To construct and validate a nursing care protocol in anesthesia. methodological study of face and content validation, judging clarity, relevance,pertinence and comprehensiveness of a care protocol, elaborated from theintegrative review of previous literature and based on the conceptual model ofassistance perioperative nursing of Castellanos and Jouclas. The protocol wasevaluated by five anesthesiologists and nurses from the surgical center. Theresults were analyzed through the content validity index. among the 119 items assessed by experts, 11 (9.2%) instrument items presentedcontent validity index of <80% and were changed. The items with disagreementwere related to the selection and availability of materials and equipment,especially before anesthetic induction. The content validity index, obtained forthe different items, proposed after the amendments mentioned, ranged from 80 to100%, in the three periods of anesthesia, indicating the proper validity of theproposed content. the nursing care protocol in anesthesia was considered valid. Anesthesia allows the patient comfort during surgery, once the choice of the anesthesiacategory is based on the type, duration and approach required during the surgicalprocedure, associated with the clinical, mental and psychological conditions of thepatient. Thus, the types of anesthesia are classified in general, regional andsedation-General anesthesia is necessary for procedures that require complete immobility andunconsciousness. It can be classified in three ways, defined as total venous, when onlyvenous drugs are infused, such as propofol and etomidate, general inhalation, whenadministration of inhalational anesthetics like sevoflurane, desflurane. The associationbetween venous and inhalational anesthetics is defined as general balancedanesthesiaThe general anesthesia is constituted by the reversible unconsciousness, immobility,analgesia and autonomic reflex block, whose components are hypnosis, analgesia, musclerelaxation and neuro-vegetative blockHypnosis is characterized by suppression of consciousness, obtained through the use ofinducing agents such as midazolam, propofol and etomidate. Analgesia consists of therelief or absence of pain by the use of drugs such as opioids and anti-inflammatories.Muscle relaxation occurs through the reduction of muscle tone, with the administrationof relaxants such as succinylcholine, atracurium and rocuronium. The neuro-vegetativeblock occurs after adequate hypnosis and analgesia, with an attenuated response of theautonomic nervous system to the surgical stimulus, such as changes in heart rate, bloodpressure and sweatingRegional anesthesia is selected for surgical procedures that address upper or lowerlimbs, abdomen or pelvic region. It can be performed by epidural nerve block,subarachnoid or plexus nerve block, with the administration of local anesthetics such asxylocaine, ropivacaine,Sedation is aimed at patient comfort in small or ambulatory surgical procedures,contributing to the reduction of anxiety, analgesia, decreased movement and maintenanceof hemodynamic stability, mainly respiratory pattern and cardiovascular functionAdverse events related to health care and patient safety endangerment originate fromhuman error, lack of teamwork and organizational failures-Studies indicate that adverse events related to anesthesia involve mainly therespiratory system, cardiovascular system, errors in the execution of regional blocks,equipment and device failures, adverse reactions to medications and lesions related tosurgical decision-The events of the respiratory system are caused by intubation difficulty, inadequateventilation and oxygenation, aspiration, early extubation and airway obstruction-Concerning the cardiovascular system, adverse events are characterized by hemorrhages,bleeding, hydroelectrolytic imbalances and stroke. Equipment and device failures includethe use of central and peripheral catheters, anesthesia equipment, burns and firescaused by the use of electric scalpel and thermal blanket-Adverse drug reactions are due to incorrect dose administration and inadequateanalgesia-The main events in regional blocks are accidental dural puncture, high blockade, cardiacarrest, inadequate analgesia, trauma and catheter retention-It should be noted, however, that the mortality risk associated with theanesthetic-surgical procedure has been reduced in the last 50 years due to initiativesfor patient safety in anesthesia, which produced a higher quality of perioperativecare-These initiatives involved the advancement of training, certification and education ofprofessionals for teamwork, development of medications and techniques, improvement ofmonitoring standards, greater quality in the risk assessment of the patient for surgery,along with the standardization behaviors through care protocolsFor the same purpose of care, the health care security, the American Committee onQuality and Health Care of the Institute of Medicine (IOM) presented, in 1999, thereport To err is human: building a safer health system, proposing the governmentalcreation of a patient safety center that defined national goals for promoting safety andpreventing errors related to health careAs a result of mortality and morbidity rates caused by surgical procedures, in 2002, TheNational Assembly of World Health Organization (WHO), released a resolution aimed atsafety during anesthetic-surgical interventions, establishing standards of qualityhealth services, including the implementation of safe anesthesia-The Safe Surgeries Saves Lives program was launched in 2008 by the WHO, with thedevelopment of a checklist that directed the assistance performed before the anestheticinduction periods, surgical incision and removal of the operating room-The checklist, among several actions, provides for the anesthetic procedure, thechecking of the functioning, availability of necessary equipment and materials, patientidentification, verification of available tests, evaluation of risks associated withdifficult airway via and blood loss, induction of anesthesia (assist) and reversal(check).The period before anesthetic induction consisted of interventions to organize thematerials and equipment required for anesthesia. The period of anesthetic inductionincluded direct assistance to the patient care and support to the anesthesiologist. Inthe reversal period, interventions were defined to check vital signs and record of thecare performed.The first version of the protocol was composed of interventions, involving the threeassistance periods, evaluated by a group of five experts, regarding content validitycriteria, clarity of items, relevance and completeness of contentThe modifications of the interventions were performed regarding the presentation andstructure, considering the result of the calculation of the Content Validity Index (CVI)for each intervention and suggestions of the experts.The main changes suggested were the improvement of the writing of the items, especiallyin the pre-induction period, and separation of materials and equipment into distinctitems, so that the professional only indicates the devices related to the type ofsurgery that will be performedIn the induction period, the judges suggested revisions of the items regarding nursingnotes and records, avoiding duplication of information, checking the patient’s historyand allergies directly in the medical chart, as well as reviewing the care of theanesthesiologist, such as assessment of ventilation and venous punctureBefore the suggestions, a second version of the care protocol was elaborated, withchanges in the items regarding the appearance and form of presentation, followed by anew stage of face and content validation by five specialists.In the second version of the care protocol, brief orientation of the objectives and formof completion of the instrument preceded the described periods. Following, the nursinginterventions for each period were described.The total validity of an instrument is measured by face, content, construct andcriterion-related validityThe validity of face represents how much a measure seems to be related to the specificcontent of the evaluated instrument, that is to say, if the content is understood bywhom uses the instrumentContent validity consists of representativeness level of the concept that the instrumentintends to measure and provides the items evaluation, according to clarity, relevance,pertinence and comprehensiveness of content totally agree, (four) I agree, (three) neither agree nor disagree, (two)disagree, (one) totally disagree. On items where disagreement was found, the expertscould suggest modifications regarding the proposed content.The Likert scale is used to measure the opinions, beliefs or attitudes of therespondents of a questionnaire or instrument, through a sequence of affirmations thatallows different levels of agreement. Depending on the research phenomenon and theresearcher’s objectives, odd or pair number of response options may accompany eachstatement, and responses vary from totally disagree to totally agreeThe researcher made e-mail contact with the experts and sent an electronic questionnaire(Google Docs), a presentation letter and the assistance protocol, defining theobjectives of the study, instructions on the completion and importance of documentevaluation by the experts.