To assess the costs of the Smoking Cessation Program in the Brazilian Unified Health System and estimate the cost of its full implementation in a Brazilian municipality. The intensive behavioral therapy and treatment for smoking cessation includes consultations, cognitive-behavioral group therapy sessions, and use of medicines. The costs of care and management of the program were estimated using micro-costing methods. The full implementation of the program in the municipality of Goiania, Goias was set as its expansion to meet the demand of all smokers motivated to quit in the municipality that would seek care at Brazilian Unified Health System. We considered direct medical and non-medical costs: human resources, medicines, consumables, general expenses, transport, travels, events, and capital costs. We included costs of federal, state, and municipal levels. The perspective of the analysis was that from the Brazilian Unified Health System. Sensitivity analysis was performed by varying parameters concerning the amount of activities and resources used. Data sources included a sample of primary care health units, municipal and state secretariats of health, and the Brazilian Ministry of Health. The costs were estimated in Brazilian Real (R$) for the year of 2010. The cost of the program in Goiania was R$429,079, with 78.0% regarding behavioral therapy and treatment of smoking. The cost per patient was R$534, and, per quitter, R$1,435. The full implementation of the program in the municipality of Goiania would generate a cost of R$20.28 million to attend 35,323 smokers. The Smoking Cessation Program has good performance in terms of cost per patient that quit smoking. In view of the burden of smoking in Brazil, the treatment for smoking cessation must be considered as a priority in allocating health resources. Smoking is an epidemic disease arising from nicotine addiction and is the leading cause of preventable deaths in the world, estimated in 6 million annuallyThe economic burden of smoking to society is also significant. The annual expenses with treatment of tobacco-related diseases and the loss of productivity resulting from the morbidity and mortality of smoking have generated an economic burden of U$193 billion in the United States between 2000-2004,In Brazil, smoking resulted in 130,000 deaths in 2008, 13.0% of total deaths, already surpassing international estimates of 10.0% of deaths attributable to tobacco in 2015. The costs of treating tobacco-related diseases amounted to R$21 billion in 2011, considering the public and supplemental health systemsSince the 1980s, the Brazilian Ministry of Health has been adopting various actions for smoking control, which culminated in the creation of the National Smoking Control Program, coordinated by the National Cancer Institute (INCA) since the early 1990sIn the treatment model adopted by Brazil, after initial assessment appointment, smokers receive intensive cognitive-behavioral therapy, which combines cognitive interventions with training of behavioral skillsThe program is managed articulately by the federal, state, and municipal levels of SUS management. The trainings, technical support to activities, and distribution of used inputs are done “cascading”, from the federal to the municipal level. Educational materials and medicines are supplied by the Ministry of Health, and may be supplemented by the states and municipalities. The information is collected and consolidated from the local to the central level.,,,,,The effectiveness of brief counseling, intensive group therapy, NRT, and bupropion was evidenced by several meta-analysesIn view of the scarcity of resources for health, as well as of effectiveness, we must also consider the costs of health programs. These are still an essential part of health economic evaluations that compare treatment alternatives, producing information on the costs and benefits of them, thus orienting the decision-makingStudies conducted in the United States indicated costs of smoking treatment programs per participant of U$67 (brief telephone counseling without NRT), U$268 (intensive counseling associated with NRT)The cost estimate of the Smoking Cessation Program in Brazil is, therefore, an important subsidy to support SUS managers in planning actions and maximizing the use of resources, as well as in decision-making regarding their prioritization, guiding the efficient allocation of resources.The aim of this study was to estimate the costs of the program in a Brazilian municipality, including the treatment of the smoker and program management, considering the different levels of management involved. We also estimated costs if the service was expanded to fully meet the demand of the municipality’s smokers motivated to quit.Cost study of the Smoking Cessation Program, implemented in primary health care. The unit of analysis was the municipality of Goiania, adopting the year of 2010 as time frame, both for measurement of data and valuation of inputs. We considered the perspective of SUS, funder of the program in the public health sector in Brazil, including direct medical and non-medical costs and management costs. Indirect costs were not considered.The activities were identified and grouped into components of the two program axes: behavioral therapy and treatment of smoking and management. The behavioral therapy and treatment axis comprises the following components: (i) consultations , including initial clinical evaluation and return visits; (ii) intensive cognitive-behavioral therapy sessions, including their preparation and execution; and (iii) phamacotherapy. In Goiania, the group sessions are conducted over six months. The brief counseling was not considered. The management axis includes two components: (i) technical support and (ii) training.The costs of behavioral therapy and treatment of smoking were estimated considering a convenience sample of health facilities and extrapolated to the municipality as a whole, also using data available to all groups and patients attended. The sample was selected considering the following criteria: (i) systematization and availability of information; (ii) time of implementation of the program; (iii) quantity of groups; (iv) type of health facility; and (v) location. Six facilities were selected, considering different types and locations, with the largest number of groups, deployment time, and better quality of information. The program management costs were was estimated considering the activities carried out by municipal, state, and federal coordinations of the program.The activities of the two axes of the program were estimated by micro-costing, measuring the amount used of each resource and assigning it the corresponding unit value. The resources used were identified as cost items and categorized as medical and non-medical costs, considering recurrent and capital costs. The cost structure, according to the components and axes of the program, is presented in Shared costs with other health programs and actions were assigned to the Smoking Cessation Program using as an indicator of the attributable fraction the proportion of professionals’ time dedicated to the program in relation to the total time of the goal activities of the health unit or, in the case of management, of the administrative sector where the coordination of the program is.,In the sampled health facilities, the costing of the behavioral therapy and treatment was made by therapeutic group, according to the specific care configuration adopted in the facility regarding the frequency and duration of activities and professionals involved. The data were obtained in interviews with the coordinators of the groups. The professionals’ time dedicated to the cognitive-behavioral therapy sessions was obtained in individual interviews, considering the average time for the cost estimate. The time of the consultations and of the dispensation of medicines was arbitrated considering the literatureTo estimate the cost of the behavioral therapy and treatment in the municipality as a whole, we considered that all smokers attended in 2010 (n = 803) underwent a common configuration of care. The parameters used in the base scenario of costs estimate of each component of behavioral and treatment and the respective data source are presented in The cost with human resources was obtained by multiplying the frequency of the activity by the number of professionals involved, by the time of duration, and by the average remuneration of professionals, plus employers’ charges. The remaining medical costs were added to the value obtained (cost with clinic equipment for consultations and cost with NRT and antidepressants for medicine treatment). Non-medical costs were estimated based on the percentage they represented in relation to medical costs in the sampled health facilities. The sum of medical and non-medical costs was multiplied by the number of patients seen, for consultations and pharmacotherapy, and by the number of groups (n = 44), for sessions. In the consultations, patients receiving or not medicines were stratified, considering that patients present at the fourth session of cognitive-behavioral therapy made return visits. The sum of the total cost with consultations, sessions of behavioral therapy, and pharmacotherapy resulted in the total cost of the therapy and treatment of smoking.Management costs were estimated for each realm of management. The data were obtained with the program coordinators, in administrative records and management information systems of the three realms. The fraction of federal and state cost attributable to the municipality of Goiania was obtained based on the number of cities managed by these coordinations. The total of management assigned to the municipality was divided between the groups conducted.The The results are presented as total cost of the program, per group, stratified by cost item, component, and funding source. Cost per patient was estimated by dividing the cost of the program among all patients attended at the first session of cognitive-behavioral therapy. The cost per patient that quit smoking corresponds to the total cost divided by the patients who were not smoking at the end of the treatment.,,The expansion of the program to meet the demand of all smokers motivated to quit smoking in the municipality was set as full implementation. For the estimation of the number of smokers to be attended, we considered the prevalence of smokers in the population with 15 years or more of age (17.0%)The smokers were distributed by the three components of the behavioral therapy and treatment, according to common care configuration of the municipality, considering maximum efficiency: all primary care facilities conducting two groups of 15 smokers per year, with provision of medicines to 84.0% of them, according to the degree of dependence to nicotine of the 2010 patients, measured by Fagerström test. The cost of management was estimated by multiplying the annual cost of 2010 by the number of years required for all smokers to access treatment.A sensitivity analysis was performed to assess the impact of the variation of parameters on the results of the behavioral therapy and treatment costs. Many parameters not known or with different values on different sources of information were analyzed. In addition to the base scenario, three new scenarios were created: (i) SMS-Goiania Guidance – considering recommendations or administrative records of the municipal coordination of the program; (ii-iii) Minimum and Maximum, considering respectively minimum and maximum values found in the sampled units and data sources .The research project was approved by the Research Ethics Committee of the Hospital das Clínicas of the Universidade Federal de Goias (Protocol 155/2011).In the sampled health facilities, the cost of the behavioral therapy and treatment per therapeutic group, composed of eight to 36 smokers, ranged from R$2,937 to R$9,864. From this total, medical costs accounted for, in average, 85.8% and human resources costs, 73.1% (ranging from 62.3% to 90.2%). Including management costs, the total cost of the Smoking Cessation Program per group ranged between R$5,130 and R$12,057. The greater participation in the funding of the program came from the municipality, responsible for 78.2% of the total cost, followed by the federal (13.6%) and state level (8.4%). The largest federal participation was related to medication, and the Ministry of Health was responsible for 67.7% of the total cost with NRT and bupropion.In the municipality as a whole, 44 groups of six to 55 smokers were conducted, generating a total program cost of R$429,079 in the base scenario, with 78.0% regarding the behavioral therapy and treatment for smoking cessation. The component of greater participation in the costs of the behavioral therapy and treatment were of cognitive-behavioral therapy sessions (54.0%), followed by pharmacotherapy (24.3%), and consultations (21.7%). The average cost per patient was R$ 534, and, per quitter, R$1,435. The average cost of pharmacotherapy per patient who used NRT or bupropion was R$174. In the sensitivity analysis, the results varied in the minimum and maximum scenarios, but not in the SMS-Goiania Guidance scenario .The full implementation of the program would require R$20.28 million, benefiting 35,323 smokers motivated to quit smoking, out of a total of 175,331 smokers, representing R$574 per patient. From this total, the behavioral therapy and treatment cost would be R$19.05 million, and the management cost, R$1.24 million. In the sensitivity analysis, the total cost ranged between R$13.61 and R$34.35 millionThis study contributes to the knowledge of the costs of the Smoking Cessation Program in Brazil, estimating the costs not only of treatment, but also of the program management in the three management levels, with cost per patient that quit smoking close to the smaller ones referred to in the international literature.,,The comparison of the results with the literature is difficult, given the methodological variations concerning the considered perspective of analysis, assumptions, costing method, and cost itemsThe proportion of costs with pharmacotherapy in Goiania (24.3%) was not high, resembling the observed in the program evaluated in Switzerland (22.8%)The cost with medicines per patient, including NRT and bupropion, which ranged from R$174 to R$194 in the different scenarios, differs from the findings of another national studyThis study has strengths and limitations. The costing methodology used allowed us to identify resources with a high degree of detail, giving precision to the results, in a comprehensive approach, which also considered the program management. Some limitations arise from the difficulty of estimating the cost and the portion attributable to the program of activities, such as the dissemination and the process of buying medicines. At the federal level, we did not include transportation costs, general expenses, and capital costs. However, as these costs were not influential in the cost of the municipal and state management, we believe that they would not significantly increase the costs at the federal level. Another limitation refers to information about smoking cessation, obtained based on the patients’ self-report, without biochemistry confirmation of abstinence.When estimating the costs of full implementation, we have incurred in uncertainties on various parameters. The number of smokers to be treated may be underestimated, because we considered only the most advanced stage of motivation for treatment, while the previous stage has been mentioned as a predictor of success,Despite the cost variation described, interventions for smoking cessation have been considered highly cost-effective,,In Brazil, 82.0% of lung cancer cases, one of the main tobacco-related diseases, are attributable to smoking. Their treatment in specialized public hospital was estimated in R$28,901 in 2006 for patients with a history of smoking, cost significantly higher than the cost per patient that quit smoking in the Smoking Cessation ProgramCorroborating the evidence available in the international literature, this study suggests that the Smoking Cessation Program, implemented on SUS about a decade ago, has good performance regarding the cost per patient that quit smoking in Goiania, a municipality that follows the treatment model recommended nationally. This cost can be even smaller with increasing access and demand management, diluting the costs of program management and promoting greater use of the cognitive-behavioral therapy sessions.In view of the major impact of smoking in the morbidity and mortality of the Brazilian population, the high cost of treating tobacco-related diseases, and the favorable cost-effectiveness of interventions for treatment of smoking, the Smoking Cessation Program must be considered a priority when planning the allocation of health resources. The evidence that the total funding of treatment, i.e., without additional cost to the patient, results in higher rates of abstinence reinforces such recommendationWe suggest the conduction of studies to assess the indication of treatment of smoking for SUS users in clinical practice, assisting in the development of strategies for referencing patients and increasing the scope of the program. Also, studies about the cost-effectiveness of the program are needed to provide more subsidies for the decision-making of managers as to their prioritization and encouragement.


