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1.  OptiVol fluid index predicts acute decompensation of heart failure with a high rate of unexplained events 
Background
Intrathoracic impedance monitoring has emerged as a promising new technique for the detection of impending heart failure (HF). Although false positive episodes have been reported in case reports and clinical trials, the efficacy and false positive rate in real-world practice remain unclear.
Objective
The aim of this study is to investigate the utility and reliability of the OptiVol alert feature in clinical practice.
Methods
We continuously recruited patients who underwent implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with defibrillator (CRT-D) implantation with feature of intrathoracic impedance monitoring system in our center from Sep. 2010 to Oct. 2012. Regular in-office follow-up were required of all patients and the following information was collected at each visit: medical history, device interrogation, N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement and an echocardiogram. Worsening HF was defined as hospitalization or the presentation of signs or symptoms of HF.
Results
Forty three patients (male: 76.7%, mean age: 57 ± 15 years, left ventricular ejection fraction (LVEF): 33% ± 14%) were included in this observational study. Fifty four alert events and 14 adjudicated worsening HF were detected within 288 ±163 days follow-up. Eleven (20.4%) alert episodes were associated with acute cardiac decompensation in 9 patients with a positive predictive value of 78.6%. Forty three audible alerts showed no connection to worsening HF. The unexplained alerts rate was 79.6% and 1.27 per person-year. Thirty seven alarm alerts were detected in patients with EF < 45%, among which 9 accompanied with HF, 17 alerts detected in patients with LVEF ≥ 45% and 2 associated with HF. There was no significant difference between the two groups (9/37 vs. 2/17; P = 0.47).
Conclusions
Patients with normal or nearly normal left ventricular systolic function also exhibited considerable alert events. The OptiVol fluid index predicted worsening cardiac events with a high unexplained detection rate, and any alert must therefore be analyzed with great caution. Efforts to improve the specificity of this monitoring system represent a significant aspect of future studies.
doi:10.3969/j.issn.1671-5411.2013.03.012
PMCID: PMC3796699  PMID: 24133513
Heart failure; Intrathoracic impedance measurement; OptiVol fluid index; Left ventricular ejection fraction
2.  Fluid status monitoring with a wireless network to reduce cardiovascular-related hospitalizations and mortality in heart failure: rationale and design of the OptiLink HF Study (Optimization of Heart Failure Management using OptiVol Fluid Status Monitoring and CareLink) 
European Journal of Heart Failure  2011;13(7):796-804.
Aims
The Optimization of Heart Failure Management using OptiVol Fluid Status Monitoring and CareLink (OptiLink HF) study is designed to investigate whether OptiVol fluid status monitoring with an automatically generated wireless CareAlert notification via the CareLink Network can reduce all-cause death and cardiovascular hospitalizations in an HF population, compared with standard clinical assessment.
Methods
Patients with newly implanted or replacement cardioverter-defibrillator devices with or without cardiac resynchronization therapy, who have chronic HF in New York Heart Association class II or III and a left ventricular ejection fraction ≤35% will be eligible to participate. Following device implantation, patients are randomized to either OptiVol fluid status monitoring through CareAlert notification or regular care (OptiLink ‘on' vs. ‘off'). The primary endpoint is a composite of all-cause death or cardiovascular hospitalization. It is estimated that 1000 patients will be required to demonstrate superiority of the intervention group to reduce the primary outcome by 30% with 80% power.
Conclusion
The OptiLink HF study is designed to investigate whether early detection of congestion reduces mortality and cardiovascular hospitalization in patients with chronic HF. The study is expected to close recruitment in September 2012 and to report first results in May 2014.
ClinicalTrials.gov Identifier: NCT00769457
doi:10.1093/eurjhf/hfr045
PMCID: PMC3125124  PMID: 21555324
Chronic heart failure; Disease management; Telemedicine; Cardiac resynchronization therapy; Implantable defibrillator; Bioimpedance
3.  Radiation Safety and Education in the Applicants of the Final Test for the Expert of Pain Medicine 
The Korean Journal of Pain  2012;25(1):16-21.
Background
The C-arm fluoroscope is known as the most important equipment in pain interventions. This study was conducted to investigate the completion rate of education on radiation safety, the knowledge of radiation exposure, the use of radiation protection, and so on.
Methods
Unsigned questionnaires were collected from the 27 pain physicians who applied for the final test to become an expert in pain medicine in 2011. The survey was composed of 12 questions about the position of the hospital, the kind of hospital, the use of C-arm fluoroscopy, radiation safety education, knowledge of annual permissible radiation dose, use of radiation protection, and efforts to reduce radiation exposure.
Results
In this study, although most respondents (93%) had used C-arm fluoroscopy, only 33% of the physicians completed radiation safety education. Even though nine (33%) had received education on radiation safety, none of the physicians knew the annual permissible radiation dose. In comparing the radiation safety education group and the no-education group, the rate of wearing radiation-protective glasses or goggles and the use of radiation badges or dosimeters were significantly higher in the education group. However, in the use of other protective equipment, knowledge of radiation safety, and efforts to reduce radiation exposure, there were no statistical differences between the two groups.