-In the scientific literature, it is recommended that the number of specialists selectedvaries between three and ten individualsThe selection of experts may vary according to the time of clinical experience of theparticipants, publications and specialization in the area of the research phenomenon,so, in this study, the experts were selected for their work as researchers/specialistsin the field of anesthesiology and/or perioperative nursing.At the end of the protocol evaluation by the expert group, the data were treated andanalyzed by the CVI, which measures the proportion or percentage of agreement amongexperts on certain items of an instrumentIn this study, the highest scores were adopted for the CVI calculation, that is,responses (four) agree and (five) totally agree for each item, divided by the totalnumber of specialists, excluding values from one to three. The acceptable agreement ratefor this proportion was defined as 80% or higherThis study was approved by the Research Ethics Committee of the Nursing School of theUniversity of São Paulo, under nº 612310.The care protocol was evaluated by five specialists, four nurses and oneanesthesiologist. Among the professionals, two are nursing professors and work in publiceducation institutions, two nurses working at surgical center and one is a coordinatorof private anesthesia service.The age of the experts varied between 29 and 58 years (average of 41 years) and theaverage time of professional training was 17 years.Regarding face validity, all experts stated that the graphical presentation, theguidelines for the filling form and the sequence structure of the items allowed anadequate reading and understanding of the care to be performed by the nurse during theanesthetic procedure.Among the 119 items evaluated, only 11 (9.2%) items of the protocol presented CVI<80%, as presented in Most of the disagreements among the specialists occurred in the period before anestheticinduction, in which the evaluated items presented CVI ranging from 40 to 100% in theclarity criteria, from 80 to 100% in relevance, from 60 to 100% in pertinence and from40 to 100% in completeness of content.Regarding the item of operation of the anesthesia equipment, the experts considered theneed for guidance on the test of the equipment and the evaluation of its operation,taking into account the diversity of brands and models. In addition, experts recommendedthe establishment of a minimum number of available breathing circuit and modification ofthe wording of the item, definition of the saturation percentage (color modification) ofsoda lime and the need for exchange .The experts suggested the definition of the type of blood pressure cuff, according tothe physical characteristics of the patient, together with the establishment of theMultiparameter monitor alarm, according to the patient’s age group (adult or child).Regarding airway materials, there were considerations regarding the separation of theendotracheal tube of different sizes, according to the patient’s physicalcharacteristics and type of surgery .The experts stated that for the clarity and completeness of content of the itemsdescribing the intubation materials, it is necessary to choose the patient’s face maskand gastric tube, considering characteristics such as age and weight .In the items on difficult airway, experts advised to better define the parameters ofchoice of materials such as the tracheostomy tube and the esophagus-tracheal tube(combitube) .In the period of anesthetic induction, the evaluated items presented CVI from 80 to 100%in the criteria of clarity, relevance and pertinence and CVI from 60 to 100% in thecompleteness of content. The only item with disagreement was patient monitoring, forwhich it was suggested to explain the type of sensor used for temperature verification.In the period of anesthesia reversal, there was no change in the initially proposeditems, which presented CVI from 80 to 100% in the criteria of clarity and completenessof content, 100% in the criteria of relevance and pertinence.Following the evaluation of the experts’ suggestions, the items were modified andsubmitted to a new round of evaluations and the CVI was recalculated, as presented inThe results indicated a good agreement between the items evaluated by the specialists,considering that only 9.2% generated some type of disagreement and the divergences weremainly related to the criteria of choice, availability and selection of materials forthe anesthetic procedure in the pre-induction period.Most of the items of the induction period and all items of anesthesia reversal wereconsidered valid by the specialists, affirming the importance of the care performed bythe nurse in a surgical room.The standardization of care offered by nursing during the anesthetic act contributes tothe determination of the nursing role within this area, establishing a package ofactions legally allowed in the country.--In Brazil, care and performance standards are clear for anesthesiologists-During anesthesia-surgical procedure, the presence of an anesthesiologist is required inthe surgical room, the supply of supplemental oxygen to patients undergoing generalanesthesia, monitoring of oxygen saturation by pulse oximetry and ventilation,circulation control and heart rate monitoring, measurement of blood pressure every fiveminutes, body temperature measurement and regular evaluation of anesthetic depth byclinical observation-All these measures seek to prevent adverse events. Thus, it is considered that thedefinition of care standards, with the identification of potential risks and necessarymeasures for the safety of interventions, combined with inter-professional work and goodcommunication, can improve health care processes and outcomes In 1993, the American Society of Anesthesiologists (ASA), aiming at the adequateplanning of anesthesia care and reduction of postoperative morbidity and mortality,considering the reality of each health service and the types of equipment available,developed a checklist, revised in 2008, which contained actions for execution beforeanesthetic inductionThe checklist suggested items, some of which are also covered by this protocol, such asthe anesthesia equipment operating test, soda lime check, auxiliary oxygen supplyavailability and bag-valve-mask device, vacuum for aspiration, availability ofmonitoring system and alarms, with emphasis on pulse oximetry and capnography,verification of the flow of gases and adequate pressure for ventilation in theanesthesia equipment, as well as the registration of any conference procedure-It is worth noting that WHO recommends minimum standards of assistance/care inanesthesia during anesthesia-surgical procedures. They involve the planning of materialsand medicines in health services, equipment testing, monitoring care, according to thecomplexity of the clientele served and the hospital institution. These measures can bedefined as highly recommended, recommended and suggestedThe highly recommended standards in anesthesia are mandatory standards, that is,applicable to all types of institutions that perform procedures under anesthesia, fromsmall hospitals to referral hospitals.-Therefore, several items contemplated in the protocol must be properly checked andrecorded, among them the availability and operation of materials in the operating roomand materials for airway , oral and nasopharyngeal Guedel cannula, aspiration system andhumidifiers), evaluation of anesthesia equipment , , blood and fluids available, monitors with alarms attached,stethoscope, sphygmomanometer and thermometer-Studies have shown that the use of checklists for the organization of anestheticinduction care can assist in the detection of errors and negligence in relation to care,reducing failures during anesthesia and surgery, by means of appropriate equipment andmaterial checks, in addition to promoting the exchange of information amongprofessionals about the clinical conditions of the patient and critical aspects such asallergies and difficult airway, thus improving the perception of professionals aboutteamwork and prevention of damages, aspects that, together, contribute for patientsafetyAll the professionals aligned with the scientific basis that guides the care to beperformed, as well as the definition of limits and performance roles, contribute to agreater synchronism between the anesthetic procedure and the activities, and, therefore,a greater probability of success interventions. As a limitation, in this study, nopilot-application of the protocol was performed.The nursing care protocol in anesthesia was validated with good agreement amongspecialists, and 90.8% of the items were considered adequate in the first round.The nursing care protocol was developed within the limits of professional performance,without overlapping functions or violation of the law of professional practice, and canguide the role of the nurse during anesthesia. With this, it is possible to standardizecare behaviors in different institutions, guaranteeing greater support to nurses intheir performance in the anesthetic procedure, with the anesthesiologist.It is emphasized that the nurse’s use of the care protocol should be linked to theexistence of systematized technical and scientific knowledge about the actions to beperformed during anesthesia, stating the importance of their presence in a surgical roomfor care activities.Thus, it is believed that this direction of nursing work, in anesthesia, can evidencethe importance of nurses’ work in a surgical center, even in the face of thedifficulties experienced in the performance of roles within health institutions and ininteraction with the medical team.Future work is needed to evaluate the practical application and feasibility of using thecare protocol in different realities.


Attractiveness plays a central role in human non-verbal communication and has been broadly examined in diverse subfields of contemporary psychology. Researchers have garnered compelling evidence in support of the evolutionary functions of physical attractiveness and its role in our daily lives, while at the same time, having largely ignored the significant contribution of non-visual modalities and the relationships among them. Acoustic and olfactory cues can, separately or in combination, strongly influence the perceived attractiveness of an individual and therefore attitudes and actions toward that person. Here, we discuss the relative importance of visual, auditory and olfactory traits in judgments of attractiveness, and review neural and behavioral studies that support the highly complex and multimodal nature of person perception. Further, we discuss three alternative evolutionary hypotheses aimed at explaining the function of multiple indices of attractiveness. In this review, we provide several lines of evidence supporting the importance of the voice, body odor, and facial and body appearance in the perception of attractiveness and mate preferences, and therefore the critical need to incorporate cross-modal perception and multisensory integration into future research on human physical attractiveness. Physical attractiveness plays a central role in the assessment of human mate value. This has made it a widely examined topic in contemporary psychology and biology. The variables that determine mate value, such as health, sexual maturity and reproductive potential, are often not directly observable. However, numerous studies have shown that these indices of mate value predict measures and ratings of physical attractiveness , researchers have focused disproportionately on visual indicators of attractiveness, underplaying the influence of scent and voice. In a recent and relatively broad theoretical review of prosocial biases in favor of attractive people, Idea of the review: PS, KP, AS, and MK. Wrote the manuscript: AG, KP, AS, JH, MK, DP, SR, and PS.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Department of Health and Human Services, the task force is an independent, nonfederal, panel of public health and prevention experts whose members are appointed by the director of CDC. The task force provides information for a wide range of persons who make decisions about programs, services, and other interventions to improve population health. Although CDC provides administrative, scientific, and technical support for the task force, the recommendations developed are those of the task force and do not undergo review or approval by CDC.


