, lagoons, solar pans, estuaries, and the open seas and ocean, and their micro- and macro-flora and fauna. The focus is on the relationships between the environment and biological systems, encompassing microbial genomics, physiology, and ecology, biogeochemical cycling, food webs, paleolimnology, biodiversity, conservation, resource management, and ecosystem structure and function. Engineered systems, such as for aquaculture, renewable resource, biofuels, biotechnology, and biomedical production, as well as constructed wetlands, are within the scope of Aquatic Biosystems.In order to facilitate communication across such an interdisciplinary spectrum, we launch the new Open Access independent journal named Aquatic Biosystems is to bridge across freshwater and saline systems, between basic and applied research, and from gene systems to ecosystems. The online Open Access format of the journal is designed to accelerate the process of disseminating important research results and information, in order to better meet the needs and demands of the highly dynamic and global science, management, and private sectors. We invite our international community of fellow scientists to contribute to Aquatic Biosystems.The goal of


The authors would like to acknowledge Matt Ardito and Annie De Groot of EpiVax, Inc.  for providing the predictions that were used to synthesize the tetramers. None of the authors are affiliated with EpiVax, Inc. Epivax, Inc. had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript, aside from the above-mentioned contribution. The authors have declared that no competing interests exist.


Francisella tularensis. The agent was named after Tulare County, California, where the agent was first isolated in 1910, and Edward Francis, an Officer of the US Public Health Service, who investigated the disease. Dr. Francis first contracted deer fly fever from a patient he visited in Utah in the early 1900s. He kept a careful record of his 3-month illness and later discovered that a single attack confers permanent immunity. He was exposed to the bacterium for 16 years and even deliberately reinfected himself 4 times.An infectious, plaguelike, zoonotic disease caused by the bacillus Tularemia occurs throughout North America, many parts of Europe, the former Soviet Union, the Peoples Republic of China, and Japan, primarily in rabbits, rodents, and humans. The disease is transmitted by the bites of deerflies, fleas, and ticks; by contact with contaminated animals; and by ingestion of contaminated food or water.Clinical manifestations vary depending on the route of introduction and the virulence of the agent. Most often, an ulcer is exhibited at the site of introduction, together with swelling of the regional lymph nodes and abrupt onset of fever, chills, weakness, headache, backache, and malaise.


That year there were many deaths in the village.Germs flew like angels from one house to the nextand every family gave up its own. Mothersdied at their mending. Children fell at school.Of three hundred twenty, there were eleven left.Then, quietly, the sun set on a day when no onedied. And the angels whispered among themselves.And that evening, as he sat on the stone steps,your grandfather felt a small wind on his neckwhen all the trees were still. And he would tell usalways, how he had felt that night, on the skinof his own neck, the angels, passing.Copyright 2004 by Lola Haskins. Reprinted from Desire Lines: New and Selected Poems, BOA Editions, 2004, by permission of the author and the publisher through American Life in Poetry, an initiative of Ted Kooser, the 2004-2006 poet laureate consultant in poetry to the Library of Congress; the American Life in Poetry project is supported by The Poetry Foundation, The Library of Congress, and the Department of English at the University of Nebraska-Lincoln.


Environmental Health Perspectives in 2004  for Meat, Poultry, and Egg Products, administered by the USDA [U.S. Department of Agriculture] FSIS, is an interagency program designed to identify, rank and test for chemical contaminants in meat, poultry, and egg products.They continue,The NRP requires the cooperation and collaboration of several agencies for its successful design and implementation. The USDA FSIS, the EPA [U.S. Environmental Protection Agency], and the Department of Health and Human Services (DHHS) FDA are the primary federal agencies managing this program. The FDA, under the Federal Food, Drug, and Cosmetic Act, establishes tolerances for veterinary drugs, and action levels for food additives and environmental contaminants. The EPA, under the Federal Insecticide, Fungicide, and Rodenticide Act , establishes tolerance levels for registered pesticides…. Representatives from FSIS, FDA, EPA, the USDA Agricultural Research Service (ARS), the USDA Agricultural Marketing Service (AMS), and the DHHS Centers for Disease Control and Prevention (CDC) collaborate to develop the scheduled sampling program.Setting and enforcing safety levels involves several steps, one of which is the collection of meat and poultry samples, followed by statistical analysis, interpretation, and action. The NRP sampling plan is designed to identify samples with residues above the allowed levels. The data are then analyzed as categorical values . Current methods of data analysis do not include estimation of mean values that can then be extrapolated to the national food supply. It was by analyzing the data as a continuous variable that my coauthors and I were able to describe the high levels of arsenic in chicken in 2004 .Concerns about arsenic levels in chicken are of increasing importance because of the increased per capita consumption of chicken over the past decade .