We read the conclusions of Lerche et al.  with greDespite the recent interest in finding biomarkers for Parkinson's disease  to thoroughly evaluate the data, as well as making use of integration models which can capture interplay between biomarkers that would have otherwise been hidden Azuaje, .Study concept and design: YA, TA, and MM; Acquisition of data: YA; Analysis and interpretation: YA, MM; Critical revision of manuscript: YA, TA, and MM; Study supervision: TA, MM.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. The reviewer ND and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


Addition of an AuthorLeo R. Quinlan was not included as an author in the published article. The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way.The original article have been updated.AR-M conceived the study, designed the study and drafted the first version of the manuscript AS, CP-L, DR-M, and MMA contributed to the study design, and performed algorithmic work and statistical analysis. They contributed to and approved the final version of the manuscript. SA, BM, PQ, BG, GV, PB, DS and LRQ performed the field work and approved the final version of the manuscript. AB, HL, AC, RA, TC, and GOL contributed to the study design and data collection in their respective study site. They contributed to and approved the final version of the manuscript. JC contributed to the study conception, coordinated the project in the different study sites and approved the final version of the manuscript.AR-M, AS, CP-L, JA, and JC are shareholders of Sense4Care, which is a spin-off company, which may commercialize the results of this research device in future. These authors declare that the possible commercialization of the product is a research outcome, not being the design, the analysis, the interpretation of the results, or the conclusions being affected by commercial interests. All other 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, 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.


This study focuses on the attributes of students of physical therapy in order to compare the profiles of students of physical therapy (PT) in two institutions of higher learning in Israel: Ben Gurion University (BGU) and the Academic College of Judea and Samaria (ACJS). This study focuses on a department where studies have an occupational/applicative/practical orientation and high status in the higher education system. Findings of this study indicate broad similarities in the profiles of students at both institutions in relation to their age, family status, country of origin, number of siblings, parental education, and financial status of student family of origin. On the other hand, students at both institutions differed in terms of gender composition, students' employment status, the source of payment for tuition, and in their academic attainments prior to admission. Specifically, students of physical therapy at ACJS had lower academic achievements prior to their admission and reported having been rejected by other physical therapy programs. Students at ACJS placed higher importance on factors relating to the quality of instruction including teacher involvement, competitiveness, organization, control, and orientation to the study material. Students at BGU attributed greater importance to teachers' support. Findings support a thesis of a converging system of higher education in Israel, traditionally dominated by national universities and regional colleges, a relatively recent phenomenon.


During preoperative evaluation for anesthesia in the Down patient, it is important to focus attention on the functional conditions of the patient and systems that frequently show anomalies. One of the challenges of evaluating pre-operative conditions and potential risks in the Down patient is the lack of a gold-standard evaluation score; cervical spine abnormalities, reduced dimensions and malformations of the airways, neurological changes, respiratory and cardiac disease, as well as endocrinological and metabolic alterations. We suggest, as a possible method of evaluation for patients with mental retardation and possible malformations, a new scale which takes the functional and mental conditions into account: the Sensorial, Psychological, Anatomical, Biological, Operational and Surgical (SPABOS) Compliance Score.