The exponential development of high-throughput technologies in the last decades, supporting and improving the OMICS science, has allowed uncovering successfully the complexity of the organizational network patterns in the cell's metabolism to the plant phenome, founding the science of system biology  expression gradient (regulated by miR165/6), which therefore has a higher concentration in internal xylem tissue. Thus, xylem tissue within the stele is defined, among other factors, by the expression of PHB, which is restricted to xylem and procambium by miR165/6, specifically expressed in the endoderm.In addition to intracellular complexity, the interaction between neighboring cells plays an important role in the responses to environmental conditions, and the plant metabolism organization as a whole. In plants, plasmodesmata connect the cytoplasts of adjacent cells across the cell wall, allowing intercellular transport and communication to adjacent cells within a tissue or organ, allowing exchange of small molecules, such as ions, sugars, and phytohormones, as well as larger molecules, including proteins, RNA, and viruses  , and thus increase the uncertainties of the bottom-up predictability models, since physiological changes in specific tissues may have non-local causes. For instance, a local application of high light results in the activation of a ROS wave, allowing an increase in stress tolerance accompanied by the accumulation of photorespiratory amino acids, including Glycine and Serine, in non-stimulated tissues  until the end of twenty and beginning of twenty-first centuries, occidental science was successful to uncover the layers of complexity underlying to the biological organisms, opening the OMICS era with the genome. But the “whole picture” was not clear yet. As exemplified in the previous sections, some problems have challenged the determinism from below, and then the Cartesian synthesis was boosted to explore higher levels of organization, inaugurating the System Biology thinking. The knowledge that has being built on transcriptome, proteome and, specially, the metabolome , the interpretation of the data shall consider the context in which the particular scale is embedded. Ultimately, in studies that intent to contribute for improvement of crop yield, the plant phenotype  should have the final word of the meaning of the changes from the lower levels of organization, since one genotype can be translated in many phenotypes when developed under different environmental conditions (Tardieu et al., MdA and GS contributed equally to the discussion of the topic.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Apoptosis has been a biological phenomenon of intense interest for 20 years, but the earlier morphological features of apoptosis have not been determined hitherto. Using the methods of semi- and ultrathin sections, the livers of intact embryos and young rats have been studied under the effect of cycloheximide to determine morphological features of an early stage of apoptosis. It is discovered that both in hepatoblasts and hepatocytes, apoptosis, besides the well-known stages, also includes an early contact stage, distinguishing features of which are agglutination of bound ribosomes (breaking of translation), elimination of the nucleolus, reduction of free polysomes , formation of cytoplasmic excrescences, and cell shape changes. The early stage of apoptosis is characterized by close contact with neighboring cells. At a certain phase of the contact stage of apoptosis, the nucleolus reappears in the nucleus and the number of free polysomes in the cytoplasm increases, which suggests the renewal of synthesis of new RNA and proteins. Close contact of differentiating and mitotic hepatoblasts with apoptotic cells indicates a certain functional relationship between these cells that is realized not only by micropinocytosis, but through gap junctions as well. We assume that the apoptotic cell, besides proteolytic products, can contain newly synthesized, low-molecular substances, the relocation of which from apoptotic to neighboring cells may contribute to both functional activity and proliferation of adjacent hepatoblasts and, therefore, the function of apoptosis may not be limited only to the elimination of harmful, damaged, and unwanted cells.


The Belgian Association of Hospital Pharmacists (BAHP) is a professional and scientific association representing all pharmacists who work in hospital institutions, whether private or public, university, general or psychiatric. This association was created in 1953. The aim of this short paper is to tell the history of its continuous development in a few words. The main development is reviewed from 1950 to now including: regulation, professional association roles, agreement and continuing education, development of clinical pharmacy, and updating of university training program. A new decree for the hospital pharmacist is in the course of being finalized, including new technologies: automated dispensing, automated compounding, centralization of sterile compounding, e-learning, traceability of medical devices and clinical pharmacy. On 10 May 2013, the Belgian Association of Hospital Pharmacists (BAHP) celebrated 60 years of existence and became a Royal Society.Created in 1953, this professional and scientific association represents all pharmacists who work in hospital institutions, whether private or public, university, general or psychiatric.The aim of this short paper is to tell the history of this development in a few words.Moniteur [Different royal decrees (RD) regulate the professional life of a Belgian hospital pharmacist. The first appeared in 1978 in the Moniteur . At the Moniteur  and the Moniteur , followiMoniteur .The RD of 4 March 1991 fixes the standards which a hospital pharmacist must satisfy to be approved, which went on to significantly regulate the general and specific tasks of the pharmacist within his/her hospital institution, creating on the same occasion the term “Fonction hospitalière” in order to classify hospital pharmacy within it . The phaBelgian hospital pharmacists are responsible for pharmaceutical specialties, extemporaneous preparations, antiseptics and disinfectants, registered dietary products, medical and surgical equipment, implants and prostheses, radio isotopes, medical gases and products that are under investigation by clinical trials.The tasks are identical to pharmacists around the world: the individualized distribution of medicines, the preparation of non sterile and sterile medicines, the supply, stocking and appropriate storage of medicines, and the analysis and quality control of raw materials and medicines.The specific tasks are very numerous: the organization of an effective, safe and economic system of distribution in the various hospital units; integration into multidisciplinary teams in order to optimize therapeutic efficacy and safety; the collection, processing and distribution, in a structured manner, of all the necessary pharmacological, toxicological and pharmaco-technical information concerning the medicines used in the hospital; active collaboration with the nursing staff regarding the use of medicines; the organization and promotion, in collaboration with the medical team, of pharmacovigilance activities; partial responsibility for the sanitary arrangements for hospitalized patients and discharged patients, in collaboration with the medical and nursing staff; making available for the hospital departments antiseptic and disinfectant solutions of an appropriate quality for the therapeutic necessities; guaranteeing at a qualitative level the daily activities of the sterilization unit; supervision of the galenical preparation of injectable solutions of radio-pharmaceuticals; drawing up, in collaboration with the doctor in charge of the hospital, an annual report, of the hospital as a whole and by department, of the consumption and cost of the medical treatment, and a report on the relation between the consumption of medicines and the pathologies treated in the hospital; contribution to clinical trials whenever they are performed in the hospital; contribution to the rapid and suitable treatment of cases of poisoning .The particular title of hospital pharmacist was also created in 2003.The RD of 11 June 2003  describeFor the extension of such recognition, the pharmacist must prove that he has obtained accreditation of 120 points during the validity period of its approval or over five years.From the beginning of its creation, the Belgian association has organized training courses. These courses are then modeled on the matters described in RD of 2003.Points can also be obtained by attendance at national and international conferences, presentation of oral communications, and publications of posters. That is why the Belgian delegation is often important to the congress of the European Association of Hospital Pharmacy and the European Society of Clinical pharmacy, for example ,11.The development of clinical pharmacy began with isolated initiatives, mainly in university hospitals .The first studies were published on geriatric inpatients .In March 2007, Rudy Demotte, the Minister of Social Affairs and Public Health at the time, launched a call for clinical pharmacy projects from general and university hospitals in Belgium. This call for proposals was in response to ongoing efforts by the Belgian Association of Hospital Pharmacists to increase funding for clinical pharmacy in the country ,15.Proposals needed to specify the exact nature of a temporarily funded position, and on which ward or wards work would take place. Altogether, 80 proposals were received by the National Network of the Pharmaceutical and Therapeutic Committee (NN-PTC). Twenty-seven were selected for funding, which included 13 full-time and 15 half-time staff posts in clinical pharmacy in the areas of pain treatment, nutrition and seamless medication care in oncology, cardiology, intensive care units and geriatrics. Positions were filled, and the first evaluations of the projects by the hospitals were sent to the ministry by the end of the year. Two further reports were required before the end of the projects on 31 December 2008. The projects and accompanying reports should aid in demonstrating the positive impact of clinical pharmacists on patients and medical staff in a variety of areas, and hopefully serve as successful pilot projects for ongoing funding for more hospitals in Belgium. In January 2009, these 27 projects of clinical pharmacy were permanently established . At the The establishment of a specialization in hospital pharmacy in Belgium began in the late 1970s and consisted of three certificates: galenic formulation, pharmacology and hospital management. Since then, in other European countries, the duration of specialization studies has increased.Furthermore, the content of the subjects taught and their diversity increased. Finally, the hospital pharmacist was involved in more and more areas and continuing education was not enough. An adaptation of study specialization was necessary.In September 2010, a new training program for hospital pharmacists was established by all of the universities in Belgium. Sixty-five student posts were opened, 39 in the Flemish-speaking community and 26 in the French-speaking community ,19. The The courses are taught by academic professors, lecturers, and ground health professionals.The first practical module, entitled “Drugs supply chain”, includes the organization and management of a hospital pharmacy, the supply chain and the following topics: control processes and quality management, and information management on both drug and clinical trials.Module 2, entitled “Hospital hygiene and central sterilization”, includes management of antibiotic therapy, organization and management of medical devices, supply chain and similar products .Module 3, entitled “Clinical pharmacy”, covers clinical pharmacy and pharmaceutical care in at least one ward  but also includes activities relating to the remit of the Pharmaceutical and Therapeutic Committee.Module 4, entitled “Production”, includes the production and/or reconstitution of chemotherapy, radiopharmaceutical drugs and other preparations, including pharmaceutical and sterile preparations. These three parts must cover, in addition to the production itself, all control and quality assurance aspects.The duration of each module is six months and the four modules are taken in sequence. The academic module is spread out over two years, at a rate of one day/week at the universities. This two-year program replaces the previous one-year program and is described in a written work which can be published. Currently, there is no English language version.In September 2013, the program was extended to three years and the number of candidates was adjusted to 50. During the third year, the candidate may make the choice of one or two of the four modules described previously. The candidates are also strongly invited to do periods in other hospitals inside and outside Belgium. This third year will be ended on September 2016. Is it too early to make a conclusion at this time but the periods in another hospital met a big success with a preference for France and Quebec.Pharmakon, the official journal of Belgian hospital pharmacy, has existed since 1969. For over 40 years, the Belgian hospital pharmacists were kept abreast of developments in their discipline by Dutch, French and sometimes English publications.The candidates must also publish the results of their work as posters or publications. Journal de Pharmaciede Belgique in 2013. The publications of candidates and hospital pharmacists are now easily accessible [However, for many reasons , the paper merged with the cessible .The RD of March 1991 is outdated and must be updated. A new decree was published in 2009 concerning community pharmacists . A new d


Department of Health and Human Services, the task force is an independent, nonfederal, uncompensated panel of public health and prevention experts whose members are appointed by the Director of CDC. The task force provides information for a wide range of decision makers on programs, services, and policies aimed at improving population health. Although CDC provides administrative, research, and technical support for the task force, the recommendations developed are those of the task force and do not undergo review or approval by CDC.