The understanding of the decision-making process in the introduction of new vaccines helps establish why vaccines are adopted or not. It also contributes to building a sustainable demand for vaccines in a country. The purpose of the study was to map and analyze the formal decision-making process in relation to the introduction of new vaccines within the context of health policy and health systems and identify the ways of making decisions to introduce new vaccines in Bangladesh. During February-April 2011, a qualitative assessment was made at the national level to evaluate the decision-making process around the adoption of new vaccines in Bangladesh. The study population included: policy-level people, programme heads or associates, and key decision-makers of the Government, private sector, non-governmental organizations, and international agencies at the national level. In total, 13 key informants were purposively selected. Data were collected by interviewing key informants and reviewing documents. Data were analyzed thematically. The findings revealed that the actors from different sectors at the policy level were involved in the decision-making process in the introduction of new vaccines. They included policy-makers from the ministries of health and family welfare, finance, and local government and rural development; academicians; researchers; representatives from professional associations; development partners; and members of different committees on EPI. They contributed to the introduction of new vaccines in their own capacity. The burden of disease, research findings on vaccine-preventable diseases, political issues relating to outbreaks of certain diseases, initiatives of international and local stakeholders, pressure of development partners, the Global Alliance for Vaccines and Immunization (GAVI) support, and financial matters were the key factors in the introduction of new vaccines in Bangladesh. The slow introduction and uptake of new vaccines is a concern in the country. Rapid action on the application of GAVI support and less time taken by the Government in processing the implementation and administrative work may expedite the introduction of new vaccines in future in this country. Immunization, a proven tool for controlling and eliminating life-threatening infectious diseases, can avert 2-3 million deaths each year globally. It is one of the most cost-effective health investments . UniversHaemophilus influenzae type b (Hib), hepatitis B (Hep-B), pneumococcal conjugate vaccine (PCV), and rotavirus vaccines are particularly geared toward children of developing countries where the burden of disease is high . New vaccines tend to be considerably more expensive than existing vaccines, and some targeted diseases are relatively ‘hidden’ and, therefore, may lack demand from public and political perspectives . The sloTo control the vaccine-preventable diseases, the Government of Bangladesh has been working to expand the EPI by introducing new vaccines. Bangladesh introduced the pentavalent Hib vaccine in January 2009 to prevent severe child pneumonia and meningitis. However, the formal decision-making process in relation to the adoption of vaccines was never studied in Bangladesh. The purpose of the present study was, therefore, to map and analyze the formal decision-making process in the introduction of new vaccines within the context of health policy and health systems and identify the ways of making decisions to uptake new vaccines in the country.During February-April 2011, a qualitative assessment was made at the national level to assess the decision-making process in relation to the adoption of new vaccines in Bangladesh.For policy analysis of the decision-making process in the adoption of vaccines, the study included: policy-level people, programme heads or associates, and key decision-makers of the Government, private sector, non-governmental organizations (NGOs), and international agencies at the national level.In total, 13 key informants were purposively selected from relevant government, non-government and international agencies, and most informants were the members of any or more committees on EPI.Data were collected by interviewing key informants and reviewing secondary documents.Key informant interviews: Considering the complexity of the decision-making process as it is driven by many different factors and involves multiple actors, the key informants were selected from the Ministry of Health and Family Welfare (MoHFW); Ministry of Local Government, Rural Development & Co-operatives (MoLGRD); Ministry of Finance; Directorate General of Health Services (DGHS); EPI; Dhaka City Corporation; World Health Organization (WHO); United Nations Children's Fund (UNICEF); representatives from different committees, including National Committee for Immunization Practice (NCIP), Scientific and Technical Sub-committee (STSC), Inter-agency Coordination Committee (ICC), National Steering Committee for Polio Eradication and Measles Control (NSCPEMC), and NGOs. Data were collected from the actors involved in decision-making on the following: time taken in decision-making, factors that influence decision-making, decisions on financing and barriers faced in the introduction of new vaccines, steps taken to solve the problems, why vaccines are adopted or not, and demand for new vaccines.Review of secondary documents: Secondary documents relating to the adoption of new vaccines were collected and reviewed. Types of documents reviewed included: comprehensive multi-year plan of the national immunization programme of Bangladesh for 2006-2010 and 2011-2016, systems research relating to EPI, policy analysis-related documents on new vaccines, immunization surveillance system-related documents, unpublished documents relating to upcoming vaccines, and minutes of meetings of different committees.Secondary data: Evidence from the review of policy documents provided general information necessary to describe the general context and introduction of new vaccines.Analysis of qualitative data: Analysis of qualitative data began following the initial data collection from the field and led to refinements as the study progressed. The interviewers prepared transcripts after the completion of each interview. At first, the transcripts were carefully read, the main findings were listed, and then the coding of main findings was carried out. After reading, re-reading, and coding the texts, the main themes were begun to formalize. Each theme was then examined separately and fully within the available data.The respondents were interviewed after obtaining their informed consents. Efforts were made to ensure that all respondents were properly informed about the study and they thoroughly understood their involvement. Participation was voluntary. The participants were ensured that refusal would have no adverse consequences for them. They were also assured that the information provided by them would be used for research purposes only and would not be shared anywhere by their names. Interviews were conducted according to the convenience of the respondents.The Research Review Committee and Ethical Review Committee of icddr,b approved the study before its implementation.The Government of Bangladesh is the main actor in making decisions on the introduction of new vaccines. The respondents mentioned that the key people involved in decision-making are: Director, Primary Health Care (PHC); Programme Manager, EPI; and Director General, DGHS. Their roles included the formulation of policy about the implementation of the existing EPI vaccines and taking initiatives for the introduction of new vaccines. They are also the key persons in all national-level EPI-related committees. The Joint Secretary, PHC-WHO at the MoHFW and the Joint Secretary, Budget, at the Ministry of Finance are particularly important. Although they do not participate in different forums relating to the introduction of new vaccines, their signatures in the Global Alliance for Vaccine and Immunization (GAVI) application for the introduction of new vaccines are essential.According to the key informants, the academicians also play important roles in introducing new vaccines. The academicians included professors of paediatrics, immunology, virology, and liver transplantation. Most respondents reported that high value is given to the opinions of the academicians in relation to the introduction of new vaccines. They stated that, if the specialists and academicians do not agree with the introduction of any vaccine, the concerned authority would not approve its