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1.  Gems from traditional north-African medicine: medicinal and aromatic plants from Sudan 
Sudanese folk medicine represents a unique blend of indigenous cultures with Islamic, Arabic and African traditions. In addition, Sudan encompasses different terrains and climatic zones, ranging from desert and semi-desert in the north to equatorial with a short rainy season (semi-aridand semi-humid) in the centre to equatorial with a long rainy season (arid-humid and equatorialhumid) in the south. This variation contributes to the immense diversity of vegetation in the region. The flora of Sudan consists of 3137 species of flowering plants belonging to 170 families and 1280 genera. It is estimated that 15% of these plants are endemic to Sudan. The intersection of diverse cultures and the unique geography holds great potential for Sudanese herbal medicine. Medicinal and aromatic plants and their derivatives represent an integral part of life in Sudan. Indigenous remedies are the only form of therapy available to the majority of poor people. It has been estimated that only 11% of the population has access to formal health care. Therefore, research on the desired pharmacological effects and possible unwanted side effects or toxicity is required to improve efficacy and safety of Sudanese herbal medicine. In the future, it would be preferable to promote the use of traditional herbal remedies by conversion of raw plant material into more sophisticated products instead of completely replacing the traditional remedies with synthetic products from industrialized countries. The present review gives an overview of traditional Sudanese medicinal and aromatic herbs and their habitats, traditional uses, and phytochemical constituents.
Electronic Supplementary Material
Supplementary material is available for this article at 10.1007/s13659-012-0015-2 and is accessible for authorized users.
PMCID: PMC4131591
herbal medicine; natural products; pharmacognosy; phytochemistry; phytotherapy; traditional medicine
2.  E-Learning as New Method of Medical Education 
Acta Informatica Medica  2008;16(2):102-117.
Distance learning refers to use of technologies based on health care delivered on distance and covers areas such as electronic health, tele-health (e-health), telematics, telemedicine, tele-education, etc. For the need of e-health, telemedicine, tele-education and distance learning there are various technologies and communication systems from standard telephone lines to the system of transmission digitalized signals with modem, optical fiber, satellite links, wireless technologies, etc. Tele-education represents health education on distance, using Information Communication Technologies (ICT), as well as continuous education of a health system beneficiaries and use of electronic libraries, data bases or electronic data with data bases of knowledge. Distance learning (E-learning) as a part of tele-education has gained popularity in the past decade; however, its use is highly variable among medical schools and appears to be more common in basic medical science courses than in clinical education. Distance learning does not preclude traditional learning processes; frequently it is used in conjunction with in-person classroom or professional training procedures and practices. Tele-education has mostly been used in biomedical education as a blended learning method, which combines tele-education technology with traditional instructor-led training, where, for example, a lecture or demonstration is supplemented by an online tutorial. Distance learning is used for self-education, tests, services and for examinations in medicine i.e. in terms of self-education and individual examination services. The possibility of working in the exercise mode with image files and questions is an attractive way of self education. Automated tracking and reporting of learners’ activities lessen faculty administrative burden. Moreover, e-learning can be designed to include outcomes assessment to determine whether learning has occurred. This review article evaluates the current status and level of tele-education development in Bosnia and Herzegovina outlining its components, faculty development needs for implementation and the possibility of its integration as official learning standard in biomedical curricula in Bosnia and Herzegovina. Tele-education refers to the use of information and communication technologies (ICT) to enhance knowledge and performance. Tele-education in biomedical education is widely accepted in the medical education community where it is mostly integrated into biomedical curricula forming part of a blended learning strategy. There are many biomedical digital repositories of e-learning materials worldwide, some peer reviewed, where instructors or developers can submit materials for widespread use. First pilot project with the aim to introduce tele-education in biomedical curricula in Bosnia and Herzegovina was initiated by Department for Medical Informatics at Medical Faculty in Sarajevo in 2002 and has been developing since. Faculty member’s skills in creating tele-education differ from those needed for traditional teaching and faculty rewards must recognize this difference and reward the effort. Tele-education and use of computers will have an impact of future medical practice in a life long learning. Bologna process, which started last years in European countries, provide us to promote and introduce modern educational methods of education at biomedical faculties in Bosnia and Herzegovina. Cathedra of Medical informatics and Cathedra of Family medicine at Medical Faculty of University of Sarajevo started to use Web based education as common way of teaching of medical students. Satisfaction with this method of education within the students is good, but not yet suitable for most of medical disciplines at biomedical faculties in Bosnia and Herzegovina.
PMCID: PMC3789161  PMID: 24109154
Medical education; Distance learning; Bosnia and Herzegovina
3.  Blended learning in health education: three case studies 
Blended learning in which online education is combined with face-to-face education is especially useful for (future) health care professionals who need to keep up-to-date. Blended learning can make learning more efficient, for instance by removing barriers of time and distance. In the past distance-based learning activities have often been associated with traditional delivery-based methods, individual learning and limited contact. The central question in this paper is: can blended learning be active and collaborative? Three cases of blended, active and collaborative learning are presented. In case 1 a virtual classroom is used to realize online problem-based learning (PBL). In case 2 PBL cases are presented in Second Life, a 3D immersive virtual world. In case 3 discussion forums, blogs and wikis were used. In all cases face-to-face meetings were also organized. Evaluation results of the three cases clearly show that active, collaborative learning at a distance is possible. Blended learning enables the use of novel instructional methods and student-centred education. The three cases employ different educational methods, thus illustrating diverse possibilities and a variety of learning activities in blended learning. Interaction and communication rules, the role of the teacher, careful selection of collaboration tools and technical preparation should be considered when designing and implementing blended learning.