Fast Track to End AIDS by 2030 program and the recent changes in the Guidelines on When to Start Antiretroviral Therapy and on Pre-exposure Prophylaxis for HIV. The success of developing HIV treatment cascades in low- and middle-income countries will require the development of National Health Identification Systems. The success of programs like Universal Health Coverage, under the recently ratified Sustainable Development Goals is also contingent on the availability of personal health information for communicable and non-communicable diseases.As increasing amounts of personal information are being collected through a plethora of electronic modalities by statutory and non-statutory organizations, ensuring the confidentiality and security of such information has become a major issue globally. While the use of many of these media can be beneficial to individuals or populations, they can also be open to abuse by individuals or statutory and non-statutory organizations. Recent examples include collection of personal information by national security systems and the development of national programs like the Chinese Social Credit System. In many low- and middle-income countries, an increasing amount of personal health information is being collected. The collection of personal health information is necessary, in order to develop longitudinal medical records and to monitor and evaluate the use, cost, outcome, and impact of health services at facility, sub-national, and national levels. However, if personal health information is not held confidentially and securely, individuals with communicable or non-communicable diseases (NCDs) may be reluctant to use preventive or therapeutic health services, due to fear of being stigmatized or discriminated against. While policymakers and other stakeholders in these countries recognize the need to develop and implement policies for protecting the privacy, confidentiality and security of personal health information, to date few of these countries have developed, let alone implemented, coherent policies. The global HIV response continues to emphasize the importance of collecting HIV-health information, recently re-iterated by the Guidance for countries to develop and implement their own guidelines for protecting HIV-information formed the basis of identifying a number of fundamental principles, governing the areas of privacy, confidentiality and security. The use of individual-level data must balance maximizing the benefits from their most effective and fullest use, and minimizing harm resulting from their malicious or inadvertent release.These general principles are described in this paper, as along with a bibliography referring to more detailed technical information. A country assessment tool and user's manual, based on these principles, have been developed to support countries to assess the privacy, confidentiality, and security of personal health information at facility, data warehouse/repository, and national levels. The successful development and implementation of national guidance will require strong collaboration at local, regional, and national levels, and this is a pre-condition for the successful implementation of a range of national and global programs.This paper is a call for action for stakeholders in low- and middle-income countries to develop and implement such coherent policies and provides fundamental principles governing the areas of privacy, confidentiality, and security of personal health information being collected in low- and middle-income countries. Fast Track to End AIDS by 2030 treatment targets, including ‘90-90-90’ and ‘95-95-95’ (UNAIDS recently announced that 15 million people living with HIV (PLHIV) were on anti-retroviral therapy (ART) . The nee5-95-95’ .Universal Health Coverage  working with colleagues from CDC Atlanta and UNAIDS. These drafts were extensively reviewed, and eventually, a draft was discussed and reviewed by participants at a workshop held in Lusaka, Zambia, in 2012 Data StorageData Backup (not included at policy level)Authorization and Access ControlData ReleaseTransmission SecurityData DisposalThe major headings include a series of subheadings and relevant questions as can be seen in the example of Governance and Policy below:PolicyGovernance StructureReview of Security PracticesResponsibilities and TrainingMonitoring Security BreachesConducting Risk AssessmentsConnectivity to Other NetworksBased on discussions with relevant members of the MOH, the tool was field-tested in two primary, two secondary, and two tertiary care facilities. In addition, the tool was also field-tested at a national data warehouse and at the national policy level. A work-plan was developed, based on discussions between relevant members of MOH, CDC and UNAIDS, other government officials, health and legal professionals, and members of civil society that also agreed to participate in the process.The primary method of data collection was through small group interviews, reaching consensus on each question of the assessment tool. Additionally, if policies or procedures existed in that department a copy of the guidelines was requested. The field-test documented responses to the questions by identifying the existing national policies, legislation, technical guidelines, including scope and coverage, for the sole purpose of assessing the questions on the tool and its ability to capture the data of interest.In general, constructive comments and suggestions were made regarding changes to the assessment tool. Although most of the questions were easy to understand, they elicited rich discussions, which did increase the length of the meetings. This enabled consensus to be reached on each question. In most instances, the discussion eventually focused on how the assessment tool should be rolled out, implemented, or moved forward in terms of informing policies and procedures. Only 18 questions, out of a total of 168 questions in the tool, needed to be modified or clarified. The field-test confirmed that the assessment tool had been well understood by informants and produced useful information.Interim Guidelines on Protecting the Confidentiality and Security of HIV Information. However, the assessment tool is a general tool and does not need major adaptation to be useful in country.The approach used in selecting and vetting the questions was considered to have been thorough based on the feedback session held at the end of the field-test. The scope of the assessment tool was considered to have adequately covered all facets of confidentiality and security and dealt with all relevant aspects of the The activities described above have led to the identification of a number of fundamental principles, governing the areas of privacy, confidentiality, and security . These pThe purpose of defining personal health information confidentiality and security principles is to ensure that health data are available and used to serve the improvement of health, as well as the reduction of harm, for all people, healthy and not healthy. Pursuing this goal involves an ongoing process of refining the balance between maximizing of benefits, which can and should come from the wise and fullest use of data, and protection from harm, which can result from either malicious or inadvertent inappropriate release of individually identifiable data. Appropriate policies, procedures, and technical methods must be balanced to protect both individual and public rights.Personal health information is generally obtained at the point of care, where services are delivered to individuals. Personal identifiable information is individual-level information that includes personal identifiers such as names and addresses. They are managed at community and health facilities whether sponsored by the public sector, NGOs, the private sector, or international organizations. However, in some cases such data are stored in regional or national databases. This category of data also includes national identification numbers, which can be directly linked to individual patients across different databases across various social sectors, for example, the social security number in the United States.The public health goal is to safeguard the health of communities through the collection, analysis, dissemination, and use of health data, which must be carefully balanced with the individual's right to privacy and confidentiality. Guidelines must allow for consideration of relevant cultural norms, which may influence these policies, while ethical principles should guide decision-making regarding the appropriate use and dissemination of data. Overall, guiding principles should be based on human rights principles.For protecting personal health information, three interrelated concepts have an impact on the development and implementation of protections for sensitive data. These are privacy, confidentiality, and security. Privacy is both a legal and an ethical concept. The legal concept refers to the legal protection that has been accorded to an individual to control both access to and use of personal information and provides the overall framework within which both confidentiality and security are implemented. Confidentiality relates to the right of individuals to protection of their data during storage, transfer, and use, in order to prevent unauthorized disclosure of that information to third parties. Security is a collection of technical approaches that address issues covering physical, electronic, and procedural aspects of protecting information collected as part of the scale-up of HIV services.The risk of harm following a breach of confidentiality varies with the national or local context according to levels of stigma, lack of comprehensive public health safety nets, legal traditions of respect of privacy, religious perspectives, and other local conditions. Within countries, privacy and confidentiality laws should be in place, or developed if not already in place, and relevant parameters of privacy or confidentiality laws must be reviewed and known by those involved with the data at all administrative levels. The greatest threats to electronic information systems are generally not from outside attack, but rather from issues inherent in the system design and implementation. These threats fall into two categories: non-availability of data due to system failure and user errors.Development and review of confidentiality and security laws and procedures should include active participation from relevant stakeholders, including civil society and community members, healthcare professionals, information technology specialists, and legal and ethical experts.Funding organizations should comply with these standards and have an obligation to make adequate funding available to implement them, sufficient to ensure protection of the data collected and used. Funding organization must also require that maintaining these standards is a condition for funding of any implementing partners or agencies.A number of organizational procedures need to be followed to ensure safeguards for the collection, transfer, storage, use, dissemination, and disposal of personal identified data and other information. Policies and procedures developed must cover both paper-based and electronic systems. Countries and organizations at all levels of the healthcare system should have a written policy that defines security procedures concerning the way data are collected, stored, transferred, and released. The policies need to be implemented at all relevant levels, and staff must understand the policies and to have signed an agreement stating that they will implement them as part of their work. This will also require training new staff and updating all staff on the relevant procedures.Data may be shared between organizations provided that the data are used for legitimate health purposes. The confidentiality and security measures of the organization receiving the data need to be equivalent to those that collected the data.These principles give rise to a number of operational recommendations. It is critical that written security procedures be produced, defining how data should be collected, stored, transferred, and released. These written policies should be accessible, understood, and implemented at all organizational and administrative levels. Staff members need to confirm, in writing, that they have read and understood the policies and that they will adhere to them .Individuals who are authorized to access personal health information should also receive appropriate training, at regular intervals. Security strategies and related laws and policies should be continuously reviewed, independently assessed, and revised when required .Cross-sectional or longitudinal paper-based or electronic information, collected as part of clinical management, need to be stored in locked cabinets or locked computers, respectively, within a locked room and a secured building. Paper-based information should be transported in secure briefcases, transmitted by secured fax or using protected mail services within or between organizations . GeograpSecurity breaches and loss of confidentiality require investigation. Organizations and individuals who are unable to adequately protect the confidentiality and security of identifiable information should be held accountable and appropriate penalties imposed. Improvements then need to be implemented . ConfideIt is important to delineate potential limits and restrictions on access to personal data. For example, individual-level information should generally not be shared with law enforcement, immigration control, management of the public welfare system, or other non-health functions without consent from the individual to whom the information relates, except in circumstances involving the threat of imminent danger of grave physical harm to individuals or populations . The devThese are just some of the operational issues associated with maintaining the confidentiality and security of personal health information. For detailed information on some of the specific issues surrounding these and other related technical issues, the extended bibliography  can refeIf the personal identifiable health information is not kept confidential and secure, under-pinned by relevant privacy laws, people with communicable or non-communicable diseases may be stigmatized and discriminated against, hampering therapeutic and preventive health measures at individual and population levels . FurtherThe collection of personal health information will also enable more detailed information to be available for monitoring and evaluating the use, cost, outcome, and impact of services at facility, sub-national, and national levels . SystemsHowever, there continues to be a general lack of interest and progressive action in this area. So far, few countries have systematically developed, let alone, implemented such policies. Why is this occurring?Possible reasons for this general lack of progress may be due to a variety of reasons. These may include cultural reasons where the local culture does not recognize the need for individual privacy or confidentiality of personal information, the relative lack of development of the country's healthcare and health information systems, perceived financial costs of the development and implementation of such guidelines, and possible disagreements as to which statutory or non-statutory organization ought to have access to such data. However, if countries do not currently invest in their health information systems as part of developing their healthcare system, the long-term social and financial costs are likely to exceed the necessary short-term investment .The development of healthcare systems may provide an opportunity for countries to develop and implement such guidelines. For instance, countries in Asia, sub-Saharan Africa, and the Caribbean are currently in the process of developing unique healthcare identifiers. Such identifiers should, however, be developed and implemented in parallel with national guidelines on the privacy, confidentiality, and security of personal health information .To assist countries in this process, an UNAIDS/PEPFAR assessment tool and user manual have been finalized and are available in paper-format in English , 36, whiFast Track to End AIDS by 2030 (Personal information is increasingly being collected and used by local, national, and global statutory and non-statutory organizations as part of the broader utilization of Big Data . The suc by 2030 , impleme by 2030  and the  by 2030  and the Click here for additional data file.