introduction.All the informants reported that the introduction of new vaccines is determined based on scientific evidence. They stated that researchers and scientists are very important in providing scientific information on the need for the introduction of new vaccines. Most respondents mentioned the contribution of researchers in the introduction of the Hib vaccine. They said that, before the introduction of the Hib vaccine, good data were available to understand the burden of disease. According to them, a survey was conducted by the international research institutions and medical colleges. Findings of studies provided information on the burden of diseases and the need for the introduction of Hib vaccine. They shared the findings with the policy level, which influenced the introduction of the vaccine in the country. The respondents informed that the researchers conduct studies and make recommendations to determine which vaccine should be introduced on a priority basis.Representatives from different professional associations play an important role in the introduction of new vaccines. The associations included: Bangladesh Paediatric Association, Bangladesh Medical Association (BMA), and Bangladesh Hepatological Society (BHS). Some of them are members of different committees on EPI, and they influence in introducing a new vaccine. One respondent said:You know.…BHS has been pressurizing the Government to introduce Hep-B birth dose. At a certain point, our Hon'ble Health Minister became convinced about it, and he is in favour of introducing it at least at the facility level before its introduction at the outreach centres.The informants stated that the media generally do not have a major role in the introduction of new vaccines. The media play roles in the implementation of a new vaccine but their role in decision-making is minor. Normally, the vaccines are introduced in phases. The respondents mentioned that the reason for the lower level of influence of the media is that, if the media are involved in decision-making, they may publicize about the vaccine all over the country, which may create confusion among the people.All key informants reported that the development partners, especially WHO, UNICEF, and GAVI, play important roles in introducing a new vaccine in Bangladesh. The other development partners, such as World Bank, USAID, and UK-AID, are also the key actors in this regard. WHO and UNICEF provide technical support to Director, PHC and Programme Manager, EPI, about initiation and preparation of GAVI application, capacity assessment of cold-chains, and implementation of a new vaccine. Some key informants stated that the role of WHO and UNICEF is more important than the Government in terms of the introduction of new vaccines. They said that no matter whether the Government is interested or not but if WHO desires, they can introduce a vaccine in BangladeshIn response to a question about the role of GAVI, the respondents mentioned that the GAVI mainly provides financial support for the introduction of new vaccines. They also added that the GAVI has some priority vaccines to introduce. If their requirements are fulfilled, they support us and provide vaccines.The GAVI funds are used under the guidance of ICC. The ICC consists of members from different governments and NGO stakeholders. Secretary, MoHFW, is the chairperson of the committee. Other members include: Director General of DGHS; Director General of Family Planning (DGFP); Joint Secretary (PHC and WHO); Programme Manager, Child Health and Limited Curative Care; and Deputy Secretary of the MoHFW. The members of the ICC from other sectors include: Joint Secretary, Local Government Division, MoLGRD; Joint Secretary, Finance Division, Ministry of Finance; Director  of the Ministry of Environment; Secretary, National Polio Plus Committee of Rotary International; development partners, such as WHO, UNICEF, USAID, World Bank, UK-AID, JICA, Royal Netherlands, and Sida; representatives from NGOs; and others, such as icddr,b, Save the Children-USA, Immunization Consultant, and GAVI. ICC is part of the decision-making body in the introduction of new vaccines.In Bangladesh, the NCIP formulates policy and monitors the EPI. It is the final body for taking steps in the introduction of new vaccines. The committee is chaired by the Secretary of MoHFW. Other members of the committee include: Director General, DGHS; Director General, DGFP; Joint Secretary ; Joint Chief (Planning); and Directors and Programme Managers, EPI, MoHFW. Other members also include professors at different medical colleges, representatives from professional associations, and development partners. The committee plays a vital role in making decisions on the introduction of new vaccines.Under the supervision of the NCIP, the STSC has been formed to review the policy of EPI. Director General, DGHS, is the chair of the committee. Other members of the committee include: Directors of National Institute of Preventive and Social Medicine (NIPSOM), Institute of Epidemiology, Disease Control and Research (IEDCR), PHC, Maternal and Child Health, MoHFW; Professors at medical colleges; Programme Manager, EPI; representatives from professional associations; and representatives from WHO and UNICEF. The issue of introduction of new vaccines is first discussed in this committee for further processing.Information on the burden of disease from research organizations leads to initiation of the process of introducing a new vaccine. Whenever information on the burden of disease comes from researchers and the Government and other technical personnel become convinced, the Government starts the process of introducing a new vaccine. The first step in the process of introducing a new vaccine is to discuss it in the STSC. The STSC also discusses about the possible funding sources, GAVI support, cold-chain capacity, and sources of other support in introducing the vaccine. If the STSC is satisfied and approves, a proposal is sent to the NCIP for its approval. Whenever the approval is provided from the NCIP, steps are taken to apply for GAVI support for the introduction of the vaccine. Before submitting the GAVI application, the ICC must endorse the proposal .The respondents informed that whenever the NCIP and ICC approve the introduction of a new vaccine, the EPI headquarter starts the preparation of GAVI application for support. After receiving the complete application, the GAVI reviews it and sends it back with their comments and queries for clarification. After having satisfactory responses to their comments, the GAVI approves the application for the introduction of a new vaccine .The respondents actively involved in the preparation and submission of the GAVI application informed that almost two years are normally required to start the implementation of a vaccine after the submission of an application to the GAVI. The GAVI generally sends their comments six months after receipt of an application. It also takes some time to address the comments provided by the GAVI and resend the application to them. After resubmission of the application, it requires again around six months for the GAVI to take a decision and inform of their approval. According to the respondents, almost another one year is required to complete all the formalities and administrative work to start the implementation of the vaccine. The respondents from the EPI informed that they submitted an application to the GAVI for its support for the introduction of the Hib vaccine in 2007 in Bangladesh, which was finally implemented in 2009.The prevalence and burden of disease, findings of research on vaccine-preventable diseases, active participation of all key stakeholders, political issues relating to outbreaks of certain diseases, initiatives from international and local stakeholders, pressure from development partners, financial matters, and the GAVI support are the key factors that influence the introduction of new vaccines in Bangladesh. All the key informants stated that the GAVI, WHO, UNICEF, and other development partners have influenced the introduction of new vaccines. These international stakeholders not only influence by financing the introduction of new vaccines, they also provide technical support to the Government for the introduction.The political issues relating to the outbreaks of certain diseases also influence decision-making. Some key informants stated that, in 2009, the newly-formed political government felt certain pressure of the Haemagglutinin type 1 and Neuraminidase type 1 (H1N1) pandemic in Bangladesh. At that time, the