To demonstrate the importance of using the family genogram in pediatric consultation, as an analysis tool to evaluate the degradation of parental bonding and also violence against children.®-2016 software. In order to evaluate the quality of bonding, the following items were included in the genograms: violence against children, drug addiction, neglect, mental disorder, type of relationship among family members. A qualitative study was conducted in 2011 wherein 63 children, aged between 2 and 6 years, enrolled in a slum nursery, was studied. In order to construct the genogram, data were collected in four stages: pediatric evaluation at nursery; interview with caregivers; interview with teachers; and interview with the nursery coordinator. The data about the families were used to construct the genograms with the aid of GenoPro The evaluated children and their families generated 55 genograms. In 38 of them, functional family arrangements, and close or very close emotional ties were observed. In 17 cases, situations involving physical, emotional, or sexual violence against children were perceived. Among these, four represented extreme cases, with fraying parental bonding, and dysfunctional family arrangements. In these families, chemical addiction was prevalent among multiple members, as well as severe mental disorder, persistent physical and verbal abuse, and sexual abuse. The use of the genogram helps to identify at an early stage the degradation of parental bonding and violence against children, and when it is incorporated into the pediatric practice routine, it may contribute to the promotion of the comprehensive health care of the child, regardless of the presence of social vulnerability. In modern society, a family arrangement is one of the different configurations that the family can embrace, such as multigenerational family, extended family, and reconstructed family.The family can be both protective against the development of mental disorder and it can turn into a triggering factor. When the mother is an alcohol consumer, an environment with low cohesion and organization, as well as great incidence of domestic violence, is observed.Sierra and Mesquita analyzed children and adolescents and concluded that intra-household violence perpetrated by the parents, as well as privation and negligence, represent high chances of causing psychological and physical damage, and the consequent delay in the full development of the child.,Among the innovative practices that provide a broader view of the child’s universe, the family genogram stands out.Therefore, this study aimed at describing the use of the family genogram in the pediatric appointment as a tool to analyze the degradation of parental bonding and violence against children.The study consisted of a qualitative study, conducted in a philanthropic day-care facility in the city of Guarulhos, São Paulo. The institution is managed by a religious order and is located at the border of the road Fernão Dias. The population of this investigation included 63 children, aged between 2 and 6 years, enrolled in the day-care facility in 2011, corresponding to 55 family genograms.To build the genogram, data collection about the children took place in four moments: at the pediatric evaluation in the daycare, by analyzing the school records; interviewing the person in charge of the child; interviewing the teachers; and interviewing the day-care coordinator. First, the mother or tutor was interviewed with a structured questionnaire. Then, the teacher in charge of the child was interviewed in order to obtain additional information such as parental involvement in the children’s routine at the daycare, health care, and signs of violence or sexual abuse. At last, the religious woman in charge of the facility was interviewed, since she had major influence on the community and had extensive knowledge about the families. In this interview, it was possible to collect information regarding the use of alcohol and other drugs by the family members, the quality and type of family bonds, and the history of physical and sexual abuse.®-2016 , in which the symbols represent the individuals, and the lines translate relationships between the individuals.,The structured questionnaire, applied during the interview of the mothers or tutors, involved the following data: general conditions of the child, identification and obstetric history of the mother, lifestyle and household, child’s medical history, family structure, qualification of the head of the family, work status, type of household, family monthly income, registration in the social program Bolsa Família, marital status, number of residents in the household, basic sanitation conditions, and presence of an electric network. Data about the families were used to build the family genograms, with the software GenoProThe research project was approved by the Research and Ethics Committee (CAAE n. 0051.1.186.000-11), and the Informed Consent Form was signed by the children’s parents or tutors after agreeing to participate in the study.The children assessed and their respective families generated 55 genograms; 38 showed functional family arrangements, with close or very close affectional bonds. Despite being socially vulnerable, most families had in place protective nuclear arrangements and functional dynamics for the child. By considering the levels in the spectrum of violence, in these families the mild form stood out. Parental bonding was strong, and physical or verbal aggression was a reproduction of models coming from paternal education. Another experience presented in these groups, with less frequency, was negligence. Parental bonding was weakened by paternal mental disorders, single-parent relationships, chemical dependence, or a mother with multiple partners.In 17 of the analyzed cases, there were situations involving physical, emotional, or sexual violence against children. The most extreme cases of violence, with weak parental bonding, occurred in families with dysfunctional arrangements. In these cases, the prevalent scenario was chemical dependence of many family members, severe mental disorder, persistent verbal and physical aggression, and sexual abuse. The child often took the role of the adult, being in charge of taking care of family members. The results present the family genograms of children who have been victims of extreme violence. The child is represented by the first letter of his or her name (as shown in Genogram F  shows a Genogram R  presentsThe families assisted at the daycare facility, living in a condition of social vulnerability, represent a heterogeneous community, concerning both family arrangements and the quality of parental bonding. When the pediatrician evaluates the child guided by the practice that is limited to the biomedical model, it is not possible to consider the complexity of interactions in the family household, which contribute to the child’s health. The action of not recognizing family dynamics may result in limited and mistaken interventions addressed to determining the real needs of the patient and his or her family, which is negative for full care.,Therefore, the use of the family genogram will enable the analysis of the psychosocial context of the children, their families and diseases, favoring the identification of stressful factors in the family context. Its applicability starts in the pediatric outpatient clinic, contributing to the construction of clinical reasoning and judgment, and goes to emergency care situations, in which the traditional model does not provide satisfactory answers to the clinical situations of the child. The conditions in which the biomedical model shows its limitations the most involve complex family contexts, with children’s behavioral issues, mental disorder, chemical dependence, and intra-household violence.The children in this study did not have clinical complaints; however, by analyzing their genograms, the vulnerability to several forms of violence became clear. All families assessed, showed high level of social vulnerability, including different family arrangements and a wide spectrum of parental bonding quality, reaching extreme degradation. In these families, the bond is weakened by maternal mental disorders, single-parent relationships with the absence of the father, chemical dependence or presence of multiple partners. It was observed that violence defined as the intentional use of physical force or power, actually put to use or threatened, self-inflicted, inter-personal or collective, leading to or with high chances of injury, psychological damage, developmental deficiencies, or privation and death, which were the reality of these families - with a variation in the level of intense and type.In dysfunctional family arrangements, the child’s physical and psychic health is under constant threat. Therefore, if the children and their families do not receive the proper assistance from supportive and protective networks, they can evolve to a long cycle of disturbances, thus perpetuating violence.,,,,The life of this child with alcoholic parents has been associated with the development of mental and behavioral disorders, such as depression, anxiety, affectional disorders, low school performance, and emotional insecurity.In the four families assessed with the genogram, the presence of family violence associated with alcohol or drug abuse by one or both parents was observed; in these cases, the children of these families had their parents as their single affectional bond. Therefore, all children in these families are subject to developing some sort of mental or behavioral disorder throughout their lives. According to the daycare, at least one child in every analyzed family presented difficulties in school performance, in socializing with other kids, and in establishing an affectional bond with the teachers.The results of this study demonstrate the importance of using the family genogram in the pediatric appointment, in extreme cases, as a tool to analyze the degradation of parental bonding and violence against children; however, this resource also allows to assess the exposure of the child to several types of stressful factors in less extreme cases. The genogram allows the pediatrician to assess the structure and the functionality of the family, as well as the role of the child in the household. Its construction is dynamic and should be completed after each appointment, according to the transformations in the lifecycles of the family. Therefore, the quality of parental bonding is shown, and violence against children can be perceived in its genesis, even at milder levels.Despite being similar to a genealogical tree, its complexity and comprehension is much larger. Its configuration is more like a relational map of family members, whose symbols have been standardized since the early 1980s, by the North-American Care Research Group. The symbols characterizing the male individuals are squares, and female figures are circles. The affectional relationships are drawn with lines, according to the intensity and type. The graphic presentation in a single page, in the medical record, allows the health team involved in childcare to be aware of the available data. This information often involves delicate situations, regarding difficult family relations, which are, however, relevant to understand an acute or chronic condition and to construct adequate therapeutic projects.Its incorporation in different scenarios of pediatric clinical practice could, in fact, contribute to the promotion of full health care for the child, increase the resoluteness of the care provided, assist the family to find new ways to see its members, promote more ways to rescue autonomy in their own therapeutic plan regardless of the presence of social vulnerabilities.