PMCID: PMC4152467  PMID: 24458338
Blended learning; Synchronous online learning; Problem-based learning (PBL); Second Life learning; Web 2.0 technology
4.  Developing a curriculum framework for global health in family medicine: emerging principles, competencies, and educational approaches 
BMC Medical Education  2011;11:46.
Recognizing the growing demand from medical students and residents for more comprehensive global health training, and the paucity of explicit curricula on such issues, global health and curriculum experts from the six Ontario Family Medicine Residency Programs worked together to design a framework for global health curricula in family medicine training programs.
A working group comprised of global health educators from Ontario's six medical schools conducted a scoping review of global health curricula, competencies, and pedagogical approaches. The working group then hosted a full day meeting, inviting experts in education, clinical care, family medicine and public health, and developed a consensus process and draft framework to design global health curricula. Through a series of weekly teleconferences over the next six months, the framework was revised and used to guide the identification of enabling global health competencies (behaviours, skills and attitudes) for Canadian Family Medicine training.
The main outcome was an evidence-informed interactive framework to provide a shared foundation to guide the design, delivery and evaluation of global health education programs for Ontario's family medicine residency programs. The curriculum framework blended a definition and mission for global health training, core values and principles, global health competencies aligning with the Canadian Medical Education Directives for Specialists (CanMEDS) competencies, and key learning approaches. The framework guided the development of subsequent enabling competencies.
The shared curriculum framework can support the design, delivery and evaluation of global health curriculum in Canada and around the world, lay the foundation for research and development, provide consistency across programmes, and support the creation of learning and evaluation tools to align with the framework. The process used to develop this framework can be applied to other aspects of residency curriculum development.
PMCID: PMC3163624  PMID: 21781319
5.  Partnerships and Pathways of Dissemination: The NIDA-SAMHSA Blending Initiative in the Clinical Trials Network 
Journal of substance abuse treatment  2010;38(Suppl 1):S31-S43.
Since 2001, the National Drug Abuse Treatment Clinical Trials Network (CTN) has worked to put the results of its trials into the hands of community treatment programs, in large part through its participation in the National Institute on Drug Abuse - Substance Abuse and Mental Health Services Administration Blending Initiative and its close involvement with the Center for Substance Abuse Treatment’s Addiction Technology Transfer Centers. This article describes 1) the CTN’s integral role in the Blending Initiative, 2) key partnerships and dissemination pathways through which the results of CTN trials are developed into blending products and then transferred to community treatment programs, and 3) three blending initiatives involving buprenorphine, motivational incentives, and motivational interviewing. The Blending Initiative has resulted in high utilization of its products, preparation of over 200 regional trainers, widespread training of service providers in most U.S. States, Puerto Rico, and the U.S. Virgin Islands, and movement toward the development of web-based implementation supports and technical assistance. Implications for future directions of the Blending Initiative and opportunities for research are discussed.
PMCID: PMC2855549  PMID: 20307793
dissemination; technology transfer; treatment adoption; treatment implementation; buprenorphine; motivational incentives; motivational interviewing; evidence-based treatment; substance abuse
6.  Need to teach family medicine concepts even before establishing such practice in a country 
The practice of family medicine is not well established in many developing countries including Sri Lanka. The Sri Lankan Government funds and runs the health facilities which cater to the health needs of a majority of the population. Services of a first contact doctor delivered by full time, vocationally trained, Family Physicians is generally overshadowed by outpatient departments of the government hospitals and after hours private practice by the government sector doctors and specialists. This process has changed the concept of the provision of comprehensive primary and continuing care for entire families, which in an ideal situation, should addresses psychosocial problems as well and deliver coordinated health care services in a society. Therefore there is a compelling need to teach Family Medicine concepts to undergraduates in all medical faculties.
A similar situation prevails in many countries in the region. Faculty of Medicine Peradeniya embarked on teaching family medicine concepts even before a department of Family Medicine was established. The faculty has recognized CanMed Family Medicine concepts as the guiding principles where being an expert, communicator, collaborator, advocate, manager and professional is considered as core competencies of a doctor. These concepts created the basis to evaluate the existing family medicine curriculum , and the adequacy of teaching knowledge and skills, related to family medicine has been confirmed. However inadequacies of teaching related to communication, collaboration, management, advocacy and professionalism were recognized. Importance of inculcating patient centred attitudes and empathy in patient care was highlighted. Adopting evaluation tools like Patient Practitioner Orientation Scale and Jefferson’s Scale of Empathy was established. Consensus has been developed among all the departments to improve their teaching programmes in order to establish a system of teaching family medicine concepts among students which would lead them to be good Family Physicians in the future.
Teaching Family Medicine concepts could be initiated even before establishing departments of family medicine in medical faculties and establishing the practice of family medicine in society. Family medicine competencies could be inculcated among graduates while promoting the establishment of the proper practice of Family Medicine in the society.
PMCID: PMC3904475  PMID: 24397851
Family medicine concepts; Undergraduate curriculum; Communication; Patient; Centeredness; Empathy
7.  Dipeptide-based Polyphosphazene and Polyester Blends for Bone Tissue Engineering 
Biomaterials  2010;31(18):4898-4908.