H1N1 pandemic became a political issue through the media coverage. Without any analysis of mortality and morbidity due to H1N1, the Government had to take decision to bring the H1N1 vaccine in the country to reduce the public panic prevalent at that time.Most respondents stated that the financial factor is important for introducing new vaccines because new vaccines are usually more costly than the traditional vaccines. For introducing any new vaccine, the Government needs support from the development partners, particularly from the GAVI. The respondents also acknowledged the GAVI's contribution to two vaccines previously introduced, such as Hep-B and Hib. They stated that the Government can co-finance in introducing the new vaccines.In Bangladesh, while introducing new vaccines, decisions are jointly taken by the Government, academicians, researchers, representatives from different professional groups, and development partners. The Government, however, plays the key role. Without the contributions of other groups mentioned above, new vaccines might not be introduced in the country. The MoHFW initiates and forwards the GAVI application for a new vaccine after being vetted by the expert academicians. The researchers help the Government by providing relevant information to the policy-makers on the burden of disease, gathered from different studies and demand for new vaccines. The professional groups contribute to providing expert opinions about the introduction of new vaccines. The development partners, especially WHO and UNICEF, provide technical support to the concerned department of the MoHFW in the initiation and preparation of GAVI application, assessment of cold-chain capacity, and implementation of a new vaccine. The study participants mentioned that the role of WHO and UNICEF is remarkable in the introduction of new vaccines. All the actors work with positive attitudes toward the introduction of new vaccines. No negative attitude was observed among any actor involved in the introduction process of a new vaccine.The process of introducing a new vaccine contributed to establishing a formal procedure in Bangladesh. Whenever information on the burden of disease becomes available from researchers and the Government and other technical personnel are convinced, the Government starts the process of introducing a new vaccine. The first step in the process is to discuss it in the STSC. The STSC also discusses about the possible funding sources, GAVI support, cold-chain capacity, and support from other sources in introducing the vaccine. If the Sub-committee is satisfied and approves, a proposal is sent to the NCIP for its approval. When the approval of the NCIP is accorded, steps are taken to apply for GAVI support for the introduction of the vaccine. Before submitting the GAVI application, the proposal has to be endorsed by the ICC. This formal procedure became structured and functional while introducing the Hib vaccine in Bangladesh in 2009.The findings of the present study have shown that about two years are generally required to introduce a new vaccine after the submission of an application to the GAVI. The GAVI generally takes six months to send their comments to the Government. A considerable time is also needed in the resubmission of the application and making a decision by the GAVI. The findings of the study revealed that, after according approval by the GAVI, one year was required to complete all formalities and administrative work to start the implementation of the Hib vaccine. The slow process in the introduction and uptake of new vaccines is, thus, a concern in Bangladesh.The prevalence and burden of a disease, research findings on vaccine-preventable diseases, political issues relating to outbreaks of certain diseases, initiatives from international and local stakeholders, pressure from the development partners, and financial matters are the key factors in the introduction of new vaccines in Bangladesh. The GAVI, WHO, UNICEF, and other development partners influence the decision in the introduction of a new vaccine. Political issues relating to the outbreaks of vaccine-preventable diseases also influence in making decisions. The Government needs financial support from the development partners, particularly from the GAVI, for introducing a new vaccine,. The issue of co-financing helped the Government take over the vaccine cost gradually. Therefore, the system of co-financing may be considered while introducing new vaccines in the country.The GAVI Alliance's initiative to introduce new vaccines in Bangladesh is of utmost importance for children of the country. The role of Alliance in providing financial and technical resources for this purpose is crucial, especially given the high costs of such vaccines .The findings of the study indicate that slashing the funding gaps for immunization and achieving financial sustainability will require several important actions in Bangladesh. For instance, a larger public-sector budget resulting from economic growth, greater government commitments to immunization within health budgets, greater multi-year commitments from donors, reduction in vaccine prices, and a major sustained effort by the GAVI Alliance to support Bangladesh to introduce new vaccines and to permit sufficient time and planning for a transition away from GAVI support may enable Bangladesh to become financially self-sustainable. Findings of others suggest similar actions for poor countries ,18.The burden of disease, findings of research on vaccine-preventable diseases, political issues relating to outbreaks of certain diseases, initiatives of international and local stakeholders, pressure from the development partners, GAVI's support, and financial matters are the key factors in the introduction of new vaccines in Bangladesh. To expedite the introduction and uptake of new vaccines, it is important that the GAVI takes rapid action on the application for its support and the Government takes less time to complete the administrative work.The study was funded by the London School of Hygiene & Tropical Medicine (LSHTM), (Grant No. 803). icddr,b acknowledges with gratitude the commitment of LSHTM to its research efforts. The authors thank all key informants for their participation in the study. The authors also thank Mr. Wazed Ali, Senior Field Research Officer, icddr,b, for his assistance during data collection and writing of the manuscript.


There is a grammatical error in the Funding section. It should read: This project was generously supported by Parks Canada, the Western Transportation Institute-Montana State University (WTI), the Woodcock Foundation, the Henry P. Kendall Foundation, and the Wilburforce Foundation. Other support was provided by the National Fish and Wildlife Foundation, Alberta Conservation Association, Calgary Foundation, and the Mountain Equipment Cooperative. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


Memories can be the most precious of possessions. Today I write about over 50 years of my journey with allergy. More than naming my field of specialization, allergy has been my passion, and has become, in its way, my own life's companion.My journey of love with allergy began in 1960 at the Royal Victoria Hospital in Montreal, Canada. I believe I was the first Asian to have trained under the legendary Dr. Bram Rose, a brilliant disciplinarian who was then President of the American Academy of Allergy . My husband, Dr. Manuel Lim, had begun his training in Otolaryngology at the Royal Vic under Dr. James McNally the year before. Manuel had made an appointment for me with Dr. Rose that July. I will never forget my first meeting with Dr. Rose in his office. His directives to me, a young fellow about to embark on a career in allergy, were blunt, to say the least: "When you do not know the answer, say that you do not know it; and when you are not sure, say nothing. I cannot stand people who talk through their______." His colorful words are forever carved in my memory, because they amounted to a rigorous standard for working in our specialty: be accurate, tolerate no nonsense. In the decades to come, I learned to fully appreciate my training under Bram  , I owe what I am today. They form the pillars of my professional life.I was allowed to see patients after a month at Royal Vic, and after 3 months I became part of the team, presenting at journal clubs and joining research. In September 1960, 6 months after my arrival at Royal Vic, Bram sent me with the "boys" to Washington, DC, to attend my first American Academy of Allergy meeting at the height