Pain is a homeostatic mechanism that intervenes to protect the organism from harmful stimuli that could damage its integrity. It is made up of two components: the sensory-discriminative component, which identifies the provenance and characteristics of the type of pain; and the affective-motivational component, on which emotional reflexes, following the painful sensation, depend.There is a system for pain control at an encephalic and spinal level, principally made up of the periaqueductal grey matter, the periventricular area, the nucleus raphe magnus, and the pain-inhibition complex situated in the posterior horns of the spinal cord. Through the activation of these pain-control systems, the nervous system suppresses the afference of pain signals. Endogenous opioids represent another analgesic system.In the course of various studies on pain transmission in Down patients, the reduced tolerance of pain and the incapacity to give a qualitative and quantitative description emerged in a powerful way. All of these aspects cause difficulty in evaluating pain. This is linked to several learning difficulties. However, it cannot be excluded that in these anomalies of pain perception, both the anatomical and the neurotransmitter alteration, typical of this syndrome, may hold a certain importance.This fact may have important clinical repercussions that could affect the choice of therapeutic and rehabilitative schemes for treatment of pathologies in which pain is the dominant symptom, such as postoperative pain. It could influence research on analgesics that are more suitable for these patients, the evaluation of the depth of analgesia during surgical operation, and ultimately, absence of obvious pain manifestations. In conclusion, alterations of the central nervous system, neurotransmitters, pain transmission, and all related problems should be considered in the management of pain in patients with Down's syndrome, especially by algologists and anesthesiologists.


To analyze whether socioeconomic and clinical aspects and the aspects of healthy life habits are associated with the quality of life of persons living with HIV/AIDS. This is a cross-sectional exploratory quantitative research, with 227 persons living with HIV/AIDS, treated at two hospitals of reference between April 2012 and June 2014. We used structured questionnaires to assess socioeconomic aspects , clinical parameters , and practice of physical exercise. To assess quality of life, we used the Quality of Life questionnaire (HAT-QoL). For characterization of the socioeconomic and clinical data and domains of quality of life, we conducted a descriptive analysis . We applied linear regression, following a hierarchical model for each domain of quality of life. The domains that presented lower averages for quality of life were financial concern, concern with confidentiality, general function, and satisfaction with life. We found associations with the variables of socioeconomic status and physical exercise, therapy, and physical exercise for the last two domains, consecutively. The quality of life of persons living with HIV/AIDS shows losses, especially in the financial and confidentiality areas, followed by general function of the body and satisfaction with life, in which socioeconomic and clinical aspects and healthy living habits, such as the practice of physical exercise, are determining factors for this reality. Acquired Immunodeficiency Syndrome (AIDS), initially considered an acute and fatal disease, currently has a profile of chronic diseaseThe QOL covers multifactorial characteristics, reflecting individual and collective experience, knowledge, and values in the historical, cultural and social time lived,,Given these characteristics, the investigation on the QOL of PLWHA becomes essential, especially because of the development of the infection, the need for drug treatment, increased survival, and life with the stigmatizing disease. All these aspects must be observed with the socio-economic characteristics and habits of life, in order to identify negative factors that contribute to biopsychosocial problemsGiven this context, this study aimed to analyze whether socioeconomic and clinical aspects and the aspects of healthy life habits are associated with the quality of life of persons living with HIV/AIDS.This is an exploratory descriptive cross-sectional studyThe sample was non-probabilistic and consecutive; among the 275 patients approached and invited to participate in the research by the evaluators after medical consultation, 46 refused because of unavailability of time or lack of interest in participating, and two did not complete the interview. Thus, 227 persons living with HIV of both genders participated in this study.Inclusion criteria were: diagnosis of infection of HIV/AIDS, being in clinical follow-up in the Specialized Care Service in HIV/AIDS, and being aged 18 years or more, of both genders. We excluded individuals who had any type of medical or cognitive condition that would prevent them from understanding the research procedures .The data were collected from personal interviews in a reserved location. The research tools were applied by two previously trained evaluators, using structured questionnaires, which assessed the socioeconomic and demographic aspects .Regarding clinical parameters, we inquired about the time of disease diagnosis and the use and time of medication. Data on clinical stage of infection, CD4 T-cell count, and viral load were obtained from the most recent exam record in the chart.To assess the QOL, we used the questionnaire Quality of Life (HAT-QoL), proposed by Holmes and SheaTo answer the questions, subjects were told to think about their QOL in the last four weeks. The answers of the instrument have a five-point Likert scale: all the time, most of the time, part of the time, little time, never. In each domain, zero is the lowest score and 100 is the best possible score. Thus, the higher the score, the lower the impact of HIV infection is in the QOL of individuals.We calculated the frequencies, averages, and standard deviations of the socioeconomic, clinical, and score data of the domains of quality of life. Subsequently, we selected the variables to be included in multiple regression models in order to eliminate the variables that showed no association with each domain of QOL from the model. In this analysis, Student’s t-test was used to compare the average scores for each domain between the levels of each variable, and the variables that had a value of p < 0.10 were selected for inclusion in the regression models.For the multivariate analysis, multiple linear regressions were used. In each regression, the dependent variable was one of the domains of QOL and the independent variables were all the variables selected in the respective bivariate analysis. In each model developed, the independent variables that showed no significant association (p < 0.05) with the dependent variable were eliminated in a step-by-step process. The results are presented as adjusted point estimates of the difference in the score of each domain between the levels of each independent variable and their 95% confidence intervals.Of the 227 individuals, 131 were men and 96 were women, and average age of 40.3 (SD = 11.5) years. The characteristics of the population of the study are presented in The multiple linear regression model can be seen in In this study, we analyzed the QOL and association between socioeconomic and clinical aspects and healthy living habits in PLWHA. We saw that the most affected domains of QOL were financial concerns, concerns about confidentiality, general function, and satisfaction with life, which were associated, respectively, with the variables: socioeconomic status and physical exercise, therapy, and only physical exercise for the last two domains .,,,,The negative results for financial concerns and concerns about confidentiality corroborate with studies that have used the HAT-QoL and identified negative behavior in these domains,,,-The domain of concern with confidentiality was associated with only the variable of therapy, corresponding to 86.8% of the persons taking antiretroviral drugs. This result is not in agreement with the study of Passos and Souza, who have identified worse QOL associated with “not taking antiretroviral drugs”,General function and satisfaction with life were associated with the variable of physical exercise and were the subsequent domains that presented the lowest averages. The justification for this is due to the negative behavior found by not practicing physical exercise as a healthy habit. There are reports in the literature on the association between QOL of persons who exercise, exactly because of the changes in lifestyle, which allow the improvement of body composition, metabolism efficiency, joint mobility, posture, cognitive functions, perception of self-image, and socialization, thus improving the overall function and satisfaction with lifeThe domains of health concerns, acceptance of HIV, concerns about medication, and sexual function presented positive averages for QOL.3, which reassures the PLWHA, as this value reduces the concerns about the prognosis of deathThe domain of health concerns was associated with age, physical exercise, and CD4 T-cell. For the first result, we observed that the association presented positive behavior of QOL with advancing age in this study. This result differs from that found by Soares et al.In the analysis of the domain of acceptance of HIV, we observed association with “being over 37 years” and “no practice of physical exercise”. The association with age can arise from the fact that older persons are more mature and thus better accept their health condition3). These data agree with the study of Passos and Souza, who have identified worse QOL associated with female and age (< 47 years)The domain of concerns about medication was positive for QOL and was associated with gender , age (> 37 years), physical exercise (no practice) and CD4 T-cell (> 350 cells/mm,Finally, among the analysis of QOL, the domain of sexual function presented one of the best averages. High score or better QOL in this aspect is due to the associations found with males, leading us to two hypotheses: either the men actually have a healthy sex life, or, because of cultural issues or even shame, men deny the impairment of their sexual lifeThe main limitation of the study arises from the impossibility of causal inferences, as it is a cross-sectional study. However, the study shows many determinants for the QOL of PLWHA, emphasizing that, when socioeconomic and clinical factors and life habits are not adequate, losses in quality of life can be emphasized.We conclude that the quality of life of persons living with HIV/AIDS presents losses, mainly in the financial and confidentiality areas, followed by general function of the body and satisfaction with life. Additionally, the domains of general function, satisfaction with life, health concerns, acceptance of HIV, financial concerns, and concerns about medication are associated with no exercise, showing that this factor, as well as some socioeconomic factors, are determinants for the QOL of PLWHA.From the premise that both the practice of physical exercise and socioeconomic factors are determinant for the quality of life of the population studied, we suggest the creation of public policies focused on both aspects, such as the encouragement of physical exercise and good nutrition. These guidelines would support the traditional treatment, providing the complete follow-up of PLWHA, from the strengthening of the multidisciplinary team. Such assistance would address the clinical, psychological, physical, and social aspects, which directly reflect on the QOL of the persons living with HIV/AIDS.