Pioneerism with theinterval of evaluation extended from three to four years, and the record and collection ofdata of the Programs through an Furthermore, the criteria used for evaluation of Academic Programs were improved and betterdelineation, identity, productivity and evaluation process of Professional Master Programswere implemented, which were exhaustively discussed and constructed with peer collaborationin seminars and forums, in addition to the exercise of a partial evaluation of the Programswith wide debate of results in a Seminar entitled “Half Term Picture”. The incorporation ofan evaluation process with a quality seal for the books produced in the Area was also implemented in the quadrennium 2013-2016, joining the traditional process ofqualification of periodicals in force.Fifty-three academic programs and 21 professional master programs in operation in the fiveregions of the country were evaluated, showing an increase of nearly 30% in the presentquadrennium, in relation to the 2010-2012 triennium, with a still asymmetrical distributionof courses, which are concentrated in the Southeast (42.9%), with advances in the Northeast(25.9%) and South (21.4%), and low numbers in the Midwest (8.0%) and North (1.8%)In this group, professional master programs stand out for their remarkable expansion in thelast six years, with a relative growth of 156%, representing 20.5% of the approved coursesof the Nursing Area in December 2016. These courses target the training of professionalsfor health services and the consolidation of the Unified Health SystemIn view of the strengthening of Nursing as Subject and Science, the expansion of the offerof PhD programs and interinstitutional academic cooperation initiatives became evident.With 38 doctoral programs, although none in the North of the country, the investments toreduce the asymmetries have been directed through academic solidarity, evidenced especiallyin the Federal and State Universities of Amazonas, Federal University of Acre andUniversity of Rondônia, with the offer of special classes outside the Headquarterfacilities, in the “Inter-institutional Doctoral program” (Dinter). The expansion of doctoral training has also been demonstrated beyond the borders of thecountry, reaching Latin America, with the assistance to implement Stricto Sensu Programsand reception of foreign professionals to conduct courses in the headquarters of thePrograms. Solidary actions of international academic cooperation, such as the offer of aDinter to PUC-Chile, and training of doctors to countries such as Mexico, Peru andColombia, among others, strengthen the Nursing Area and the Brazilian Programs.3.Since the implementation of the first course in 1972ranking of theScopus/SCImago database in 2006 to the seventh in 2016 in terms of number of documents,overtaking the United States, United Kingdom, Australia, Canada, France and China. Thechallenge is to maintain stability in the ranking in citation ofpublications and raise the position in the H index, which has remained at 96, correspondingto the 22nd placeThe quantitative-qualitative growth of the Programs reverberated in the expressivescientific production evidenced in this quadrennium, which counted the publication of16,321 articles, representing a relative growth of 77% in relation to the last triennium.The impact of this production can be seen in the international projection of BrazilianNursing, in the jump from the eleventh position in the expertise of professors who, as seen in the evaluationof the Programs, have worked on many and diverse work fronts in institutions, associations,societies, scientific journals and international events. The international visibility of Researchers and Programs of the Nursing Area is expressedthrough various activities that take place in the framework of agreements, technicalcooperation and other types of interinstitutional partnerships, as well as initiatives ofincentive of research and events that increase mobility actions of researchers andstudents. These insertions have resulted in institutional academic ackowledgement,objectified in the stricto sensu postgraduate education, financed research, relevantpositions in the management/headship of services and academia, among others. The data haveshown the good placement or mobility of graduates with a rise in the labor market.Because these are programs whose goal is to qualify professionals, indicators to evaluatethe insertion of new doctors in the labor market have also been applied in the evaluationof the Area and have evidenced the important work carried out in the field ofInternationalization has been the target of Nursing training, with expansion ofinternational collaborative networks, exchanges of professors and students, and attractionof foreign professionals for qualification in Brazil, both in master’s and doctoralcourses, reaffirming the excellence of the Programs of the Area. In the meantime, thescientific production of international circulation is the one that most strongly evidencesthe capillarity of diffusion and recognition of the Nursing Science produced in Brazil, somuch that 40% of the weight of the evaluation of potential programs classified as 6 and 7regarding international excellence is attributed to this aspect, followed by internationalparticipation (25%) and complemented by the analysis of indicators of faculty leadership(15%), nucleation (10%), and solidarity (10%)When this scientific production is done in partnership with foreign researchers, itdistinguishes and discriminates the international excellence of the Programs. In thisquadriennium, among the 3,198 articles produced by the seven programs to whichinternational excellence (6 and 7) was assigned, 10.7% were published with foreignauthors.Besides increased scientific production, the number of qualified journals in which theNursing Programs have published increased by 30%, from 1,213 in the previous triennium to1,579 in the present quadriennium, 39% of them with JCR/WoS and 53% with H/SCImagoindexDespite the increase of collaborative and multicentric research in partnership with foreignresearchers, with consequent increase in joint scientific production, this aspect of theinternationalization process still needs to improve, as well as the development oftechnological production in the Nursing Area, co-advising, double degrees, provision ofclassess in the English language and the raising of funds in foreign agencies/institutions.These represent challenges to be overcome in the coming years, requiring a strategic planwith actions to be implemented by the Programs.In the process of evaluation of the present quadrennium, there were pioneerisms, as said,but portrayed achievements in itself, in the overcoming of adversities of the contemporaryworld, of shortage of funding, and of the impacts of retirement plans that imply thereformulation of the teaching staff. Nonetheless, the Area is aware of the challenges to befaced and remains firmly committed to advancing in training and evaluation processes thatcause impacts with quality, applicable, and change-generating academic-scientificproducts.


Recent research indicates that (a) the perception and expression of facial emotion are lateralized to a great extent in the right hemisphere, and, (b) whereas facial expressions of emotion embody universal signals, culture-specific learning moderates the expression and interpretation of these emotions. In the present article, we review the literature on laterality and universality, and propose that, although some components of facial expressions of emotion are governed biologically, others are culturally influenced. We suggest that the left side of the face is more expressive of emotions, is more uninhibited, and displays culture-specific emotional norms. The right side of face, on the other hand, is less susceptible to cultural display norms and exhibits more universal emotional signals.


Zhong He was not included in the author byline. He should be listed as the tenth author and affiliated with the Division of Infectious Diseases, Vaccine & Gene Therapy Institute of Florida, Port Saint Lucie, Florida, USA. The contributions of this author are as follows: Performed the experiments and Analyzed the data.