Conclusions
The respondents knew very little about radiation safety and had low interest in their radiation exposure. To make the use of fluoroscopy safer, additional education, as well as attention to and knowledge of practices of radiation safety are required for pain physicians.
doi:10.3344/kjp.2012.25.1.16
PMCID: PMC3259132  PMID: 22259711
education; fluoroscopy; radiation; radiation monitoring; radiation protection
4.  Clinicians’ justification of imaging: do radiation issues play a role? 
Insights into Imaging  2010;1(3):193-200.
Objective
To explore clinicians’ knowledge and consideration of radiation, in relation to their referral practice and use of referral guidelines for imaging.
Methods
A questionnaire was handed out to 213 clinicians in Norway; all responded: 77 general practitioners, 71 hospital physicians and 65 non-physicians (55 manual physiotherapists, 10 chiropractors). Questions concerned weighting of radiation dose, guideline use, referrals unlikely to affect treatment, doses from imaging procedures, ranking of imaging as radiation source, and deterministic and stochastic effects. For radiation knowledge, a total score was aggregated.
Results
The mean radiation knowledge score was 30.4/71. Most respondents underestimated doses from high-dose imaging, e.g., barium enema (94.7%), chest CT (57.7%) and abdominal CT (52.7%). Limited radiation knowledge was not compensated by using guidelines. Only 20% of physicians and 72% of non-physicians used referral guidelines. Non-physicians weighted radiation dose as being more important than physicians when referring; they also reported fewer referrals as being unlikely to affect treatment. Such referrals and not using guidelines were related to lower weighting of radiation dose but not to radiation knowledge.
Conclusion
Limited radiation knowledge and guideline use indicate suboptimal justification of referrals. When justifying imaging, weighting of radiation dose may play a larger role than detailed radiation knowledge.
doi:10.1007/s13244-010-0029-4
PMCID: PMC3259314  PMID: 22347915
Diagnostic imaging; Referral guidelines; Radiation dosage; Questionnaires; Radiation protection
5.  Clinicians’ justification of imaging: do radiation issues play a role? 
Insights into Imaging  2010;1(3):193-200.
Objective
To explore clinicians’ knowledge and consideration of radiation, in relation to their referral practice and use of referral guidelines for imaging.
Methods
A questionnaire was handed out to 213 clinicians in Norway; all responded: 77 general practitioners, 71 hospital physicians and 65 non-physicians (55 manual physiotherapists, 10 chiropractors). Questions concerned weighting of radiation dose, guideline use, referrals unlikely to affect treatment, doses from imaging procedures, ranking of imaging as radiation source, and deterministic and stochastic effects. For radiation knowledge, a total score was aggregated.
Results
The mean radiation knowledge score was 30.4/71. Most respondents underestimated doses from high-dose imaging, e.g., barium enema (94.7%), chest CT (57.7%) and abdominal CT (52.7%). Limited radiation knowledge was not compensated by using guidelines. Only 20% of physicians and 72% of non-physicians used referral guidelines. Non-physicians weighted radiation dose as being more important than physicians when referring; they also reported fewer referrals as being unlikely to affect treatment. Such referrals and not using guidelines were related to lower weighting of radiation dose but not to radiation knowledge.
Conclusion
Limited radiation knowledge and guideline use indicate suboptimal justification of referrals. When justifying imaging, weighting of radiation dose may play a larger role than detailed radiation knowledge.
doi:10.1007/s13244-010-0029-4
PMCID: PMC3259314  PMID: 22347915
Diagnostic imaging; Referral guidelines; Radiation dosage; Questionnaires; Radiation protection
6.  Gene Expression Signatures That Predict Radiation Exposure in Mice and Humans 
PLoS Medicine  2007;4(4):e106.
Background
The capacity to assess environmental inputs to biological phenotypes is limited by methods that can accurately and quantitatively measure these contributions. One such example can be seen in the context of exposure to ionizing radiation.
Methods and Findings
We have made use of gene expression analysis of peripheral blood (PB) mononuclear cells to develop expression profiles that accurately reflect prior radiation exposure. We demonstrate that expression profiles can be developed that not only predict radiation exposure in mice but also distinguish the level of radiation exposure, ranging from 50 cGy to 1,000 cGy. Likewise, a molecular signature of radiation response developed solely from irradiated human patient samples can predict and distinguish irradiated human PB samples from nonirradiated samples with an accuracy of 90%, sensitivity of 85%, and specificity of 94%. We further demonstrate that a radiation profile developed in the mouse can correctly distinguish PB samples from irradiated and nonirradiated human patients with an accuracy of 77%, sensitivity of 82%, and specificity of 75%. Taken together, these data demonstrate that molecular profiles can be generated that are highly predictive of different levels of radiation exposure in mice and humans.
Conclusions
We suggest that this approach, with additional refinement, could provide a method to assess the effects of various environmental inputs into biological phenotypes as well as providing a more practical application of a rapid molecular screening test for the diagnosis of radiation exposure.
John Chute and colleagues report that gene expression patterns in peripheral blood mononuclear cells from mice and humans reflect prior radiation exposure.