In the Americas, leishmaniasis is endemic in 18 countries, and from 2001 through 2015, 17 countries reported 843,931 cases of cutaneous and mucocutaneous leishmaniasis, and 12 countries reported 52,176 cases of visceral leishmaniasis. A Regional Information System (SisLeish) was created in order to provide knowledge of the distribution and tendency of this disease to analyze and monitor the leishmaniasis status. This article analyses the performance and progress of SisLeish from 2012–2015.modus operandi of the system and indicators utilized.The performance of SisLeish was evaluated by country adhesion, data completeness and delay in entering the data, and also by the SWOT technique. Furthermore, we outlined the structure and In 2012, only 18% of the countries entered the data in SisLeish before the deadline, where 66.7% and 50% of the countries with autochthonous CL/ML and VL reported their cases to the system, respectively. Whereas in 2015, 59% of the countries reached the deadline, where 94.4% and 58.3% of the countries reported their CL/ML and VL data, respectively. Regarding data completeness, there was great progress for different variables since its launch, such as gender, which had an approximately 100% improvement from 2012 to 2015. The SWOT analysis of SisLeish showed 12 strengths, 11 opportunities, seven weaknesses and six threats.From 2012–2015 there has been an improvement in the adhesion, quality and data completeness, showing the effort of the majority of the countries to enhance their national database. The SWOT analysis demonstrated that strengths and opportunities exceed weaknesses and threats; however, it highlighted the system frailties and challenges that need to be addressed. Furthermore, it has stimulated several National Programs to advance their surveillance system. Therefore, SisLeish has become an essential tool to prioritize areas, assist in decision-making processes, and to guide surveillance and control actions. there has been an improvement in the adhesion, quality and data completeness and the results show the effort of the majority of the countries to improve their national database in terms of completeness and availability. Furthermore, it has stimulated several programs to advance their surveillance system and program, and has been an alternative for countries that currently do not have a national information system available. SisLeish has become an essential tool to prioritize areas, where the occurrence of leishmaniasis requires additional attention, assist in the decision-making process, and to guide surveillance and control actions. This article analyses the performance and progress of SisLeish from 2012–2015.Leishmaniasis is among the most neglected diseases and remains a challenge for surveillance and control programs. In response to this challenge, the Regional Program for Leishmaniasis (PAHO/WHO), with the support of advisors and representatives from endemic countries, have created a Regional Information System (SisLeish), based on epidemiological and operational indicators, to provide knowledge of the distribution and tendency of this disease to analyze and monitor the leishmaniasis status in the Americas. Since the implementation of SisLeish,  Leishmania from the Trypanosomatidae family [Lutzomyia is the most important vector in the Americas [Leishmaniasis is an infectious disease caused by protozoan parasites of the genus e family . It is aAmericas . LeishmaAmericas , 3, and Americas , 4–7.Since mid-2000, the World Health Organization (WHO) has worked intensely to integrate leishmaniasis into the political agenda. In 2007, during the World Health Assembly, Member States adopted the Resolution WHA 60.13, assuming the commitment to strengthen the surveillance and control of leishmaniasis, which was reaffirmed by the approval of the Pan-American Health Organization (PAHO)/WHO Resolution, CD 49–19. During a meeting between the PAHO/WHO and representatives from endemic countries of the Americas, in 2008, the participants suggested the development of a regional tool to collect epidemiological data of leishmaniasis, which would standardize, update and release the information to all countries. In 2011, the individual Regional Program for Leishmaniasis (RPL) was instituted by the PAHO/WHO, with the main goals of improving the surveillance and control actions in the Americas, and supporting endemic countries through cooperation, technical consultations and mechanisms to strengthen these actions.The RPL began defining the epidemiological variables and operation indicators to monitor this disease in the region, in 2012, along with advisors of the PAHO’s communicable diseases, representatives of Leishmaniasis National Programs, and Surveillance Services from endemic countries. In sequence, the RPL developed the Leishmaniasis Regional Information System (SisLeish), which was validated and refined at different stages by the National Programs. The official system was presented during the Leishmaniasis Regional Meeting, held in Panama City on October, 2013, embodying efforts from all endemic countries of the Americas. SisLeish is a simple tool for analysing and monitoring leishmaniasis in the Americas. The system is based on epidemiological and operational indicators, allowing knowledge of distribution and tendency of this disease in the region.In the Americas, leishmaniasis is endemic in 18 countries, and from 2001 through 2015, 17 countries reported 843,931 cases of cutaneous (CL) and mucocutaneous leishmaniasis (MCL), and 12 countries reported 52,176 cases of visceral leishmaniasis (VL) [Health indicators are the synthesis of measures, which contain information about distinct attributes and dimensions, as well the performance of a health system, and they must reflect the sanitary status of a population and be suitable for surveillance of health conditions . TherefoRaw single indicators are widely used in traditional epidemiology to compare situations across different countries and regions, as these are often readily available in most countries and are easy to interpret and to compare , 12. On modus operandi of the system and the indicators utilized. This study is intended as a reference to inform current or potential stakeholders involved with leishmaniasis to promote awareness and use of this initiative.The objective of this article is to analyse the performance and progress of SisLeish from 2012 to 2015. Additionally, this article provides a deep overview of the structure and SisLeish is an on-line health information system, available in Spanish, developed with the purpose of being a simple tool and user-friendly system for inclusion and consolidation of data, and analysis of leishmaniasis in the Americas. The same provides knowledge and allows monitoring through information from epidemiological and operational indicators of distribution and tendency in the region.All data available in SisLeish are provided by the Leishmaniasis National Programs or their equivalents from each country that report cases of leishmaniasis, in the Americas. People with access to SisLeish are users appointed by the Ministry of Health (MoH), who are responsible for entering annual information regarding leishmaniasis occurrence and population.th of each year.The users enter their annual aggregated leishmaniasis data at the second administrative sub-national level. Moreover, the endemic State Members of the region have agreed upon an annual deadline to enter all of the leishmaniasis data, which is April 30ASP.NET with the Microsoft SQL Database Server Engine and the Crystal Report to generate data reports and information. This system is structured across three modules: i) module for epidemiological information, such as demographic data, clinical forms, confirmed cases of leishmaniasis by diagnostic criteria and progression of the disease (recovery or death); ii) module for surveillance, control and assistance; iii) specific module for species of Leishmania and suspected/involved vectors in the transmission, by region or country. Additionally, the output information is displayed in form of reports and is available by region, sub-region, and country at the first and second sub-national administrative level.SisLeish is a dynamic web page system created in th). Countries that have their own information system may fill the data into a standard issued table and import this table into the system; this process is currently being done by only two countries (Brazil and Colombia). Countries that do not have an information system are required to enter manually the data into the system through web forms. Afterwards, the data is imported into the database of the system and the indicators are calculated, generating different outputs, such as demographic, clinical form, diagnosis, treatment, and progression reports, at the first and second sub-national administrative level. These outputs are analyzed and used for epidemiological reports and mapping of the data.The users have a specific login to access SisLeish