Flora of Republicae Popularis Sinicae . He was also a leading character in the history of botanical collection by Chinese botanists, and published hundreds of new genera and species, including the famous “living fossil” plant—Cathaya argyrophylla Chun et Kuang , a leading botanist and taxonomist , CAS and Guangxi Institute of Plant Research Fig. . MoreoveSunyatsenia in China, co-founded the Botanical Society of China, and served as the editor and president of The Chinese Journal of Botany. In honor of his great contributions, many plants were named after him, such as the genera Chunia, Chuniophoenix, Chunechites, and the species Lindera chunii, Neolitsea chui and Vernonia chunii, etc  and published by Commercial Press in 1922.The following year, Huan-Yong Chen was appointed as a professor of forestry at the University of Nanking and started teaching at National Southeast University in 1922, where he worked together with Xian-Su Hu , Zhi Bing (秉志) and other renowned biologists in China Fig. . In 1922In 1927, Prof. Huan-Yong Chen was appointed as a professor in Sun Yat-Sen University, and in the following year, he founded and directed a new institute of botany in the university. He helped to establish the professional and qualified herbarium in Southern China in 1928. Furthermore, he made specimens exchanges with more than 60 countries and obtained more than 30,000 foreign specimens to enrich the specimens for herbarium in the 1920s. This herbarium is still considered as one of the top three Herbariums in China till now. In 1929, Prof. Chen was appointed as the first director of Institute of Agriculture and Forestry, which was the predecessor of SCBG. Since then, he devoted his entire life as the director of SCBG and donated hundreds of publications to the library of SCBG. In 1935, he also founded the Economic Institute of Botany in Guangxi University and served as the first director, and he was also involved in the design and construction of the Guilin Botanical Garden Hu, .Deriration of Genera Names, the English version of Chinese Seed Plant Identification, and books for teaching Latin: Question from botanical latin and Eseential Latin for Chinese taxonomy botany. In 1930, he established and edited Sunyatsenia, the first Chinese professional plant taxonomy journal in English, and till 1948, 7 volumes 26 issues were published . This journal gained a great reputation and received awards from home and abroad by its high quality and professional articles.As an educator, Prof. Chen trained numerous famous botanists including Ren-chang Qin, Feng-Huai Chen, Ying Jiang , et al. He also edited and compiled a number of textbooks and reference books for teaching, for example, the Latin version of Icones Plantarum Sincarum from 1925 to 1932, in which they reviewed all the published illustrations and descriptions of Chinese plants. The scientific researches on the flora in South China gradually expanded under Prof. Chen’s leadership. In 1933, Chong-Shu Qian, Xian-Su Hu and Huan-Yong Chen were invited to found the Botanical Society of China, and in the same year, Prof. Chen was appointed as the editor and academic council member of The Chinese Journal of Botany. In 1936, he became the president of The Chinese Journal of Botany, after serving as vice president since 1934.Prof. Chen became well-known as the leading botanist in South China by both Chinese and foreign scientists in 1930s. He collaborated with Xian-Su Hu and published five volumes of During World War II and the War of Resistance against Japanese Aggression, in order to preserve thousands of precious specimens and literatures, Prof. Chen risked his life to ship them from Guangzhou to Hong Kong. In 1938, with his staff, he managed to keep on doing researches in the Kowlong office until Hongkong was also occupied in 1941. In 1942, he moved the stuff back to Guangzhou in order to continue his research. At that time, he was forced to collaborate with the Puppet Government (Japanese forces), which brought him into trouble in 1945 when the nationalist government accused him for collaborating with the enemy . Although the charges were squashed later, the development and the research work of the institute were badly affected by the lack of research funding and the war.In spite of those adverse situations, Prof. Chen still chose to stay in Mainland rather than Taiwan when P. R. China was established in 1949. He became the first director of SCBG in 1954. In the same year, he was elected as a member of the first National People’s Congress (NPC), and was subsequently reappointed for second and third NPCs. He was also, a faculty member of Biology and Earth Sciences department in Chinese Academy of Sciences (CAS). In 1955, Prof. Chen was elected as one of the first academicians in CAS for his outstanding contribution in the field of botany and taxonomy, which is the highest honor for a Chinese scientist.Cathaya with Ke-Ren Kuang  and published the famous “living fossil” plant—Cathaya argyrophylla Chunet Kuang. In addition, he described more than 100 new species and more than 10 new genera including Tsoongiodendron (Magnoliaceae) and Zenia (Fabaceae) within ten years  and later he led a team to complete a survey of the Flora of Guangzhou, which was the first Chinese endemic flora survey completed by Chinese botanists. He also participated in the publication of the Flora in Hainan. In 1963, Prof. Chen was elected as academic chairman of the 30th anniversary conference for Botanical Society of China in Beijing and a member of Academic Committee of Institute of Botany, CAS .In 1959, Prof. Chen was appointed as the Associate Editor-in-Chief of Prof. Chen was born mixed-blood parentage, his father was a Chinese Consul in Cuba and his mother was a Spanish Cuban. In addition, he studied and lived in the US for decades, which broadened his international viewpoints and understanding of both eastern and western cultures. He was good at both English and professional Latin, which gave him more opportunities to present and improve the perception of Chinese botanical researches. In fact, before 1949, most of his thesis and academic articles were written in English or Latin.Species Muscorum Frondosorum , which was a significant milestone of a worldwide appreciation of Chinese botanists. In 1936, Prof. Chen was awarded as Honorary Vice President of British Gladiolus Society, and appointed as a member of Massachusetts Horticulture Society . In 1951, at the symposium on Origin and distribution of cultivated plants of South Asia held in New Delhi, India, Prof. Chen presented his research work as the head of the delegation of CAS. He also visited several Plant Research Centers on behalf of CAS and helped identify plant specimens in Leningrad (Saint Petersburg), former Soviet Union in 1958  kept a life-long friendship with him ever since they meet in 1920. Dr. Merrill donated a lot of precious publications to the library and specimens to the herbarium, and also wrote an article for the first issue of the journal South China Morning Post (Chen, In addition to his botanic research, Prof. Chen was also interested in literature. He read lots of European and American novels from the library during his study at Harvard University and some of his poems were published in the Hong Kong newspaper st Chen, .Memorial collections of Huan-Yong Chen was published in 1996 to memorize all his endeavors to the development of SCBG.Prof. Chen passed away in 1971, and left countless treasures for the next generations. In 1978, a memorial meeting was held by Guangdong Academy of Sciences. Many government officials and scientists attended this meeting to greet Prof. Chen’s outstanding contributions to the development of Chinese botanical sciences. In 1996 and 2006 respectively, his bronze statues were built in the Herbarium and the garden of SCBG. And the internal book of As one of the most outstanding botanists in 20th century and one of the pioneers and founders of modern plant taxonomy in China, with a strong determination to establish the modern Chinese botanical research, Prof. Chen considered the development of Chinese botanical science as his life-long mission. He was blessed to do what he loved, and made his dream come true-to set up China’s own botanical research, Herbarium, botanical library, Chinese flora, botanical gardens/institutions and natural reserves, which were deeply respected all over the world.


Health-related quality of life (HRQOL) measures are used to assess the multifaceted impact of disease, and determine the utility and associated disability. In addition, the impact of medical interventions must be assessed by psychometrically robust HRQOL measures based on a comprehensive and dynamic model. To develop such a model, the concepts of life, its quality, domains, essence, and purpose must be properly and clearly understood. The correct understanding of these entities is specifically important for patient-centered medicine and has universal implications for all fields of human endeavor. Therefore, in order to explore questions about life and quality of life adequately, every necessary field of knowledge should be employed. A multilinguistic and etymological appraisal reveals that life is related to medicine, freedom, being, soul, and spirit, all of which must therefore be considered in its conceptualization.


Editor-in-chief of the Journal of Intensive Care. To date, this Journal, which was launched in October 2013, as the official journal of the Japanese Society of Intensive Care Medicine (JSICM), has been outstandingly led by Professor Satoshi Gando, the founding Editor-in-chief. Being an international journal, the members of Advisory and Editorial Board embrace many worldwide leaders in the intensive care field. Based on their continuous and persevering efforts, in addition to the enthusiastic contribution by all authors and/or researchers, we are proud of a number of remarkable and significant articles published in the first stage of this newborn journal. In the first 2 years after its launch, more than 55% of the submissions came from Japanese researchers and/or intensivists; now, almost 75% of the submissions come from researchers in other areas of the world, including North America and Europe, as well as Asia, Middle East, and Oceania , implying that the journal is close to obtaining Social Sciences Citations Index value .Owing to the countless journals that have been launched in the last decade, international journals must now compete with each other within the same field of medicine. By the end of 2017, there were 57 and 137 journals including the term, intensive care and critical care, respectively. To prevail and thereby step forward in these types of struggles between the journals, we must continue to work hard on improving both the academic and clinical quality of this journal by publishing high-quality articles and simultaneously providing more constructive peer-review processes. To date, all articles published in the Towards the Second Stage as an international journal, the Journal of Intensive Care shall work hard to contribute to the development of state-of-the-art intensive care and to thereby amend both the short- and long-term outcomes of critically ill patients. Our Editorial Board members earnestly look forward to a number of submissions from all over the world that will further improve the state of intensive care better than today.


After publication of the original article , it cameDr. Papp contributed to the conception, design, and initial draft of the study protocol, so the Author contributions section of the article should be revised as follows:Author contributionsAll authors contributed to the development of the trial protocol and approved the final manuscript. KS led the development of the operations manual and standardization of data collection, undertook initial drafting of the manuscript, and is involved in the overall coordination of the multi-site study. LS, SW, and KM conceived the study, obtained funding, drafted the initial protocol, and are responsible for the communication of the study results. Guidance on clinical data, participant examinations, and study procedures were provided by SW, KM, ML, and MY. JR contributed to the design of this pilot study. SW, KM, ML, MY, NL, and MS led the study at the site responsible for patient recruitment, follow-up, and clinical evaluation. EP contributed to the conception, design, and initial draft of the study protocol.Dr. Papp has no conflicts of interest to declare.


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.


Disease Selection: The Way Disease Changed the World by Roger Webber is written in the tradition of Rats, Lice and History by Hans Zinsser; Guns, Germs and Steel: The Fates of Human Societies by Jared M. Diamond; and Viruses, Plagues, and History by Michael B.A. Oldstone. These volumes focus on the role of diseases, particularly infectious diseases, in history. Compared with the others, however, Dr. Webber’s book is more focused on the effects of diseases on natural selection and evolution. These factors sometimes work in parallel and sometimes in opposition but always in highly complex and often unpredictable ways. The book is clearly written for a knowledgeable lay audience, a difficult task when covering evolution, microbiology, a wide variety of diseases and modes of their transmission, and immunologic responses to those diseases.The book begins with a brief review of the origins of life on earth, including a discussion of the earliest life forms, the archaea and bacteria. Dr. Webber then describes the development of the various means of reproduction and their effects on the evolution of species and increasing complexity of life forms. In the first chapter, he covers the evolution of sexual reproduction and its effect on survival of species. Later, he discusses the role of diseases and the likely influence of endogenous viruses in the evolution of higher life forms, including humans.Plasmodium spp., the cause of malaria. When the role of mosquitoes in transmission of malaria and other diseases was recognized in the 19th century, the complexity of biological relationships at all levels was revealed. For instance, because mosquitoes are damaged by blood infected with filarial parasites, those mosquitoes are less likely to transmit other disease agents such as those that cause malaria.Human ancestors originated in Africa and, to this day, this continent contains a unique variety of infectious agents that have likely effected human evolution. Malaria, for example, has probably led to the ability of populations to sustain sickle cell anemia because of the relative resistance of sickle red cells to Smallpox, plague, influenza, and other diseases have killed large percentages of the world’s populations at various times in the past. When smallpox and measles were brought to the New World, by Europeans who were carrying variola and measles viruses, indigenous populations in South America suffered great loss of life. After these epidemics, mortality rates for survivors and their progeny were lower than for newly exposed persons who became ill. This lends support to the concept of selection of populations resistant to diseases after substantial proportions of the populations have been killed by these diseases. Later chapters deal with the effects of war, breast feeding, diet, climate change, migration, and domesticated animals on the evolution of human beings.Dr. Webber has succeeded in the ambitious task of describing the evolution of a broad range of organisms and their interrelationships during that process, with special emphasis on how diseases have influenced the evolution of humans. The book is clearly written, and many will find the index and extensive references useful. It will be an enjoyable read for audiences with a broad range of expertise in the biological sciences.