Polyphosphazene-polyester blends are attractive materials for bone tissue engineering applications due to their controllable degradation pattern with non-toxic and neutral pH degradation products. In our ongoing quest for an ideal completely miscible polyphosphazene-polyester blend system, we report synthesis and characterization of a mixed-substituent biodegradable polyphosphazene poly[(glycine ethyl glycinato)1(phenyl phenoxy)1phosphazene] (PNGEG/PhPh) and its blends with a polyester. Two dipeptide-based blends namely 25:75 (Matrix1) and 50:50 (Matrix2) were produced at two different weight ratios of PNGEG/PhPh to poly(lactic acid-glycolic acid) (PLAGA). Blend miscibility was confirmed by differential scanning calorimetry, Fourier transform infrared spectroscopy, and scanning electron microscopy. Both blends resulted in higher tensile modulus and strength than the polyester. The blends showed a degradation rate in the order of Matrix2 < Matrix1 < PLAGA in phosphate buffered saline at 37°C over 12 weeks. Significantly higher pH values of degradation media were observed for blends compared to PLAGA confirming the neutralization of PLAGA acidic degradation by polyphosphazene hydrolysis products. The blend components PLAGA and polyphosphazene exhibited a similar degradation pattern as characterized by the molecular weight loss. Furthermore, blends demonstrated significantly higher osteoblast growth rates compared to PLAGA while maintaining osteoblast phenotype over a 21-day culture. Both blends demonstrated improved biocompatibility in a rat subcutaneous implantation model compared to PLAGA over 12 weeks.
PMCID: PMC2856749  PMID: 20334909
Polyphosphazenes; poly(lactic acid-glycolic acid); polymeric blends; biodegradation; biocompatibility; bone tissue engineering
8.  Identifying the barriers to conducting outcomes research in integrative health care clinic settings - a qualitative study 
Integrative health care (IHC) is an interdisciplinary blending of conventional medicine and complementary and alternative medicine (CAM) with the purpose of enhancing patients' health. In 2006, we designed a study to assess outcomes that are relevant to people using such care. However, we faced major challenges in conducting this study and hypothesized that this might be due to the lack of a research climate in these clinics. To investigate these challenges, we initiated a further study in 2008, to explore the reasons why IHC clinics are not conducting outcomes research and to identify strategies for conducting successful in-house outcomes research programs. The results of the latter study are reported here.
A total of 25 qualitative interviews were conducted with key participants from 19 IHC clinics across Canada. Basic content analysis was used to identify key themes from the transcribed interviews.
Barriers identified by participants fell into four categories: organizational culture, organizational resources, organizational environment and logistical challenges. Cultural challenges relate to the philosophy of IHC, organizational leadership and practitioner attitudes and beliefs. Participants also identified significant issues relating to their organization's lack of resources such as funding, compensation, infrastructure and partnerships/linkages. Environmental challenges such as the nature of a clinic's patient population and logistical issues such as the actual implementation of a research program and the applicability of research data also posed challenges to the conduct of research. Embedded research leadership, integration of personal and professional values about research, alignment of research activities and clinical workflow processes are some of the factors identified by participants that support IHC clinics' ability to conduct outcomes research.
Assessing and enhancing the broader evaluation culture of IHC clinics prior to implementing outcomes research may be a critical step towards ensuring productive and cost-effective research programs. However, as IHC clinics are often complex systems, a whole systems approach to research should be used taking into account the multidimensional and complex nature of such treatment systems so that the results are useful and reflect real life.
PMCID: PMC2826302  PMID: 20074354
9.  Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study 
BMC Psychiatry  2014;14(1):355.
Blending online modules into face-to-face therapy offers perspectives to enhance patient self-management and to increase the (cost-)effectiveness of therapy, while still providing the support patients need. The aim of this study was to outline optimal usage of blended care for depression, according to patients and therapists.
A Delphi method was used to find consensus on suitable blended protocols (content, sequence and ratio). Phase 1 was an explorative phase, conducted in two rounds of online questionnaires, in which patients’ and therapists’ preferences and opinions about online psychotherapy were surveyed. In phase 2, data from phase 1 was used in face-to-face interviews with therapists to investigate how blended therapy protocols could be set up and what essential preconditions would be.
Twelve therapists and nine patients completed the surveys. Blended therapy was positively perceived among all respondents, especially to enhance the self-management of patients. According to most respondents, practical therapy components (assignments, diaries and psycho-education) may be provided via online modules, while process-related components (introduction, evaluation and discussing thoughts and feelings), should be supported face-to-face. The preferred blend of online and face-to-face sessions differs between therapists and patients; most therapists prefer 75% face-to-face sessions, most patients 50 to 60%. The interviews showed that tailoring treatment to individual patients is essential in secondary mental health care, due to the complexity of their problems. The amount and ratio of online modules needs to be adjusted according to the patient’s problems, skills and characteristics. Therapists themselves should also develop skills to integrate online and face-to-face sessions.
Blending online and face-to-face sessions in an integrated depression therapy is viewed as a positive innovation by patients and therapists. Following a standard blended protocol, however, would be difficult in secondary mental health care. A database of online modules could provide flexibility to tailor treatment to individual patients, which asks motivation and skills of both patients and therapists. Further research is necessary to determine the (cost-)effectiveness of blended care, but this study provides starting points and preconditions to blend online and face-to-face sessions and create a treatment combining the best of both worlds.