and are responsible for entering the leishmaniasis, population and surveillance, control and assistance data collected annually in their country , created by the United Nations Geographic Information Working Group . The carFor the SisLeish analyses, we evaluated the system performance in aspects such as country adhesion and data completeness. Furthermore, we used the strengths-weaknesses-opportunities-threats (SWOT) technique, which is a simple tool to analyze different types of scenarios and support planning, management and improvement of projects, systems and companies . This stBy 2015, all endemic countries have been granted access to SisLeish .In 2012, six of the 12 countries with autochthonous VL reported data to SisLeish , and 12 of the 18 countries with CL/ML transmission reported their cases . As for 2015, seven countries reported VL cases  and 17 reported CL/MCL cases . Further details of the progress on country adhesion can be observed in th of each year), in 2012 only three (18%) countries did meet the deadline, increasing to 10 (59%) countries in 2015. The results are shown in Regarding the established deadline to enter the annual data  analysis are summarized in This study describes SisLeish, which is an information system that consolidates and analyses the leishmaniasis data, and allows monitoring and knowledge of the epidemiological status of 18 countries in the Americas. One of the main objectives behind the development of this system was to provide information to the countries and Regional Programs in order to guide surveillance and control actions, against CL/ML and VL, within the countries and to assist the definition of regional technical cooperation priorities.Leishmania [In the Americas, leishmaniasis produces different clinical forms involving distinct species of ishmania . The conThere has been a considerable improvement in the adhesion, quality and data completeness. We observed a decrease in the delay to meet the established deadline to enter data into the system by the reduction of the median of days after the due date from 2012 (71 days after deadline) to 2015 (-1days after deadline). The results of SisLeish show the effort of the majority of the countries to improve their national database in terms of completeness and availability, mainly for CL/ML data, which is of compulsory notification in all of the endemic countries. In fact, SisLeish has stimulated several country programs to advance their surveillance system, and has been of particular incentive for countries that currently do not have a national information system available. For some countries, nevertheless, the notification of cases is aggregated at the second sub-national administrative level, which means a limitation in the quality of information provided by these countries. Thus, quantity and quality of information remain the main limiting factors of SisLeish, such as the well-known underreporting of leishmaniasis cases , 18, andThis information system has become an essential tool to improve knowledge and prioritize areas where the occurrence of leishmaniasis requires additional attention. The areas are identified utilizing the information provided by three single indicators, on the occurrence of leishmaniasis, and the results of the CICL. The solely use of single indicators  could lead, however, to an incomplete, or even misleading, interpretation of the occurrence. For instance, the relevance of an area with high number of cases could be “diluted” when accounting for the population and/or surface area, potentially deflecting the real problem. In contrast, the CICL allows combining the different indicators of occurrence, presenting their overall standardized additive value. Additionally, the Jenks natural breaks classification method allowed SisLeish to provide meaningful results on how to split the different categories of the CICL, in “natural clusters”. Thus, for example, SisLeish is able to identify areas with particularly very high results in the CICL, compared with the other categories, which are denoted as “very intense transmission”. These groups are clearly differentiated areas, since the Jenks method seeks to reduce the variance within classes while maximizing the variance between them . Other wWhen choosing health indicators it is essential to understand the nature of the data and the purpose behind the development of an indicator, otherwise the indicators could actually confuse or misguide decision-makers . In SisLDespite knowing the limitations of the use of single indicators for decision-making processes, the composite indicator for VL is still unavailable in the system. Brazil represents 96% of the VL cases in the Americas, and since 2003 the Brazilian MoH has been stratifying the areas of transmission, based exclusively on the average of human cases from the previous three years, to direct the surveillance and control actions. In addition to the limitation of the “average of cases” indicator, there is also a need to include other relevant epidemiological data, such as vector, infected dogs, among others; however, these additional data are not fully available and do not hold the required quality to be incorporated in an epidemiological analyses. In this context, due to a request from the Brazilian MoH, the RPL is currently working to combine the data available in the system into another composite indicator for VL.The visualization of the categorized data and indicators in maps allows a better understanding of the leishmaniasis epidemiological status. The database geocoding of SisLeish, at the first and second sub-national administrative levels, allows systematic mapping, which enables geographical monitoring of the occurrence. Hence, the data should be available at the most disaggregated administrative level to facilitate local analyses that contribute to the guidance and effectiveness of surveillance and control actions , 22. TheThrough the use of geographical information systems tools , 25, 26,Acceptance and implementation of an information system is one of the greatest challenges for epidemiological surveillance programs, which require continuous monitoring to reinforce the countries commitment to share information. Furthermore, SisLeish is providing support to sub-regional projects for cross-border surveillance, facilitating the exchange of information on the occurrence of leishmaniasis in the country borders. Additionally, SisLeish has developed a pilot alert system for VL in the borders of the MERCOSUR countries, which allows data sharing on phlebotomine presence, human and canine VL cases. Likewise, a surveillance, control and assistance module was created in 2015 to monitor and follow up with National Programs; this module was designed to become compatible with the database from the WHO, in order to reduce efforts and to avoid database duplicity. At first, this module had a low adhesion, only incorporating the data from two countries; nonetheless, there was a rise to nine countries in 2015.Despite being a simple methodology, the SWOT analysis has been increasingly used by managers and professionals to identify the strengths, weaknesses, opportunities and threats of programs, services or systems, to define and select appropriate strategies to improve actions and goals , 28. FigCurrently, SisLeish is undergoing a restructuring to enhance its functionality, which implies an improvement of the graphic and geographic interfaces, with the addition of interactive reports and maps, and providing public access to its information. Likewise, the system is being translated into the three main regional languages ; given that nowadays it is only available in Spanish.Since the implementation of SisLeish, the adhesion is continually growing, and presently has the data from all endemic countries available in the system. Therefore, it is imperative to continue encouraging countries to report their data, through improvements and an ongoing evolution of the system, so it can remain as an important surveillance tool in order to guide and implement actions.


Essential physiological functions in eukaryotic cells, such as release of hormones and digestive enzymes, neurotransmission, and intercellular signaling, are all achieved by cell secretion. In regulated  secretion, membrane-bound secretory vesicles dock and transiently fuse with specialized, permanent, plasma membrane structures, called porosomes or fusion pores. Porosomes are supramolecular, cup-shaped lipoprotein structures at the cell plasma membrane that mediate and control the release of vesicle cargo to the outside of the cell. The sizes of porosomes range from 150nm in diameter in acinar cells of the exocrine pancreas to 12nm in neurons. In recent years, significant progress has been made in our understanding of the porosome and the cellular activities required for cell secretion, such as membrane fusion and swelling of secretory vesicles. The discovery of the porosome complex and the molecular mechanism of cell secretion are summarized in this article.