To understand the implementation quality of the Tier 1 Program of the Project P.A.T.H.S., two observers carried out process evaluation in six schools randomly selected from the participating schools in the form of systematic observations of 12 units. Results showed that the overall level of program adherence was generally high, ranging from 50% to 95%, with an average of 84.5%. High implementation quality of the program in the areas of student interest, student participation and involvement, classroom control, use of interactive delivery method, use of strategies to enhance student motivation, instructors familiarity with the students, opportunity for reflection, degree of achievement of the objectives, quality of preparation, overall implementation quality, and success of implementation was also observed. The findings provide support for the implementation quality of the program.


This study determines the influence of the different soil components and of the cation-exchange capacity on the adsorption and retention of different heavy metals: cadmium, chromium, copper, nickel, lead and zinc. In order to do so, regression models were created through decision trees and the importance of soil components was assessed. Used variables were: humified organic matter, specific cation-exchange capacity, percentages of sand and silt, proportions of Mn, Fe and Al oxides and hematite, and the proportion of quartz, plagioclase and mica, and the proportions of the different clays: kaolinite, vermiculite, gibbsite and chlorite. The most important components in the obtained models were vermiculite and gibbsite, especially for the adsorption of cadmium and zinc, while clays were less relevant. Oxides are less important than clays, especially for the adsorption of chromium and lead and the retention of chromium, copper and lead. Heavy metal contamination id defined as excessive contamination from a series of metal elements, most of which are potentially toxic for the organism in a given ecosystem . As for Although contamination by these elements affects all the levels in an ecosystem ,4, the mAspergillus niger and Penicilium sp tolerating Cr and Cd 59].Kaolinite is the most important clay for copper retention, just like in the case of adsorption. As for oxides, they show a lower importance, and Mn oxides are not importance, so their affinity with copper is low, although they can be associated with clays for a higher efficiency .For nickel retention, kaolinite is the most important clay, followed by gibbsite. As for oxides, Fe oxides are the most important ones, although their importance is lower than the coefficient of kaolinite, which means clays predict the retention of this metal better than oxides .In lead retention, the most important clay is gibbsite. The contribution of oxides is not very important, although they are important for . HematitIn zinc retention, gibbsite is the most important clay, while Fe oxides are the most important oxides when these compounds are considered, although they do not appear in the optimal tree. This contribution by clays, together with the fact that the percentage of silt is the most important variable for Zn retention, coincides with the descriptions by , 46.Machine Learning) enables to know how the migration of inorganic pollution, both metallic and non-metallic, occurs.With these techniques, it is possible to study how it affects the different components of an ecosystem depending on its characteristics , where iCynodon dactilon and Humulus scandens [From a broader perspective, these techniques enable us to know what the most serious contamination problems are and to select the best bioremediation method, if it is possible. This was the case with the selection of the best plant species for the restoration of the dump in a manganese mine, where different aspects, such as the concentration of heavy metals, were studied. Apart from manganese, cadmium, copper and zinc were mainly found. After studying the accumulation of heavy metals, it was found that the best species for revegetation were scandens .As general conclusions, the following can be mentioned:2 in all metals retention and absorption, except in the case of Zn retention, in which there was no change.Regression tree models (CART) allowed ranking the relative importance of the different soil components according to their relevance coefficients, on the adsorption and retention of 6 metals using 14 different soils. The cross-validation method allowed the improving of the models in terms of RThe behaviour of the different adsorption and retention models for the 6 studied metals are different, with the first variable splitting the regression tree being quite variable.The metals can be sorted out in two groups. One of them includes Cd, Ni and Zn, which generally show a high importance of the texture components such as the percentage of sand. The other group, including Cr, Cu and Pb, shows that the exchange capacity, humified organic matter and the proportion of hematite are the most important variables, as it happens in , 46.Lastly, in some cases, there are cases of co-adsorption of several metals or of to components having a joint adsorption, as it happens with gibbsite in the adsorption of chromium . As for S1 Table(PDF)Click here for additional data file.