PMCID: PMC4271498  PMID: 25496393
10.  Complex Families and Late-Life Outcomes Among Elderly Persons: Disability, Institutionalization, and Longevity 
Journal of marriage and the family  2013;75(5):1084-1097.
The authors examined the effects of marital status and family structure on disability, institutionalization, and longevity for a nationally representative sample of elderly persons using Gompertz duration models applied to longitudinal data from 3 cohorts of the Health and Retirement Study (N = 11,481). They found that parents with only stepchildren have worse outcomes than parents with only biological children. Elderly mothers with only stepchildren become disabled and institutionalized sooner, and elderly men with only stepchildren have shorter longevity relative to their counterparts with only biological children. The effect of membership in a blended family differs by gender. Relative to those with only biological children, women in blended families have greater longevity and become disabled later, whereas men in blended families have reduced longevity. The findings indicate that changing marital patterns and increased complexity in family life have adverse effects on late-life health outcomes.
PMCID: PMC3767441  PMID: 24031097
aging; disability; divorce; families in middle and later life; intergenerational relations; stepfamilies
11.  Maternal bodies and medicines: a commentary on risk and decision-making of pregnant and breastfeeding women and health professionals 
BMC Public Health  2011;11(Suppl 5):S5.
The perceived risk/benefit balance of prescribed and over-the-counter (OTC) medicine, as well as complementary therapies, will significantly impact on an individual’s decision-making to use medicine. For women who are pregnant or breastfeeding, this weighing of risks and benefits becomes immensely more complex because they are considering the effect on two bodies rather than one. Indeed the balance may lie in opposite directions for the mother and baby/fetus. The aim of this paper is to generate a discussion that focuses on the complexity around risk, responsibility and decision-making of medicine use by pregnant and breastfeeding women. We will also consider the competing discourses that pregnant and breastfeeding women encounter when making decisions about medicine.
Women rely not only on biomedical information and the expert knowledge of their health care professionals but on their own experiences and cultural understandings as well. When making decisions about medicines, pregnant and breastfeeding women are influenced by their families, partners and their cultural societal norms and expectations. Pregnant and breastfeeding women are influenced by a number of competing discourses. “Good” mothers should manage and avoid any risks, thereby protecting their babies from harm and put their children’s needs before their own – they should not allow toxins to enter the body. On the other hand, “responsible” women take and act on medical advice – they should take the medicine as directed by their health professional. This is the inherent conflict in medicine use for maternal bodies.
The increased complexity involved when one body’s actions impact the body of another – as in the pregnant and lactating body – has received little acknowledgment. We consider possibilities for future research and methodologies. We argue that considering the complexity of issues for maternal bodies can improve our understanding of risk and public health education.
PMCID: PMC3247028  PMID: 22168473
12.  Non-linear blend coding in the moth antennal lobe emerges from random glomerular networks 
Neural responses to odor blends often exhibit non-linear interactions to blend components. The first olfactory processing center in insects, the antennal lobe (AL), exhibits a complex network connectivity. We attempt to determine if non-linear blend interactions can arise purely as a function of the AL network connectivity itself, without necessitating additional factors such as competitive ligand binding at the periphery or intrinsic cellular properties. To assess this, we compared blend interactions among responses from single neurons recorded intracellularly in the AL of the moth Manduca sexta with those generated using a population-based computational model constructed from the morphologically based connectivity pattern of projection neurons (PNs) and local interneurons (LNs) with randomized connection probabilities from which we excluded detailed intrinsic neuronal properties. The model accurately predicted most of the proportions of blend interaction types observed in the physiological data. Our simulations also indicate that input from LNs is important in establishing both the type of blend interaction and the nature of the neuronal response (excitation or inhibition) exhibited by AL neurons. For LNs, the only input that significantly impacted the blend interaction type was received from other LNs, while for PNs the input from olfactory sensory neurons and other PNs contributed agonistically with the LN input to shape the AL output. Our results demonstrate that non-linear blend interactions can be a natural consequence of AL connectivity, and highlight the importance of lateral inhibition as a key feature of blend coding to be addressed in future experimental and computational studies.
PMCID: PMC3329896  PMID: 22529799
olfaction; computational modeling; neural circuits; mixture processing; synaptic input; inhibitory interneurons; Manduca sexta
13.  Effects of a blended learning approach on student outcomes in a graduate-level public health course 
BMC Medical Education  2014;14:47.
Blended learning approaches, in which in-person and online course components are combined in a single course, are rapidly increasing in health sciences education. Evidence for the relative effectiveness of blended learning versus more traditional course approaches is mixed.
The impact of a blended learning approach on student learning in a graduate-level public health course was examined using a quasi-experimental, non-equivalent control group design. Exam scores and course point total data from a baseline, “traditional” approach semester (n = 28) was compared to that from a semester utilizing a blended learning approach (n = 38). In addition, student evaluations of the blended learning approach were evaluated.
There was a statistically significant increase in student performance under the blended learning approach (final course point total d = 0.57; a medium effect size), even after accounting for previous academic performance. Moreover, student evaluations of the blended approach were very positive and the majority of students (83%) preferred the blended learning approach.
Blended learning approaches may be an effective means of optimizing student learning and improving student performance in health sciences courses.