of winter. A generous mentor, Bram introduced me to luminaries of allergy in the 1960s , and to younger physicians who would become famous in the years to come . This early mentorship and collegiality sparked an intense desire for the pursuit of knowledge in allergy, a solid foundation for what I could become as an allergist.In 1961, Bram gave me a grant to attend my first International Association of Allergology and Clinical Immunology (IAACI) convention. It was a thrilling and terrifying experience for me, because all the "giants" in the field  were in attendance at New York City. In fact, the IAACI, now the World Allergy Organization (WAO) has become a tradition for me: I have not missed a meeting since 1967, the year when I also became Fellow of the American Academy of Allergy. A year after I qualified for the American Board of Allergy and Immunology in 1975, Dr. Alec Sehon nominated me to serve as member-at-large of the IAACI Executive Board a year later. It was a great privilege for me to be the first female physician to sit on the IAACI board.Let me now switch gears and describe the early decades of our specialty in the Philippines. I returned to my homeland from my training in Royal Vic in June 1963, and my arrival caused quite a stir. At that time, allergy was still considered a "controversial subspecialty." Asthmatics were in the hands of pulmonologists, patients with atopic eczema/dermatitis and urticaria were being seen by dermatologists, and those suffering from allergic rhinitis were treated by Otolaryngologists. In such a situation, my friends in Manila worried about my potential patient base as an allergist. In fact, at one of my first public lectures on allergy, our specialty was dismissed by a prominent Philippine University's Chair of Dermatology who stated that "allergy is a waste basket diagnosis." I was crushed, but Dr. Arturo B. Rotor, my country's first trained allergist and Assistant Dean of the University of the Philippines' College of Medicine, defended my presentation as a concise summary of the state of the field. Encouraged, I began consulting with Dr. Rotor about my idea of organizing a national society of allergy, but at that point, such a dream seemed unrealistic since there were only 5 allergists in the country.The discovery of IgE by Professors Bennich and SGO Johannson Figure  and KimiThe 1970s were a formative period for allergy in the Philippines. In the early 1970s, with the help of palynologist Dr. Pacifico Payawal and pharmacist Gloria Laserna, both formerly with the National Science Development Board (NSDB), I conducted pioneering pollen surveys in 5 regions of the Philippines and mold surveys in Metro Manila. I conducted these studies because, as Oren Durham once said, "the allergist must know his pollens." Morris Webb of Hollister-Stier laboratories and Dr. Bob Esch of Greer laboratories created extracts from the local pollen fiora I supplied, while with the help of Dr. Vin Bristow, the Commonwealth laboratories of Australia, Dr. John Trinca, and Kathy Stringer, we were able to analyze and identify Philippine house dust mites. Three pioneering Filipino allergists  disseminated the knowledge of allergy and immunology to urban centers and rural towns in the Philippines, using chalkboards and mimeographed handouts, speaking to both friendly and pessimistic audiences of various religious and ideological groups. A handful of pioneering researchers on allergy represented various Philippine universities: myself and Dr. Noche of the University of Santo Tomas (UST), Dr. Agbayani and Dr. A. Lingao of the University of the Philippines (UP), and Dr. Manuel Ferreria of Manila Central University. I also remember Dr. Avelina Bacnis for her principles and discretion. A Secretary of PSAI for more than ten years, Dr. Bacnis refused to be elected President. And I appreciate the contributions of another of the ten founding members of PSAI, Dr. Amelia Ochoa-Bulmer, who served as Secretary-Treasurer of PSAI and who is currently in private practice in the Philippines. At present, research is being carried on by a younger generation of Filipino allergists, among them, Dr. Agnes Gonzales-Andaya and Dr. Remedios Ong at UST, Dr. Madeleine Sumpaico at UP-Philippine General Hospital, Dr. Manuel Po and Dr. F. Padua at Fe del Mundo Medical Center and National Kidney and Transplant Institute. The PSAI became a member of the IAACI in 1976 and today, what is now called the Philippine Society of Allergy, Asthma, and Immunology (PSAAI) has nearly a hundred members. The PSAAI is in very good hands.One of PSAAIs greatest accomplishments, to my mind, is our hosting of the 1998 Third Asia Pacific Congress of Allergology and Clinical Immunology in Manila. Graced by the presence of then WAO president, Prof. SGO Johannson, and over 30 international speakers, the Congress drew a record number of attendees, with over 1300 participants from all over the world. I remain incredibly grateful to WAO for honoring me in Munich, Germany with the 2005 Outstanding Clinician Award; this was the greatest surprise of my life, and to this day I feel humbled, honored, and privileged to be so recognized. In coming to the final section of this editorial , I would like to thank Professor Lanny Rosenwasser and Sofia Dorsano for their invitation to contribute my perspective on changes in our field and the continuing importance of global exchanges to our specialty. In that spirit, I would like to offer these observations and recommendations:I would like to see the WAO continue to play a formative part in encouraging the development of national allergy societies throughout the world. For nations in what used to be called the "Third World" and is today referred to as the "Global South, " honoraria for the most distinguished and sought-after international speakers can be prohibitive. WAO's help in this regard--either through cosponsorship of speakers or organizing volunteer lecturers to speak at national allergy societies overseas--could make a crucial difference. WAO, through the World Allergy Forum and (GLORIA), has already been giving grants to national allergy societies of at least one speaker for their conventions, and I would like to see such grants expanded. A tandem between a clinical allergist and a clinical immunologist would be ideal. Locally, I believe that continuing medical education credit requirements should be mandatory for the national medical societies.In an era of transnational economic recession, many allergists who would like to attend international conventions may be barred from doing so by financial considerations. Discounts could be given to delegates from developing nations and perhaps, like the AAAAI and ACAAI, seniors  could be offered free or discounted registration. In the Philippines today, both government grants and pharmaceutical sponsors rarely underwrite the travel costs of delegates to international medical conventions; in the few occasions when they do, they tend to prioritize infectious diseases and cardiovascular and endocrine disorders to the detriment of immunology and allergy.Dr. Allen Kaplan and Dr. Carlos Baena-Cagnani, both Past Presidents of WAO, were among the first to voice the ideal of a global exchange of ideas on allergy, allowing poor and wealthy nations alike to share ideas. In my view, national allergy societies play a crucial role in both national and global exchanges, providing critical education and training for specialists and allowing collegial partnerships and discussions with other specialists. By eludicating proper management techniques, such national and transnational fora ultimately help to improve the quality of life for our patients.Felicidad Cua-Lim, MD  is the Founding President of the Philippine Society of Allergology and Immunology (1972-1978) and has served as Honorary President of the Philippine Society of Allergy, Asthma, and Immunology from 2000 to the present. She was also Founding Chair of the National Asthma Movement (1994-1996), President of the Philippine College of Physicians (1996-1997), and President of the Asia Pacific Association of Allergology and Clinical Immunology (1998-2000). In addition to being named Outstanding Clinician by the WAO in 2005, she was honored as Outstanding Physician of the Year by the Professional Regulation Commission in 1984, Honorary International Distinguished Fellow by the American College of Allergy and Immunology in 1990, and Most Distinguished Physician by the Philippine College of Physicians in 2002. She taught at the University of Santo Tomas for 40 years, retiring as Professor 1 in 1995.