The perspective of the integrated health system has a network of care withmultiple integration dimensions among subsystems as nuclear representation,relating the clinical aspects and governance to the representations andcollective values. The normative integration aims to ensure coherence betweenthe system of representations and values of society simultaneously with theinterfaces of clinical and functional integration. It builds a bridge withgovernance, which allows, through their skills, management of all systemcomponents, encouraging cooperation, communication and information, in order toensure the population under their responsibility to access excellence services,exceeding their expectations. The integration of care consists of a durablecoordination of clinical practices for those who suffer from health problems inorder to ensure continuity and full range of the required professional servicesand organizations, coordinated in time and space, in accordance with theavailable knowledge. It is possible to establish the type of health equipmentfor each level of care for patients with congenital heart diseases. Thisstrategy intends to offer timely care in appropriate moments and places,efficiently, operating cooperatively an interdependently, with ongoing exchangeof its resources. Thus, situational integration establishes the systemconnection with the assessment environment that proposes to carry out valuejudgment, guided by an objective worldview, about an intervention or any of itscomponents, in order to objectify the decision making. Similarly,the executive power can directly influence and create an appropriate environment for thewritten norms, and the more participatory, lower the risk of distortions in itsdeliberations. No less important than discuss the justifications and methodology of itsimplementation is to set goals and metrics for evaluation. Setting goals in light ofsocial needs and political and economic reality is a negotiation exercise whose outcomemust meet the principles as equity and integrity, which are in the guidelines of theUnified Health System (SUS), even not experienced in its completeness.In this thread, the society acquires the condition and the capacity to share with otheragents the political control, thus, providing the responsibility to maintain, adapt andexpand its scope.Consequently, the society starts to communicate with the system through an integrationand control link.The sensitization of the political environment moves towards influencing the decisions ofthe executive power, and, thus, enables continuity of the agreed actions, which shouldbe more of a monitoring agent of the results. Even at the strategic level, the executivepower, with its bureaucratic status, are entitled to format the normative content bybringing the knowledge of the SUS guidelines, conducting health actions. In thisenvironment, the budget is allocated to all stages of the policies; however, theidealized amount is not accompanied by sufficient financial resources to solve theproblems, which is explained by the lack of knowledge on the project size or thedeliberate restriction of the budget to health. Anyhow, the financial failure willimpact over the implementation of the policy and determine its degree ofeffectiveness..The normative integration aims to ensure coherence between the system of representationsand values of society simultaneously with the interfaces of clinical and functionalintegrationIt builds a bridge with governance, which allows, through their skills, management of allsystem components, encouraging cooperation, communication and information, in order toensure the population under their responsibility to access excellence services,exceeding their expectations.Due to the complexity surrounding the governance, another organizational level was instituted beyond the tactical level, formed by financial andadministrative environments, structural, in order to give expression to vital sectors inthe development, maintenance and results of care networks. This organizational level iscomposed by logistics and information technology. The interface among theseenvironments, functional integration, ensures a common coordination, guided by a systemof agile and flexible information with ability to make decisions about responsibility,attributions and financial resources..The logistics systems are technological solutions, strongly anchored in informationtechnology, and linked to the concept of vertical integration. It consists in therealization of an effective system of reference and counter-reference of people andefficient exchange of goods and information over the health care and supportsystems.Another structural pillar in the integrated care networks in the governance environment,the information technology, had a significant development in recent decades and is afunctional support, whether strategic or operational, of the providers of health careorganizations. Its application extends quickness in providing information and sharingknowledge, enabling effective and agile decisions, as well as better coordination amongentities. It also requires further information and capacity to handle problems relatedto confidential informationThe governance interface, responsible for tactical and structural actions, andoperational and clinical level, is done by clinical integration, which is based onmanagement strategies, finance, logistics and information in an effort to provide theclinical practice of multidisciplinary skills with a view to providing comprehensivecare to a given population..The integration of care consists of a durable coordination of clinical practices forthose who suffer from health problems in order to ensure continuity and full range ofthe required professional services and organizations, coordinated in time and space, inaccordance with the available knowledge. The integration of clinical teams has as mainattributes the multidisciplinary constitution of its members and its structural andparticipatory inclusion in the care networkBasic content of health care networks emerge from this definition: denote mission andcommon objectives; operate cooperatively and interdependently; constantly interchangetheir resources; are established without hierarchy among components, organize themselvesin a polyarchic way in which all health care points are equally important; imply acontinuum of care in primary, secondary and tertiary levels; call for a comprehensivecare with promotional, preventive, curative, caregivers, rehabilitative and palliativeinterventions; work under the coordination of primary health care; provide timely carein appropriate moments and places, offer safe and effective services in line with theavailable evidence; focus on the full cycle of care to a health condition; have clearhealth and economic responsibilities for its population; and produce a value for itspopulation .The first point of care is the primary care, which can be understood as defined in theAlma Ata Conference, in 1978:."[...] essential health care based on practical technologies, scientificallyreasoned and socially acceptable, made universally accessible to individuals andfamilies in the community through their full participation and at a cost thatthe community and country can maintain at every stage of their development, inthe spirit of self-reliance and selfdetermination. It is the first level ofcontact of individuals, family and community with the national health system,whereby health care are taken as close as possible to where people live andwork, and constitutes the first element of a continuing health careprocess".The other components of health care networks are the points of secondary and tertiarycare, the network nodes where they offer certain specialized services produced by aunique production function. They are distinguished by their respective technologydensities, and tertiary points are technologically denser than the secondary points and,therefore, tend to be more spatially concentratedIt is possible to establish the type of health equipment for each level of care forpatients with congenital heart diseases. This strategy intends to offer timely care inappropriate moments and places, efficiently, operating cooperatively aninterdependently, with ongoing exchange of its resources . (The integration of clinical care in the primary, secondary and tertiary care dimensionsis linked to the concept of vertical integration, which refers to the combination,within the same organization or an interorganizational alliance, previously independentproduction units, but whose products are input from one unit to another ., compiling definitions, say that vertical integration is thecreation of a single management entity of two or more entities that provide services inlevels of care in order to improve the overall health status of a population in acertain geo-demographic regional context. For the WHO, vertical integration considers the aggregation ofinputs, provision and service management related to the prevention, promotion,diagnosis, treatment and rehabilitation of health. It is a synonymous term with theservices related to access, quality, user satisfaction and efficiency.By the same measure, Santana & CostaThe motivating factors to overcome the fragmentation of health care systems are the lowertransaction costs in the system and increased productivity for optimal use of commonresources., the division betweenprimary and secondary health care essentially corresponds to a preferred provider, sincethe perception of the consumer is focused on health care, unaware if it suffers from aproblem of 'primary' or 'secondary' nature.In customer perceptiveness asymmetrically informed in the face of supply agent in adisease situation, there is no perception and consecutively the capacity of decision toopt for health care consumption that offers varying levels of care. According toCostaIn this way, you can determine for each unit providing clinical care in the variouslevels of care, which services are made available to the user, observing concepts ofvertical integration ..In this context, territorial integration emerges, which enables the system to establishthe health needs of a specific population, under its responsibility, according to therisks, and implement and evaluate sanitary interventions for this population and toprovide care for people in the context of their culture and their preferences.Planning processes, organization, management and financing of health policy must be basedon knowledge of the regional reality historically constituted and expressed in updatedindicators of demographic, socioeconomic, political, epidemiological and sanitarynature, in other words, specific spaces and population. Such information and indicatorsshould be organized and articulated in models to establish causal relationships able toguide and support the action of the State in effective policies for intervention inreality.The knowledge of the regional reality depends on the recognition of professional andequipment deficits able to offer specialized care to specific population segment.Therefore, it is priority to establish a formal system of allocation of resources withappropriate geographical distribution of health facilities, human resources and programsso that professional activities cover the entire spectrum of comprehensive, primary,secondary, tertiary and long-term cares, with all agreements, connections and referenceneeded, mechanisms established to integrate various levels and institutions in acoherent and capable group to meet all patients' needs, within a definedpopulation-based scenario.In conclusion, situational integration establishes the system connection with theassessment environment that proposes to carry out value judgment, guided by an objectiveworldview, about an intervention or any of its components, in order to objectify thedecision making. Agents must be willing to reevaluate their logics, interests andspecific cultures to accept the proposed objectives, the method of work in pursuit ofcommon goals, more ambitious than the sectored and welfare ones