PMCID: PMC3975233  PMID: 24612923
Blended learning; Flipped classroom; Graduate education in public health; Online education; Student learning
14.  Antecedents of hospital admission for deliberate self-harm from a 14-year follow-up study using data-linkage 
BMC Psychiatry  2010;10:82.
A prior episode of deliberate self-harm (DSH) is one of the strongest predictors of future completed suicide. Identifying antecedents of DSH may inform strategies designed to reduce suicide rates. This study aimed to determine whether individual and socio-ecological factors collected in childhood and adolescence were associated with later hospitalisation for DSH.
Longitudinal follow-up of a Western Australian population-wide random sample of 2,736 children aged 4-16 years, and their carers, from 1993 until 2007 using administrative record linkage. Children were aged between 18 and 31 years at end of follow-up. Proportional hazards regression was used to examine the relationship between child, parent, family, school and community factors measured in 1993, and subsequent hospitalisation for DSH.
There were six factors measured in 1993 that increased a child's risk of future hospitalisation with DSH: female sex; primary carer being a smoker; being in a step/blended family; having more emotional or behavioural problems than other children; living in a family with inconsistent parenting style; and having a teenage mother. Factors found to be not significant included birth weight, combined carer income, carer's lifetime treatment for a mental health problem, and carer education.
The persistence of carer smoking as an independent risk factor for later DSH, after adjusting for child, carer, family, school and community level socio-ecological factors, adds to the known risk domains for DSH, and invites further investigation into the underlying mechanisms of this relationship. This study has also confirmed the association of five previously known risk factors for DSH.
PMCID: PMC2970584  PMID: 20955563
15.  The Role of Health Systems Factors in Facilitating Access to Psychotropic Medicines: A Cross-Sectional Analysis of the WHO-AIMS in 63 Low- and Middle-Income Countries 
PLoS Medicine  2012;9(1):e1001166.
In a cross-sectional analysis of WHO-AIMS data, Ryan McBain and colleagues investigate the associations between health system components and access to psychotropic drugs in 63 low and middle income countries.
Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue.
Methods and Findings
This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability.
Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.
Please see later in the article for the Editors' Summary
Editors' Summary
Mental disorders—conditions that involve impairment of thinking, emotions, and behavior—are extremely common. Worldwide, mental illness affects about 450 million people and accounts for 13.5% of the global burden of disease. About one in four people will have a mental health problem at some time in their life. For some people, this will be a short period of mild depression, anxiety, or stress. For others, it will be a serious, long-lasting condition such as schizophrenia, bipolar disorder, or major depression. People with mental health problems need help and support from professionals and from their friends and families to help them cope with their illness but are often discriminated against, which can make their illness worse. Treatments include counseling and psychotherapy (talking therapies), and psychotropic medicines—drugs that act mainly on the brain. Left untreated, many people with serious mental illnesses commit suicide.
Why Was This Study Done?
About 80% of people with mental illnesses live in low- and middle-income countries (LAMICs) where up to 85% of patients remain untreated. Access to psychotropic medicines, which constitute an essential and cost-effective component in the treatment of mental illnesses, is particularly poor in many LAMICs. To improve this situation, it is necessary to understand what health systems factors limit the availability and affordability of psychotropic drugs; a health system is the sum of all the organizations, institutions, and resources that act together to improve health. In this cross-sectional study, the researchers look for associations between specific health system components and access to psychotropic medicines by analyzing data collected from LAMICs using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). A cross-sectional study analyzes data collected at a single time. WHO-AIMS, which was created to evaluate mental health systems primarily in LAMICs, is a 155-item survey that Ministries of Health and other country-based agencies can use to collect information on mental health indicators.
What Did the Researchers Do and Find?
The researchers used WHO-AIMS data from 63 countries/country regions and multiple regression analysis to evaluate the role of mental health legislation, human rights implementation, mental health care financing, human resources, and advocacy in shaping medicine availability and affordability. For each of these health systems domains, the researchers developed one or more summary measurements. For example, they measured financing as the percentage of government health expenditure directed toward mental health. Availability of psychotropic medicines was defined as the percentage of mental health facilities in which at least one psychotropic medication for each therapeutic category was always available. Affordability was measured by calculating the percentage of daily minimum wage needed to purchase medicine by the average consumer. The availability of psychotropic medicines was related to features of all five mental health systems domains, report the researchers. Notably, having a national mental health plan (part of the legislation domain) and the participation (advocacy) of family-based organizations in mental health legislation formulation were associated with 15% and 17% greater availability of medicines, respectively. By contrast, only the levels of human resources and financing, and the availability of mental health care in prisons (part of the human rights domain) were associated with the affordability of psychotropic medicines. Once overall country development was taken into account, most of the associations between health systems factors and medicine availability remained significant, while the associations between health systems factors and medicine affordability were no longer significant. In part, this was because country development was more strongly associated with affordability and explained most of the relationships: for example, countries with greater overall development have higher expenditures on mental health and greater medicine affordability compared to availability.
What Do These Findings Mean?
These findings indicate that access to psychotropic medicines in LAMICs is related to key components within the mental health systems of these countries but that availability and affordability are affected to different extents by these components. They also show that country development plays a strong role in determining affordability but has less effect on determining availability. Because cross-sectional data were used in this study, these findings only indicate associations; they do not imply causality. They are also limited by the relatively small number of observations included in this study, by the methods used to collect mental health systems data in many LAMICs, and by the possibility that some countries may have reported biased results. Despite these limitations, these findings suggest that strengthening specific mental health system features may be an important way to facilitate access to psychotropic medicines but also highlight the role that country wealth and development play in promoting the treatment of mental disorders.