The famous Professor Eliot Sorel from GWU, DHC and “Carol Davila” University of Medicine and Pharmacy in Bucharest affirmed that: “Health, healthcare and the transformations in the health systems need complementary innovations at the level of the professions in the health field, as far as education and training is concerned. Moreover, a new approach regarding health, healthcare, health and research systems is needed together with the creation of a new partnership between the bidders, consumers, decision makers, private, public and non-governmental sectors in all the countries, the economies with low, medium and high incomes”. In the welcoming note of the 4th Edition of “Carol Davila” University of Medicine and Pharmacy Congress, which took place in June at the Palace of Parliament, the distinguished Academician, Ioanel Sinescu, Rector of “Carol Davila” University of Medicine and Pharmacy in Bucharest, Romania, stated: “In a context of new beginnings, in order for this project to be continued, so as to keep the tradition of organizing this event alive, we need bold people, solidarity and common effort, which should be in agreement with a strategy that we should all build together. I am talking about the involvement of all the members of “Carol Davila” University of Medicine and Pharmacy in Bucharest, Romania”.In order to materialize these ideas, “Carol Davila” University of Medicine and Pharmacy increased its valuable academic teaching staff with six remarkable personalities who are worldwide famous. Prof. C. ChappleMember of the Royal College of Surgeons in Great Britain  and secretary general of the European Association of Urology, Professor Christopher Chapple graduated from the University of London as Bachelor of Medicine and Bachelor of Surgery. From the beginning, he had a keen interest in LUTS, female incontinence and reconstructive surgery, and has performed surgeries regarding the functional reconstruction of the urinary tract, later developing the European School of Urology on behalf of the European Association of Urology. In 2006, he was appointed Visiting Professor of Urology at the Sheffield Hallam University and in 2013, he became Honorary Professor of Urology at the University of Sheffield. Aside from being a brilliant surgeon, he is already responsible for more than 350 scientific articles published in prestigious journals and more than 50 books or chapters in the field of urology, with a great impact on the professional life and activity of the urological community. Moreover, he has also been acting as Editor in Chief of the journal “Neurourology and Urodynamics”, which is the official journal of the International Continence Society and the Section of Urodynamic and Female Urology of the American Urological Association, and, in 2011, he was awarded the St. Peter’s Medal of the British Association of Urological Surgeons. Professor Chapple was the first to localize the alpha-receptor subtypes within the human prostate, has thoroughly investigated the mechanisms involved in the alpha adrenergic and muscarinic innervations, urothelial relaxing factor, neurokinins and purinoceptors. He has ongoing projects on tissue engineering for autologous buccal mucosa for urethroplasty, and has been envisioning new approaches in the management of pelvic floor prolapse and stress urinary incontinence.Prof. D. AtarProf. D. Atar is the Head of Research at Oslo University Hospital, Norway. He holds a full Professorship in Cardiology at the University of Oslo, along with a Visiting Associate Professorship at the Johns Hopkins University, Baltimore, United States. He first went to Denmark, where he trained in internal medicine and cardiology at the University of Copenhagen. During 1990 and 1994, Professor Dan Atar moved to Baltimore, where he continued his career at the University of Maryland and the Johns Hopkins University, in the field of cardiology and as a researcher in heart problems. Later, he went to the University of Zurich, where he was trained in interventional cardiology, and where he became a cardiology faculty member, under the guidance of Thomas Lüscher, Editor in Chief of the European Heart Journal. His research focuses on myocardial biomarkers, myocardial function in myocardial infarction, particularly regarding the aspect of prevention of reperfusion injury, heart failure, and cardiovascular pharmacology. He has written more than 300 articles and book chapters and has more than 35,000 citations and a Hirsch Index of 56. At the same time, he is Associate Editor of journal “Cardiology” and member of the Editorial Board of the “European Heart Journal” and “Cardiovascular Diabetology”. Consequently to his outstanding activity, he received a number of Awards such as: Research Award of the International Society of Heart Research in 1994, Cardiology Award of the Swiss Heart Foundation in 1996, “Andreas Grüntzig Award in Interventional Cardiology” in 1997), and the Scientific Award of the Norwegian Society of Cardiology in 2014.Prof. Piotr Radziszewski, MD, PhDProfessor Piotr Radziszewski graduated from the School of Medicine – University of Medicine of Silesia, in Katowice, Poland.He was Head of the Neurourology Research Unit in the Department of Urology of the Medical University of Warsaw, fellow of the European Board of Urology, Head of the Urogynecology and Functional Urology Unit and Chairman of the Department of General, Oncological, and Functional Urology of Medical University of Warsaw. The European Association of Urology acknowledged his interest and activity in the field of Neurourology and Urodynamics by appointing him as a member of the “Board of the Functional and Female Urology Section” of the European Association of Urology and as member of the “Guidelines Committee on Neurogenic Bladder”.He is also a member of the Neurology Committee and of the Educational Committee of the International Continence Society. Professor Piotr Radziszewski published over 250 original articles in prestigious medical journals and authored 18 book chapters and 3 books. He is a member of the Editorial Board of many prestigious international medical publications such as “Neurourology and Urodynamics”, the “Central European Journal of Urology”, “Annals of Urology”, “Archives of Medical Sciences”, “Urologia Internationalis”.In October 2015, the President of Poland, Andrew Duda, appointed Professor Piotr Radziszewski as a member of the Healthcare Committee of the National Development Council.Prof. L. SchmettererProf. L. Schmetterer graduated from the Technical University of Vienna in 1986 and University of Vienna Medical School in 1989. He is currently an Extraordinary Professor at the Centre of Medical Physics and Biomedical Engineering and at the Department of Clinical Pharmacology, Medical University of Vienna.Professor Leopold Schmetterer has published over 270 original papers and reviews in Diabetes, Diabetes Care, Neurology, Ophthalmology, Progress in Retinal and Eye, his impact factor being of 10 and his works being cited over 11000 times. He is the author of a milestone book about Ocular Blood Flow  and coauthor of more than 30 book chapters.He owns 16 patents, among them 10 in the field of OCT (Ocular Coherence Tomography).He was President of EVER (European Association for Vision and Eye Research), member of the board of the Austrian Science Foundation and he is member of the editorial board of many international scientific journals including the highest ranked ophthalmological ones.Recently, as recognition of his scientific contribution, it has been proposed to join one of the most famous and respected research institutions of the world: SERI (Singapore Eye Research Institute).Prof. V. Shah, MD, PhDProf. Vinod Shah, MD, PhD is a Pharmacy graduate with Gold Medal from Madras University, India, worked for 5 years in the pharmaceutical industry, Sarabhai Chemicals, Baroda, India, and from 1975 joined US FDA (Food and Drug Administration) in the Division of Biopharmaceutics. He has received several FDA Awards including Award of Merit , Scientific Achievement Award (2000), Commendable Service Award (2000) and Distinguished Career Service Award (2005). He is author/co-author of over 300 scientific papers and is a co-editor of five books. He was an Adjunct Professor at College of Pharmacy, University of Kentucky (2001-2011), a visiting professor at University of Philippines Manila, etc. Vinod Shah, MD, PhD is also an Honorary Member of Indian Pharmaceutical Association (2003), Honorary Member of Hungarian Society for Experimental and Clinical Pharmacology (2012). He is a recipient of FIP Industrial Pharmacy Award (2001 and 2008); IDMA - Eminent Pharmaceutical Analyst Award, India (2009) and SPDS Excellence Award, India (2014). He was the President of the American Association of Pharmaceutical Scientist (AAPS) in 2003 and a member of the International Affairs Committee of AAPS (2003-2014). Prof. F. HuismanProfessor Frank Huisman is a member of Utrecht University in Netherlands. He was President of the European Association of History of Medicine (EAHMH). He started his academic career in the field of history of medicine and medical ethics at the University of Amsterdam, where he completed his PhD studies with a paper regarding the beginnings of the medical system and of modernity in Netherlands, which received the Lindeboom academic award. He continued his career in the Department of History of Medicine at the University of Maastricht and, in 2006, he became a Professor of History of Medicine at the University of Utrecht, where he currently activates. Professor Huisman is involved in the activity of one of the most important centers of scientific research in Europe, Descartes Centre for the History and Philosophy of the Sciences and the Humanities. The range of his interdisciplinary preoccupations in the field of history of medicine and of interdisciplinarity between medicine, society and human sciences, is impressive: history and ethics of health systems, analysis of the pharmaceutical infrastructure in medicine - De Nederlandse farmaceutische industrie in de negentiende en twintigste eeuw , history of medical culture and of the concepts of medical school, theory and terminology of medicine. He has also made wide researches in the following fields: History, Philosophy, and Ethics of the sciences of life. Another excellence field is his preoccupation for opening histories and medical biographies in Europe in the context of scientific internationalization, which he highlighted with important, highly cited studies, such as Locating Medical History, The Stories and Their Meanings  and Dictionary of Medical Biography (the Netherlands and Flanders).He is also actively involved in interdisciplinary research commissions in the University of Utrecht and the University of Maastricht - Historical and Comparative Studies of the Sciences and Humanities.Moreover, Professor Huisman has many leading positions at the European and national level, being the Head of some prestigious medical organizations and societies. In addition, between 2009 and 2011 he was the President of the European Association of History of Medicine (EAHMH). He was also the unique author and co-author of many important books. The scientific studies published in the last 10 years alone prove the polyvalent mind of a true humanist scientist, recognized at the international level as an authority in the field.Executive EditorProf. Dr. Eng. Victor Lorin Purcarea


Chlorinated dioxins are the group of environmental pollutants consisting of 210 chlorinated dibenzo-p-dioxins and dibenzofurans. They are highly toxic and persistent. They are lipophilic and can easily biomagnify in the food chain, hence posing a serious threat to human health. The daily consumption of low-level contaminated food, mainly of animal origin, leads to the accumulation of dioxins in the human body. The exposures of the general human population to dioxins and the specific issues of a risk assessment of dioxin pose serious concerns in public environmental and nutritional health. This paper reviews the analysis of chlorinated dioxins in ground beef. The sources of contamination of chlorinated dioxins in ground beef are first reviewed to form a basis for a clear understanding of the health implications of chlorinated dioxins in the human food chain and why it is necessary to monitor the level of dioxins in animal food products, especially ground beef. The methods of collection, sampling, and processing of ground beef, and the methods of sample clean up prior to the analysis, are reviewed. Emphasis is laid on the new techniques that are available and that might be effective in the analysis of chlorinated dioxins in ground beef. Among these new methods and techniques are: the synergistic combination of ELISA/GC/MS, direct sample introduction to /GC/MS-MS, automated clean-up method, and the supercritical fluid extraction methods. The possible treatments of results from each method and technique are discussed and their respective efficiencies are compared. Finally, quality control and quality assurance parameters are evaluated for levels of accuracy, reproducibility, and precision.


The process of peer review for submissions to scientific journals is a well-established and widely used procedure. Review by one's peers is a well-recognised and long-standing method of appraisal. Throughout all branches of science, medicine, humanities, art, literature, politics, sport, and in fact almost all areas of human endeavour, the judgement of work by an individual or group of experts in similar fields of study is the most rigorous and valuable form of recognition. “Peer review”, as this process is commonly known, is an important method of assuring quality, relevance and novelty of work. However, is there still room for improvement in the procedural aspects of peer review?