Response to the 2014–2015 Ebola virus disease (EVD) outbreak in Sierra Leone overwhelmed the national capacity to contain it and necessitated a massive international response and strong coordination platform. Consequently, the Sierra Leone Government, with support of the international humanitarian community, established and implemented various models for national coordination of the outbreak. In this article, we review the strengths and limitations of the EVD outbreak response coordination systems in Sierra Leone and propose recommendations for improving coordination of similar outbreaks in the future.There were two main frameworks used for the coordination of the outbreak; the Emergency Operation Center (EOC) and the National Ebola Response Center (NERC). We observed an improvement in outbreak coordination as the management mechanism evolved from the EOC to the NERC. Both coordination systems had their advantages and disadvantages; however, the NERC coordination mechanism appeared to be more robust. We identified challenges, such as competition and duplication of efforts between the numerous coordination groups, slow resource mobilization, inadequate capacity of NERC/EOC staff for health coordination, and an overtly centralized coordination and decision-making system as the main coordination challenges during the outbreak.We recommend the establishment of EOCs with simple incident management system-based coordination prior to outbreaks, strong government leadership, decentralization of coordination systems, and functions to the epicenter of outbreaks, with clear demarcation of roles and responsibilities between different levels, regular training of key coordination leaders, and better community participation as methods to improve coordination of future disease outbreaks. With a total of 14,122 suspected, probable, and confirmed cases, and 3,955 deaths in all 14 health districts, the 2014–2015 Ebola virus disease (EVD) outbreak in Sierra Leone was the single largest in the history of the disease .Involvement of numerous national and international partners in the outbreak response necessitated the establishment of a strong EVD outbreak response coordination platform. In response to this, the Sierra Leone Government, with support from the international humanitarian community, established and implemented various frameworks for the national coordination of the outbreak from July 2014 until November 2015 , when thHealth coordination aims to ensure a coordinated and effective approach to emergency health program planning, implementation, supervision, and monitoring. It plays a critical role in ensuring available resources are effectively deployed and used, activities are well planned and synchronized and complement each other so that any gaps in the response operation are efficiently identified and resolved . OutbreaDuring our time supporting the outbreak response in Sierra Leone  was used as the coordination model, whereas from October 2014 until the end of the outbreak, the Sierra Leone Government established a command and control style incident management system (IMS), called the National Ebola Response Center (NERC), to coordinate the outbreak.Under the EOC coordination framework, three main EVD coordination groups, a national EOC, a Presidential task force, and a national EVD task force, were established at the national level Figure . The natA Presidential EVD task force, chaired by the Head of State, provided overall policy, strategic, and political direction for the outbreak response. An inter-ministerial committee, which included relevant cabinet ministers, heads of relevant multilateral agencies such as the United Nations (UN) and international non-governmental organizations (NGOs) and bilateral partners such as US Centers for Disease Prevention and Control and Public Health England, oversaw implementation of the decisions of the Presidential task force. A national EVD task force was also established, with the aim of involving a broader spectrum of national, district, and community stakeholders in the EVD response. In reality, this task force, which only met on a few occasions, did not function effectively.At the district level, the EOC coordination structure (district Ebola task forces) comprised five technical components; coordination; epidemiology/surveillance/laboratory; case management/infection control; social mobilization/psychosocial support; and logistics. The district task forces were chaired by the district council Chairmen, who organized daily meetings; each technical group also met on a daily basis. The coordination component included the leads for all the technical components, and discussions in these meetings were similar to those of the district task force meetings. At the supra-national level, a multiagency body, known as the Sub-regional Ebola Operations Coordinating Center (SEOCC), based in Conakry, Guinea, which coordinated the international and cross-border aspects of the outbreak and provided technical support to the national EOCs, was operational from June to October 2014.The NERC, which succeeded the EOC in October 2014, was more sophisticated and incorporated a civil–military cooperative style of coordination, with deployment of Sierra Leonean and other foreign military personnel to support coordination and operation of the EVD response. It was chaired by a Chief Executive Officer who reported directly to the Head of State. Under this coordination framework, the operational and technical aspects of the outbreak response were clearly separated, with the establishment of a situation room that focused on monitoring the operational aspects of the outbreak, and the CMO leading the technical aspects, which were similar to the former EOC  was subsequently established to strengthen leadership and bridge the communication gap between the two main NERC groups; the situation room and the technical components. Structures similar to the NERC, District Ebola Response Centers (DERCs), with district Ebola situation rooms and Ebola response components, each with a district coordinator, were established at the district level. In October 2014, the United Nations Mission for Ebola Emergency Response (UNMEER) replaced the SEOCC. National and district offices of UNMEER were established in the three principally affected countries in October 2014, each with its own coordinator.In general, we observed progressive improvements in the coordination of the outbreak . HoweverAt the initial implementation stages of the NERC system, there was a lack of clarity about the roles, responsibilities, and channels of communication between the different coordination groups. This was particularly evident with the District Health Management Teams (DHMT), which comprised the district EOCs and the newly established DERCs. The same situation was experienced at the national level, with the technical components operating independently from the operational components, without effective collaboration with the NERC (and the Ebola situation room).Communication between the operational and technical components of the NERC was often suboptimal, at both district and national levels. This was mainly because of a lack of understanding of the new coordination mechanism, as no orientation was provided on the new mechanisms for civil–military cooperation. This often resulted in duplication of efforts and unnecessary competition between the two NERC groups . This was reflected in the production of different technical epidemiological information by both groups.Furthermore, there were at least three EVD coordinators at the district level  leading to tension and conflict over control of the outbreak response. In districts such as Bombali, Port Loko, Kambia, and Western Area, foreign military personnel were also designated as coordinators, further compounding this conflict. Technical meetings were held with no clear mechanism for conveying recommendations to the main coordinating group. The i-PACT system was established to provide technical advice and improve communication between the two main coordination groups of the NERC at the national level; however, it achieved limited success. There was no direct funding to facilitate coordination between national and district level technical components.The community was involved in the coordination of the response at the district level, through regular participation of the paramount Chiefs at daily DERC meetings. This was however, not sufficient to obtain the full cooperation of community members on response activities such as active case finding, contact tracing, burials, and social mobilization. It appeared that the inadequate cooperation was because of misconceptions and fear. One of which was the perception that the treatment centers represented “points of no return”; whoever was taken there was thought not likely to return to the community alive. This resulted in community resistance, which was a distinct feature of this outbreak , 9.During the initial stages of the outbreak, the management of some of the coordination meetings was poor; meetings were unnecessarily long, and some did not reach any concrete decisions. This was evidenced by poorly prepared minutes and the lack of clear mechanisms for follow-up on agreed action points. Consequently, there were often delays of several days to weeks before action points were implemented. This often resulted in apathetic officials, poor attendance, and repeated discussions of the same topics.Many officials were members of multiple technical components or coordination groups, and the roles of other officials overlapped, resulting in the engagement of some of the key actors in frequent and prolonged meetings. For instance, the district Ebola task forces and their technical coordination component essentially included the same people and discussed the same issues. Slight reductions in these challenges were noted under the NERC system, which streamlined the number, participation in, and duration of coordination meetings. For example, the national Ebola situation room met twice a day for a maximum of 1 h. Conversely, this led to concerns from some partners about the limited time for in-depth discussions of critical issues.Our observations highlighted multiple EVD information sharing channels and situation reports, each conveying different information and epidemiological data. This often fueled disagreements between partners resulting in poor use of the available data to guide the ongoing response. For instance, many stakeholders had different data collection guidelines and reporting formats, which challenged data aggregation at the national level. This resulted in poor coordination of the EVD data collection system and several versions of the national EVD database, each of which had its own limitations . At the We observed that weak coordination of the mobilization, and deployment of the resources required for the EVD outbreak response was one of the most critical challenges for effective control of the outbreak, particularly during the early phases. The logistical components were unable to estimate or quantify available logistics, supplies, and essential medicines. This led to inaccurate forecasts, which often resulted in insufficient supplies, as most medical supplies were imported. This was largely because of multiple supply chain systems, many of which were not captured in the national EVD inventory systems. The EVD resources, which were channeled through the EOC and NERC systems, often arrived late at the district level because of the bureaucratic financial and logistical management systems of both the EOC and NERC.Furthermore, the EVD coordination hubs (and associated resources) were often not located in appropriate places. This resulted in a breakdown in communication between the field teams and coordination hubs and delays in receiving the required support to the field teams. For example in Koinadugu district, although the epicenter of the outbreak was in Neine, a remote chiefdom at least 4–5 h drive from the district headquarters, the outbreak coordination mechanisms and resources were predominantly located at the district headquarters. This severely limited the initial response to the outbreak in that area.The supervision, monitoring, and evaluation component of the EVD coordination system was observed to be weak, late into the outbreak response. There was no clear system for ensuring support supervision from national to district levels and from district to ward levels, to ensure that corrective action was taken when required. Thus it was difficult to ensure the quality of interventions and to rapidly identify gaps in the response effort. From July 2015, the NERC, supported by partners, established a critical monitoring team to monitor the quality of the response in districts reporting cases, as well as the preparedness level in districts that were not reporting.Coordination of outbreak response efforts plays a part in breaking the chain of transmission but will not ultimately control it single-handedly. Nevertheless, effective coordination of disease outbreak response should be an integral and critical component of overall outbreak control interventions . EffectiCoordination practices during the EVD outbreak highlighted improvement in outbreak coordination, as the mechanism evolved from the EOC to the NERC . Our obsWe observed several pitfalls, common to both coordination frameworks (EOC and NERC), which should be avoided during future outbreaks. These included competition and duplication of efforts between the numerous coordination groups; poor communication and relationships between the national and district coordination groups; weak and bureaucratic response components; and inadequate logistics and supplies. Other challenges include slow resource mobilization and disbursement because of bureaucratic systems; inadequate capacity of NERC/EOC staff for health coordination; overtly centralized and top-heavy coordination; and a decision-making system that concentrated on Freetown and district headquarters. Our observations also highlighted that although UNMEER was established to enhance outbreak coordination, its impact was limited  because We believe that early implementation of an IMS coordination system, such as the NERC, which is based on humanitarian cluster coordination principles, combined with a command and control style of coordination would have provided opportunities for better coordination of the outbreak response at the initial stages –18. ThisBased on our observations, we propose five recommendations to improve a coordinated response needed to control this type of disease outbreak in the future.First, all countries should establish EOCs, with simple IMS-based coordination mechanisms as part of outbreak preparedness and response efforts. Such centers should be led and maintained by the government , 19 to eSecond, decentralization of coordination systems and functions to the epicenter of outbreaks, with a clear demarcation of roles and responsibilities between the national, districts, and local levels should be encouraged. The national level should focus on technical guidance, policy and strategy development, resource mobilization, and technical oversight, while the district should be empowered to conduct the day-to-day coordination and operation of the outbreak response.Third, on-the-job training of all key coordination leaders to ensure better understanding of the coordination mechanism and enhance their coordination capacity is critical to enhance effective coordination. The content of such training should include general principles of health coordination, management of coordination meetings, strategies for identification and filling of critical gaps in the response, communication, conflict management, and inventory/logistics management skills.Fourth, better community engagement and participation in the coordination of future EVD outbreaks control is imperative. Modalities for ensuring better engagement of the community, such as conducting ongoing anthropological studies to better understand the community context and cultural norms should be prioritized.Finally, operational researches and monitoring and evaluation systems are needed to better understand outbreak coordination dynamics and to assess the effectiveness of health coordination mechanisms during disease outbreak responses in resource constrained settings, such as in the countries affected by Ebola.OO, ML, and NN were WHO Ebola response national technical coordinators in Sierra Leone at various times. In this capacity, they represented WHO in the EOC/NERC and were actively involved in the operations of these bodies. AC was WHO liaison officer to the EOC/NERC and was involved in the establishment and day-to-day management of the bodies. AA, IC, and K-BK were WHO district Ebola response coordinators in various districts. In this capacity, they represented WHO in the district EOC/DERC and were actively involved in the coordination of the outbreak at the district level. NS was WHO data management support to Western Area district, one of the epicenters of the outbreak, and participated actively in the coordination of the surveillance and epidemiology component. FD is a staff of MOHS Sierra Leone who was based in the EOC/NERC and actively participated in their establishment and day-to-day management.OO, ML, AC, AA, and IC conceived and coordinated the study. OO, ML, AC, IC, AA, NN, NS, K-BK, and FD drafted the manuscript. All authors read and provided significant inputs into the final draft of the manuscript, agreed to be accountable for all aspects of the work, and approved the final draft of the manuscript for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling Editor declared a past coauthorship with the authors and states that the process nevertheless met the standards of a fair and objective review.