Additional Information
Please access these Web sites via the online version of this summary at 10.1371/journal.pmed.1001166.
The US National Institute of Mental Health provides information on all aspects of mental health (in English and Spanish)
The UK National Health Service Choices website provides information on mental health; its Live Well feature provides practical advice on dealing with mental health problems and personal stories
The UK charity Mind provides further information about mental illness, including personal stories
MedlinePlus provides links to many other sources of information on mental health (in English and Spanish)
Information on WHO-AIMS, including versions of the instrument in several languages, and WHO-AIMS country reports are available
PMCID: PMC3269418  PMID: 22303288
16.  Paving the Way to Personalized Genomic Medicine: Steps to Successful Implementation 
Over the last decade there has been vast interest in and focus on the implementation of personalized genomic medicine. Although there is general agreement that personalized genomic medicine involves utilizing genome technology to assess individual risk and ensure the delivery of the “right treatment, for the right patient, at the right time,” different categories of stakeholders focus on different aspects of personalized genomic medicine and operationalize it in diverse ways. In order to move toward a clearer, more holistic understanding of the concept, this article begins by identifying and defining three major elements of personalized genomic medicine commonly discussed by stakeholders: molecular medicine, pharmacogenomics, and health information technology. The integration of these three elements has the potential to improve health and reduce health care costs, but it also raises many challenges. This article endeavors to address these challenges by identifying five strategic areas that will require significant investment for the successful integration of personalized genomics into clinical care: (1) health technology assessment; (2) health outcomes research; (3) education (of both health professionals and the public); (4) communication among stakeholders; and (5) the development of best practices and guidelines. While different countries and global regions display marked heterogeneity in funding of health care in the form of public, private, or blended payor systems, previous analyses of personalized genomic medicine and attendant technological innovations have been performed without due attention to this complexity. Hence, this article focuses on personalized genomic medicine in the United States as a model case study wherein a significant portion of health care payors represent private, nongovernment resources. Lessons learned from the present analysis of personalized genomic medicine could usefully inform health care systems in other global regions where payment for personalized genomic medicine will be enabled through private or hybrid public-private funding systems.
PMCID: PMC2809376  PMID: 20098629
Personalized Genomic Medicine; Personalized Medicine; Ethics; Genomics; Policy
17.  Predicting Relationship Stability Among Midlife African American Couples 
This study examined predictors of relationship stability over 5 years among heterosexual cohabiting and married African American couples raising an elementary-school-age child. The vulnerability–stress–adaptation model of relationships (Karney & Bradbury, 1995) guided the investigation. Contextual variables were conceptualized as important determinants of education and income, which in turn influence family structure, stress, and relationship quality and stability. Religiosity was tested as a resource variable that enhances relationship stability.
Couples (N = 207) were drawn from the Family and Community Health Study. Variables assessed at Wave 1 (education, income, religiosity, biological vs. stepfamily status, marital status, financial strain, and relationship quality) were used to predict relationship stability 5 years later.
Higher levels of education were associated with higher income, lower financial strain, and family structures that research has shown to be more stable (marriage rather than cohabitation and biological-family rather than stepfamily status; Bumpass & Lu, 2000). These variables, in turn, influenced relationship quality and stability. Religiosity, an important resource in the lives of African Americans, promoted relationship stability through its association with marriage, biological-family status, and women’s relationship quality.
Enhancing the stability of African American couples’ relationships will require changes in societal conditions that limit opportunities for education and income and weaken relationship bonds. Programs to assist couples with blended families are needed, and incorporation of spirituality into culturally sensitive relationship interventions for African American couples may also prove beneficial.
PMCID: PMC3495553  PMID: 22004304
African Americans; couples; cohabitating; marriage; relationship quality
18.  Evolution of the integrative health care literature in the CAM field—a bibliometric analysis 
Integrative health care (IHC) has become a popular term used in practice and research to define the blending of complementary and alternative medicine (CAM) and conventional care as an innovative approach to health care delivery.
Purpose and objectives
To conduct a bibliometric analysis to develop a better understanding of the evolution of the concept of IHC in the CAM field.
All articles on IHC published between 1915 and 2008 indexed in the ISI web of knowledge database were retrieved. Title and abstract review were conducted to determine eligibility. Inclusion criteria included a research report and integration of CAM and conventional therapies. A second review of the full papers will be conducted to determine the final article sample, which will be analyzed using a rigorous bibliometric analysis approach.
Three thousand and five articles were retrieved and 35% met the inclusion criteria in the first screening round. Descriptive and relational bibliometric indicators will be presented, including the volume of research by year, keywords used, impact of the publication and collaboration amongst researchers.
Discussion and conclusion
Application of a bibliometric analysis allows for a broad and focused overview of the IHC literature within its historical and cultural context, and evaluation of the research output and its impact.