The aim of this study was to analyze the influence of filters  to improve the image of Cone Beam Computed Tomography (CBCT) in diagnosis of osteolytic lesions of the mandible, in order to establish the protocols for viewing images more suitable for CBCT diagnostics. 15 dry mandibles in which perforations were performed, simulating lesions, were submitted to CBCT examination. Two examiners analyzed the images, using filters to improve image Hard, Normal, and Very Sharp, contained in the iCAT Vision software, and protocols for assessment: axial; sagittal and coronal; and axial, sagittal and coronal planes simultaneously (MPR), on two occasions. The sensitivity and specificity  of the cone beam computed tomography (CBCT) have been demonstrated as the values achieved were above 75% for sensitivity and above 85% for specificity, reaching around 95.5% of sensitivity and 99% of specificity when we used the appropriate observation protocol. It was concluded that the use of filters  to improve the CBCT image influences the diagnosis, due to the fact that all measured values were correspondingly higher when it was used the filter Very Sharp, which justifies its use for clinical activities, followed by Hard and Normal filters, in order of decreasing values. According to the parameters published by the American Academy of Oral and Maxillofacial Radiology (AAOMR), criteria should be used by dentists who are responsible for the clinical management of patients with anormalities in the oral and maxillofacial region .Although the combination of conventional projections and panoramic radiographs is appropriate in a large number of clinical situations, radiographic assessment can often be facilitated by multiplanar image viewing, including the computed tomography images , 3.Furthermore, technological evolvement results in improvement of diagnosis of bone lesions. In this regard, filters of refining the image can be used to further enhance CBCT images, producing better diagnosis of osteolytic lesions of the jaws. The evaluation of the presence of bone destructions is fundamental, since it directs the prognosis, planning, and conducting of the therapeutic process.Following these statements, the purpose of this study was to analyze the impact of image filters and observations parameters in diagnostic enhancement of CBCT image, in order to establish protocols for CBCT interpretation, regarding the scope of mandibular osteolytic lesions diagnosis.in vivo situation, the specimens were installed in a plastic container containing about 1 liter of water, so as to be totally submerged. Subsequently, the tomographic acquisition was performed using a cone beam device iCAT cone beam 3D dental Imaging System , with the following acquisition parameters: 0,25 mm of voxel size and 40 seconds of time of acquisition.The sample consisted by CBCT scans of 15 dry mandibles, in which lesions were produced involving only cortical or cortical and medullary, using a high-speed hand piece with dental carbide burs . The lesions were located in the buccal or lingual cortex of the mandibular body, and they presented different dimensions, shapes, and loci numbers, depending on the size of the used burr, in order to simulate uni- and multilocular lesions. In order to simulate the attenuation caused by soft tissue in an After acquisition of RAW data, the images were stored in natively universal DICOM format to avoid data loss and transferred to workstation located in an environment adjacent to console. Original volumes of CBCT scans were examined by two examiners, radiologists with previous experience in reports of CT scans, independently, who analyzed the images in the iCAT Vision software (version 1.6.20), without prior knowledge of any information on the simulated lesions, and the interpretation followed the principle of randomization of the images, on a personal computer, according to the established protocols of observation, on two occasions with an interval of seven consecutive days between assessments. The evaluation of artificial bone perforations followed the protocol of interpretation and was always the same for all images taken by the same examiner.All assessments were conducted individually and sequenced (a filter to improve the image at a time) for each examiner and images in question, under controlled light and environment free of external stimuli. evaluation of images obtained by CBCT acquisition on axial images with the use of following filters: hard, normal, and very sharp, through the program iCAT Vision in an independent workstation; evaluation of images obtained by CBCT acquisition on coronal and sagittal protocols with the use of the same sequence of image filters; evaluation of images obtained by CBCT acquisition on axial, coronal, and sagittal protocols simultaneously (MPR) with the use of the same sequence of image filters.The sequence analysis of the images complied with the following protocols:During the study of the images, only the studied image plane was displayed on the computer monitor, remaining the other pictures hidden using tools available in the program, in order to avoid interference in the assertion of presence or absence of mandibular lesion. Then, data were recorded properly for subsequent statistical analysis.P < 0.5).The statistical evaluation was performed by using validity test (sensitivity and specificity), positive predictive value (PPV), negative predictive value (NPV), and accuracy , to estaIn order to check the reproducibility of the method above, testing intra- and interobserver agreement, were obtained Kappa scores including obtaining an interval of 95.0% of confidence for the population Kappa.The significance level used in the decision of the statistical test was 5%. Data were entered via Excel 2007 spreadsheet, and the software used to obtain statistical calculations was SPSS version 17.0 for windows  [This work was submitted to the Ethics Committee of FOUSP under number 149/03, protocol 151/03.Tables Tables The cone beam computerized tomography (CBCT) was a big step in the improvement of CT examinations in dentistry, because the proposed improvements added quality to the image, facilitating diagnosis, and also increase the study, the facility, and the interest of dentists , 6. The use of cone beam computed tomography as a tool to perform morphologic and morphometric studies of the mandible is due to the advantages of this type of scan features, such as the observation of an extensive region of the mandibular arch, including areas and anatomical structures adjacent to the mandibular canal, allowing a precise analysis of the tract and its relationship with anatomical reference points , 8.The use of reduced thicknesses cut and reduced sizes of voxels in