PMCID: PMC2807054
bibliometrics; complementary and alternative medicine (CAM)
19.  Historical Evolution and Present Status of Family Medicine in Sri Lanka 
Sri Lankan health system consists of Allopathic, Ayurvedic, Unani, and several other systems of medicine and allopathic medicine is catering to the majority of the health needs of the people. As in many other countries, Sri Lankan health system consists of both the state and the private sector General practitioners, MOs in OPDs of hospitals and MOs of central dispensaries, provide primary medical care in Sri Lanka. Most of the general practices are solo practices. One does not need postgraduate qualification or training in general practice to start a general practice. There is no registered population for any particular health care institution in the state sector or in the private sector and there is no strict referral procedure from primary care to secondary or tertiary care. Family doctors have been practicing in Sri Lanka for well over 150 years. The first national organization of general practitioners was Independent Medical Practitioner (IMPA)'s organization which was founded in 1929 and the College of General Practitioners of Sri Lanka was founded in 1974. College conducts its own Membership Course and Examination (MCGP) since 1999. Family Medicine was introduced to undergraduate curriculum in Sri Lanka in early 1980s and now almost all the medical faculties in the country have included Family Medicine in their curricula. In 1979, General Practice/Family Medicine was recognized as a specialty in Sri Lanka by the postgraduate institute of Medicine. Diploma in Family Medicine (DFM) and MD Family Medicine are the pathways for postgraduate training in Sri Lanka. At present 50 to 60 doctors enroll for DFM every year and the country has about 20 specialists (with MD) in Family Medicine. The author's vision for the future is that all the primary care doctors to have a postgraduate qualification in Family Medicine either DFM, MD, or MCGP which is a far cry from the present status.
PMCID: PMC3894032  PMID: 24479065
Family Medicine; history; Sri Lanka
20.  Shades of greener grass. 
Canadian Family Physician  1997;43:1483-1492.
Neither system or culture is perfect; a blend just might be. I can't say that one is definitely better, only different. Many Canadian doctors have emigrated only to return within a year or two, frustrated with a market-driven health care system and a much more eclectic and individualistic society. Yes, family physicians can earn more money here and have better access to diagnostics and treatment. But that has to be balanced with a larger bureaucracy and-at least on the surface-less freedom to access those resources. With time and the ubiquitous fiscal imperative, both countries could emerge from their respective crises at similar destinations, but by separate paths. Traveling and particularly working in another culture has been a positive experience for our family. It might not be for everyone. Each physician, with his or her family, must weigh the pros and cons of such a decision. To boldly go where you've never been before, to move or not to move: that is the question.
PMCID: PMC2255358  PMID: 9303220
21.  Ascaroside Expression in Caenorhabditis elegans Is Strongly Dependent on Diet and Developmental Stage 
PLoS ONE  2011;6(3):e17804.
The ascarosides form a family of small molecules that have been isolated from cultures of the nematode Caenorhabditis elegans. They are often referred to as “dauer pheromones” because most of them induce formation of long-lived and highly stress resistant dauer larvae. More recent studies have shown that ascarosides serve additional functions as social signals and mating pheromones. Thus, ascarosides have multiple functions. Until now, it has been generally assumed that ascarosides are constitutively expressed during nematode development.
Methodology/Principal Findings
Cultures of C. elegans were developmentally synchronized on controlled diets. Ascarosides released into the media, as well as stored internally, were quantified by LC/MS. We found that ascaroside biosynthesis and release were strongly dependent on developmental stage and diet. The male attracting pheromone was verified to be a blend of at least four ascarosides, and peak production of the two most potent mating pheromone components, ascr#3 and asc#8 immediately preceded or coincided with the temporal window for mating. The concentration of ascr#2 increased under starvation conditions and peaked during dauer formation, strongly supporting ascr#2 as the main population density signal (dauer pheromone). After dauer formation, ascaroside production largely ceased and dauer larvae did not release any ascarosides. These findings show that both total ascaroside production and the relative proportions of individual ascarosides strongly correlate with these compounds' stage-specific biological functions.
Ascaroside expression changes with development and environmental conditions. This is consistent with multiple functions of these signaling molecules. Knowledge of such differential regulation will make it possible to associate ascaroside production to gene expression profiles (transcript, protein or enzyme activity) and help to determine genetic pathways that control ascaroside biosynthesis. In conjunction with findings from previous studies, our results show that the pheromone system of C. elegans mimics that of insects in many ways, suggesting that pheromone signaling in C. elegans may exhibit functional homology also at the sensory level. In addition, our results provide a strong foundation for future behavioral modeling studies.
PMCID: PMC3058051  PMID: 21423575
22.  Novel chitosan-polycaprolactone blends as potential scaffold and carrier for corneal endothelial transplantation 
Molecular Vision  2012;18:255-264.
The aim of this prospective study was to evaluate whether blending two kinds of biomaterials, chitosan and polycaprolactone (PCL), can be used as scaffold and carrier for growth and differentiation of corneal endothelial cells (CECs).
A transparent, biocompatible carrier with cultured CECs on scaffold would be a perfect replacement graft. In the initial part of experiment, for essential and biocompatible test, chitosan and PCL were evaluated respectively and blended in various proportions by coating. In the later part of this study, for evaluation of potential application, homogenous solutions of 25%, 50%, and 75% PCL compositions were attempted to structure blend membranes.
Chitosan, PCL 25, PCL 50, and PCL 75 blends could maintain transparency of culturing substrata. BCECs were found to be reached confluence successfully after 7 days on PCL 25, PCL 50, and PCL 75. The expression of tight junction and extracellular matrix protein were observed as well. Alternatively, only PCL 25 could make blend membrane with enough strength during preparation for carrier in culture. On this blend membrane, the growth pattern and phenotype of BCECs could be observed well.
A ratio of 75:25 (chitosan:PCL) blends showed enough mechanical properties as well as suitable support for cellular activity in cultivating BCECs. Thus, a novel methodology of biodegradable carrier from chitosan and PCL has potential to be a good replacement scaffold for raising CECs for clinical transplantation.
PMCID: PMC3276373  PMID: 22328821
23.  Asháninka medicinal plants: a case study from the native community of Bajo Quimiriki, Junín, Peru 
The Asháninka Native Community Bajo Quimiriki, District Pichanaki, Junín, Peru, is located only 4 km from a larger urban area and is dissected by a major road. Therefore the loss of traditional knowledge is a main concern of the local headman and inhabitants. The present study assesses the state of traditional medicinal plant knowledge in the community and compares the local pharmacopoeia with the one from a related ethnic group.
Fieldwork was conducted between July and September 2007. Data were collected through semi-structured interviews, collection of medicinal plants in the homegardens, forest walks, a walk along the river banks, participant observation, informal conversation, cross check through voucher specimens and a focus group interview with children.
Four-hundred and two medicinal plants, mainly herbs, were indicated by the informants. The most important families in terms of taxa were Asteraceae, Araceae, Rubiaceae, Euphorbiaceae, Solanaceae and Piperaceae. Eighty-four percent of the medicinal plants were wild and 63% were collected from the forest. Exotics accounted to only 2% of the medicinal plants. Problems related to the dermal system, digestive system, and cultural belief system represented 57% of all the medicinal applications. Some traditional healers received non-indigenous customers, using their knowledge as a source of income. Age and gender were significantly correlated to medicinal plant knowledge. Children knew the medicinal plants almost exclusively by their Spanish names. Sixteen percent of the medicinal plants found in this community were also reported among the Yanesha of the Pasco Region.
Despite the vicinity to a city, knowledge on medicinal plants and cultural beliefs are still abundant in this Asháninka Native Community and the medicinal plants are still available in the surroundings. Nevertheless, the use of Spanish names for the medicinal plants and the shift of healing practices towards a source of income with mainly non-indigenous customers, are signs of acculturation. Future studies on quantification of the use of medicinal plants, dynamics of transmission of ethno-medicinal knowledge to the young generations and comparison with available pharmacological data on the most promising medicinal plants are suggested.
PMCID: PMC2933607  PMID: 20707893
24.  Traditional perspectives on child and family health 
Paediatrics & Child Health  2005;10(9):542-544.
First Nations and American Indian communities experience significant health disparities compared with the general populations of Canada and the United States. Children from these communities experience higher rates of infant mortality, suicide and unintentional injury. From a traditional Lakota perspective, many of the health disparities faced in Aboriginal communities are linked to imbalances in the family and community. These imbalances can lead to detrimental behaviours, including substance abuse, alcoholism and domestic violence. The Medicine Wheel is a traditional symbol that can be used to attain a better understanding of these imbalances and how they relate to family and child health. However, significant differences exist between the perspectives of modern medical science and traditional cultures. To promote wellness and to prevent morbidity and mortality in a culturally appropriate way, current efforts need to focus attention on traditional cultural values and perspectives that incorporate the balance of the community and the health of the family. Traditionally, we understood that the health of the family and community has a significant impact on the health of children. To more effectively promote health and to prevent imbalance, children from these communities need to understand traditional values and to feel that they are an important link between traditional culture and future generations.
PMCID: PMC2722639  PMID: 19668686
First Nations; Health disparities; Lakota; Medicine Wheel; Traditional
25.  Tuning the Degradation Profiles of Poly(l-lactide)-Based Materials through Miscibility 
Biomacromolecules  2013;15(1):391-402.
The effective use of biodegradable polymers relies on the ability to control the onset of and time needed for degradation. Preferably, the material properties should be retained throughout the intended time frame, and the material should degrade in a rapid and controlled manner afterward. The degradation profiles of polyester materials were controlled through their miscibility. Systems composed of PLLA blended with poly[(R,S)-3-hydroxybutyrate] (a-PHB) and polypropylene adipate (PPA) with various molar masses were prepared through extrusion. Three different systems were used: miscible (PLLA/a-PHB5 and PLLA/a-PHB20), partially miscible (PLLA/PPA5/comp and PLLA/PPA20/comp), and immiscible (PLLA/PPA5 and PLLA/PPA20) blends. These blends and their respective homopolymers were hydrolytically degraded in water at 37 °C for up to 1 year. The blends exhibited entirely different degradation profiles but showed no diversity between the total degradation times of the materials. PLLA presented a two-stage degradation profile with a rapid decrease in molar mass during the early stages of degradation, similar to the profile of PLLA/a-PHB5. PLLA/a-PHB20 presented a single, constant linear degradation profile. PLLA/PPA5 and PLLA/PPA20 showed completely opposing degradation profiles relative to PLLA, exhibiting a slow initial phase and a rapid decrease after a prolonged degradation time. PLLA/PPA5/comp and PLLA/PPA20/comp had degradation profiles between those of the miscible and the immiscible blends. The molar masses of the materials were approximately the same after 1 year of degradation despite their different profiles. The blend composition and topographical images captured at the last degradation time point demonstrate that the blending component was not leached out during the period of study. The hydrolytic stability of degradable polyester materials can be tailored to obtain different and predetermined degradation profiles for future applications.
PMCID: PMC3892759  PMID: 24279455

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