CBCT allows greater sensitivity and specificity –11.Our results found, in general, sensitivity above 75% and specificity above 85% Tables to 4. AcThe use of more advanced algorithms and the greatest number of visualization tools have an important role in determining the number of bone lesions in the jaws, as well as improving the process of diagnosis and treatment –17, thusSuomalainen et al., in 2008 , said th initial screen display: hard filter for all images, screen for planning implants: hard filter for all images, screen for ATM viewing: hard filter for the 3 first images and normal filter to Condyle images in preview mode Ortho, MPR screen: normal filter for all images, Cephalometric screen (Ortho view mode): very sharp image filter for left and right top images and hard filter for all others.According to the manual of use of the iCAT Vision software, patterns of use of filters to improve the images to be followed are the following:According to the results obtained in our research, Normal filter was inferior for the visualization and detection of simulated osteolytic lesions in the jaws.The use of filters  to refining the image is critical for sensitivity and specificity involved in the diagnosis of lytic areas of the jaws. The evaluation of the presence of bone destruction is very important, since it directs the prognosis and the planning and conducting of therapeutic process. High-resolution iCAT CBCT images resulted in an increase in sensitivity without jeopardizing specificity .Observation protocols play an important role in the analysis of mandibular bone lesions. The junction of viewing plans (MPR), in our study, shows excellent values of sensitivity, specificity, and accuracy, with respect to the assertion of the presence of simulated osteolytic lesions .Analyses were done by regions of the mandible , and with regard to verification of the presence of bone lesions, the values of the measures were correspondingly lower for lesions located in the lingual and higher for lesions found on the buccal .In the present study, stands out the agreement between the examiners, in each assessment, with the gold standard, which ranged from 84.3% to 89.3%, whereas the agreement of each examiner was higher at the second moment of your assessment. Kappa values ranged from 0.77 (good agreement) to 0.84 (excellent agreement) .In the evaluation of intraobserver agreement in the assessment of loci number, In the evaluation of interobserver agreement  comparedin vitro study, and based on the values found, it can be a basis for further studies, including those performed in vivo.The analysis of intra- and interobservers kappa values showed excellence in most of the results, demonstrating the reproducibility of the method used. Thus, this was an  The sensitivity and specificity  of cone beam computed tomography (CBCT) for diagnosis of osteolytic lesions (simulated) in the mandible, using standalone workstation, was shown. The influence of filters  to improve the CBCT image was confirmed, and the very sharp filter was higher, which justifies its use for clinical activities, followed by normal and hard filters, in order to decrease values. The best protocol for visualization the simulated osteolytic lesions was the MPR.


The aims were to identify whether there is burnout and the burnout levels of doctors and nurses working in ICUs . Also, to identify factors that may lead to the development of burnout in doctors and nurses working in the ICU.Application of a self-completion questionnaire with three items: the sociodemographic data of the study population, experiences in the workplace, and the Maslach Burnout Inventory - General Survey (Portuguese Version for Investigation 2006). For the implementation of methodological tools, we requested the authorization of the relevant institutional bodies, the ethics committee and directors of services. The professionals who participated in the study were asked for informed consent, whether formal or informal. Observation of the contexts of work and interviews was also done. In this study we will focus on the results of the questionnaire. Statistical analysis was performed using SPSS v.17.0.A total of six hospitals, 10 polyvalent adult ICUs in the north of the country, 300 professionals, 73% nurses. Age of respondents was a median 32 years, with 8 years of professional experience and 4 years on the ICU. Results of the MBI: average levels of burnout in physicians and nurses working in the ICU. The risk of developing burnout is highest being a nurse 1:54 OR, yet there is no statistically significant difference at 95% . Nine percent of professionals studied showed burnout, 31% with Burnout syndrome and high risk of burnout. Distribution of levels of burnout by occupational category: higher levels of emotional exhaustion in nurses, personal and professional achievement smaller in nurses, and higher depersonalization in doctors.The results of the study underline the importance of promoting the prevention of burnout in doctors and nurses in the ICU.


Patients with colorectal cancer undergoing surgical treatment require planning and preparation of interventions for prevention of postoperative complications, especially considering the complexity and commitment of its clinical and psychosocial condition.To identify and synthesize the factors that influence the occurrence of postoperative complications and establish the implications of these scientific evidence for nursing care.It is an integrative review of literature where descriptors were used, wound, colorectal cancer and complications with search in the databases Medline, CINAHL and Lilacs, resulting in a sample of 10 scientific articles.Results indicated that the preoperative bowel preparation, staging and tumor location, surgical technique and care of the wound in the postoperative period as the factors influencing the occurrence of postoperative complications.Thus, measures of prevention and infection control can be implemented that are related to the rigor of the completion of the enema, ensure the conduct, preparation and guidance of patients for diagnostic tests and specialized  , fitness and education on pre-operative surgery and its consequences, evaluation of patient outcome and the surgical wound and hospital discharge planning with primary care for the patient and family, encouraging the physiological recovery and wound healing. These nursing interventions could help in decreasing the rates of postoperative complications and mortality of this clientele, as well as improve the quality of perioperative nursing care.J. Silva Other review, H. Sonobe: None declared, D. Andrade: None declared, A. Giordani: None declared, C. Naka Shimura: None declared, E. Watanabe: None declared.


It is a great honor to assume the role of Editor-in-Chief of the Journal of Epidemiology from Dr. Tomotaka Sobue. Under Dr. Sobue’s outstanding leadership, the average impact factor reached 2.113 in 2012, and the expansion of the Journal beyond its original base has continued to accelerate. Indeed, the Journal is now recognized as an international rather than a domestic journal, and manuscripts from abroad account for two-thirds of the total. On behalf of the Board, I wish to thank Dr. Sobue for his inspiring dedication and service.Like many journals, the Journal of Epidemiology has recently faced major challenges in the global publishing environment. One broad-reaching change has been the introduction of open access licensing. Our adoption of the Creative Commons Attribution License (CC BY v3.0) for all papers allows authors to retain ownership of the copyright of their papers, but also allows anyone to download, reuse, copy, reprint, distribute, or modify the paper, provided they cite the original authors and source. The global change in policy towards open access for papers supported by research grants is unstoppable, and our decision to adopt this model is critical to the future of the journal.Second, the Editorial Board warmly welcomes the participation of five new associate editors from abroad, starting from 2014. We believe these new colleagues will contribute to the continuing globalization of the Journal.The editorial team seeks to maintain the Journal’s high international standards and will continue to publish original and review articles on a wide range of topics. Looking to the future, our goal is to establish the Journal as one of the leading journals in epidemiology. I warmly welcome the participation and support of every reader in attaining this goal.Manami Inoue, MD, PhDEditor-in-ChiefJournal of EpidemiologyProject ProfessorAXA Department of Health and Human SecurityGraduate School of MedicineThe University of Tokyo


Please view the complete, correct, equations here: In the Methods section of Experiment Two, there is an error in the third, fourth and fifth equations. The coefficient of the complex valued result (A


The codes and practices of professional morality had been enunciated centuries ago in the traditional Indian systems of medicine. The modern code of medical and research ethics has its origin in the Nuremberg Code, Universal Declaration of Human Rights, Code of Medical Ethics by Medical Council of India, World Health Assembly Helsinki Declaration, Belmont report and the Revised Council for International Organizations of Medical Sciences (CIOMS) guidelines. The revised Indian Council of Medical Research (ICMR) guidelines have been adopted in 2006.The ethical principles of autonomy, justice, non-maleficense and beneficense are applicable to any research undertaken. Careful attention has to be given to the processes of taking consent, assent from minors, re-consent, community engagement, risk-benefit assessment, interventions, data management and follow up. Special concerns for cohorts include the difficulty in conveying results due to the absence of immediate benefits and unpredictable susceptibility due to genetic variations. There are issues of confidentiality and stigmatization due to the allotment of unique identification. There is a need for translational research in cohort studies to understand the priorities, validity and applicability in different cultural settings and the role of community based participatory research. There are concerns in research methodology due to shifting from acute paradigm to chronic paradigm, involvement of special population groups.Bio-banks have advantages such as advancement of scientific knowledge, present and future medical benefits for the individual, improved pharmaco-genomic understanding and commercial benefits through patents. The major ethical concerns revolve around collection, storage and management of samples. Human dignity, right to share benefits, intellectual property rights, access to personal data, sample sharing by researchers, movement of samples outside the country, samples from deceased or non-traceable persons are all issues which has to be carefully thought out. Breach of confidentiality and unwanted information flow can result in anxiety, depression, social stigma and discrimination. There are also issues of cultural and social acceptability for taking samples.The ICMR has issued guidelines for DNA banking in 2006 for primary and secondary use of samples. A draft DNA Profiling Bill, 2007 is under the consideration of the Indian Parliament which looks to legalize the collection and analysis of DNA samples and to create a balance between the constitutional rights of an individual and the public interest along with accountability and transparency in the practice of DNA collection and testing. It will be essential to establish standards for laboratories, staff qualifications, training, proficiency testing, collection of body substances, custody trail from collection to reporting and a data Bank with policies of use and access to information therein, its retention and deletion. Thus genetic technology faces ethical challenges in the clinical, social, economic, scientific, legal and political domains.


The rapid and evolving nature of hair research has led to the foundation of the European Hair Research Society (EHRS) in 1989, dedicated to the advancement of basic and clinical research focused on hair. Since the first meeting in Brussels, Belgium, the Society has held annual meetings in different cities in Europe, which attract more and more hair experts from universities, research institutions and industries from all over the world. Indeed, the EHRS stands in close contact with international hair research societies, and together with the North American Hair Research Society, the Korean Hair Research Society, the Society for Hair Science Research (Japan), the Australasian Hair and Wool Research Society, and the Indian Hair Research Society, co-organizes international scientific meetings.th annual meeting of the EHRS will be held this year in Jerusalem, Israel, from July 6–9, 2011 [http://www.ehrs.org or go directly to http://www.ehrs.org/conference/2011jerusalem/). The main conference will be preceded by a specialized hair course covering aspects of hair anatomy, pathology and genetics, fungal and parasitic infestations of the scalp, drugs affecting the hair and hair-associated contact dermatitis. The course will also present the basic and updated methods of hair trichoscopy. The opening lecture will be exceptionally attractive, and will discuss the momentous topic of “Hair in Movies”.The 15–9, 2011 . The sciDuring the following two days, all major aspects of basic and clinical hair research will be discussed, from hair follicle physiology and biochemistry and hair growth cycles, through various pathological conditions of hypotrichosis and hirsutism, alopecia areata, androgenetic and cicatricial alopecia to various techniques of hair imaging and medical, molecular, cosmetic and surgical methods for hair regrowth or removal.Prof. Desmond Tobin was selected to give the prestigious John Ebling lecture, an honor awarded to leading scientists in hair research for their exceptional achievements in this field. The topic of the lecture this year is the hair follicle melanocyte. In addition to plenary lectures on current topics of broad interest, short talks will be selected from the submitted abstracts and will be presented. We expect a large poster session, incorporating topics from all fields of hair research. The best posters and lectures will be honored with a Poster and Lecture Prizes. The EHRS is dedicated to the encouragement of the scientific careers of young investigators, and also grants the annual Jurgen Schweizer Prize for the best presentation during the meeting. Additionally, a Travel Grant will be provided to selected delegates after acceptance of their abstract. But above all, the EHRS allows young people to interact with leading hair researchers in an unhurried, intimate atmosphere. The unperturbed atmosphere of the EHRS meetings allows also for informal close interactions, and these unscripted meetings make the EHRS especially valuable and distinctive.The venue of the EHRS 2011 will be the Ramada Hotel, located close to the heart of the city of Jerusalem. In addition to enjoying the scientific spirit of this meeting, delegates will also have the opportunity to appreciate the beauties of Jerusalem and its surroundings. Jerusalem is unique for incorporating a magnificent mix of cultures and people, and its breathtaking historical sights are sure to become an unforgettable experience for visitors. The social itinerary will include a visit to the Israel Museum, Light and Sound Show at the David Tower, Tour of the Old City of Jerusalem, Masada and the Dead Sea.jerusalem2011@ehrs.org. Early registration via jerusalem2011@ehrs.org by April 15th. We look forward to welcoming you in Jerusalem on 6–9 July, 2011.We invite you to submit abstracts for posters and oral presentations via Yours friendly,