Editors' Summary
Background.
Everyone living on earth is constantly exposed to low levels of ionizing radiation—energy in the form of waves or particles that is powerful enough to strip electrons out of atoms and to break chemical bonds in important biomolecules. These low levels of ionizing radiation come from radioactive chemicals in the ground and cosmic rays, for example, and are relatively harmless. Occasionally, though, individuals are exposed to larger amounts of ionizing radiation, often as a result of medical tests and treatments but sometimes through the accidental or deliberate release of radioactive chemicals. These larger doses, which permanently damage or kill cells, can cause radiation sickness, a condition characterized by bone marrow failure, gut problems, susceptibility to bacterial infections, and other symptoms that develop days or months after exposure to ionizing radiation. Particularly large doses can be lethal but even moderate doses can increase an individual's risk of developing cancer later in life.
Why Was This Study Done?
Some of the effects of ionizing radiation can be reduced if suitable treatment is started immediately after exposure. Unfortunately, it takes several days to estimate the amount of ionizing radiation to which an individual has been exposed. It would be useful to measure personal exposures more quickly, especially in emergency situations where ideally doctors would be able to distinguish rapidly and accurately between the “worried well” and exposed individuals. As cells respond to irradiation by altering the expression of some genes, the researchers in this study investigated whether gene expression profiling (a molecular biology technique that catalogues all the genes expressed by a cell) can be used to define a set of gene expression changes—called a metagene—that differentiates between irradiated and non-irradiated cells.
What Did the Researchers Do and Find?
The researchers exposed mice to no ionizing radiation, a low dose that causes no medical problems, an intermediate dose that damages blood cells, or a lethal dose. Six hours later, they isolated blood cells from the mice, and catalogued which genes each sample expressed. Using this information, the researchers identified and validated metagenes that accurately distinguished between blood samples from non-irradiated and irradiated animals and between samples from animals exposed to different radiation doses. The researchers then developed a metagene for human radiation exposure using blood samples taken from patients before and after total body irradiation given as part of their medical treatment. This metagene correctly identified 18 of 20 pre-irradiation samples and 17 of 20 post-irradiation samples. Finally, the researchers tested whether the radiation metagenes developed in mice could distinguish between samples taken from irradiated and non-irradiated people. Although the high-dose mouse metagene correctly identified all of the samples from healthy donors as being non-irradiated, it correctly identified only two-thirds of the pre-irradiated samples from patients.
What Do These Findings Mean?
These findings indicate that metagenes can be generated that recognize different levels of radiation exposure in mice and people. In the mouse study a metagene was identified that correctly identified in all cases whether a sample came from a non-irradiated mouse or an animal exposed to the lowest dose of radiation. This result suggests that it might be possible to use a metagene to identify exposed individuals among thousands of “worried well” after a radiation emergency. First, however, the mouse and human metagenes identified here need to be refined to improve their accuracy and then validated in more people. The current high-dose mouse metagene may be bad at identifying non-irradiated patients, for example, because of gene expression changes that are a result of the patients' underlying disease or previous medical treatments. By studying additional patients, it might be possible to improve the accuracy of the metagene by taking these radiation-independent changes into account. Finally and more generally, these findings suggest that the metagene approach could be used to monitor people's exposure to other dangerous environmental agents.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040106.
US Environmental Protection Agency offers information on understanding radiation and factsheets on ionizing radiation
MedlinePlus provides links to information on radiation exposure and pages on radiation sickness
US Centers for Disease Control and Prevention has information on emergency preparedness and response to radiation emergencies
Wikipedia has pages on ionizing radiation, radiation poisoning, and expression profiling (note that Wikipedia is a free online encyclopedia that anyone can edit)
doi:10.1371/journal.pmed.0040106
PMCID: PMC1845155  PMID: 17407386
7.  Assessment of radiation protection practices among radiographers in Lagos, Nigeria 
Background:
Use of ionising radiation in diagnostic radiography could lead to hazards such as somatic and genetic damages. Compliance to safe work and radiation protection practices could mitigate such risks. The aim of the study was to assess the knowledge and radiation protection practices among radiographers in Lagos, Nigeria.
Materials and Methods:
The study was a prospective cross sectional survey. Convenience sampling technique was used to select four x-ray diagnostic centres in four tertiary hospitals in Lagos metropolis. Data were analysed with Epi- info software, version 3.5.1.
Results:
Average score on assessment of knowledge was 73%. Most modern radiation protection instruments were lacking in all the centres studied. Application of shielding devices such as gonad shield for protection was neglected mostly in government hospitals. Most x-ray machines were quite old and evidence of quality assurance tests performed on such machines were lacking.
Conclusion:
Radiographers within Lagos metropolis showed an excellent knowledge of radiation protection within the study period. Adherence to radiation protection practices among radiographers in Lagos metropolis during the period studied was, however, poor. Radiographers in Lagos, Nigeria should embrace current trends in radiation protection and make more concerted efforts to apply their knowledge in protecting themselves and patients from harmful effects of ionising radiation.
doi:10.4103/0300-1652.126290
PMCID: PMC3948960  PMID: 24665152
Attitude; ionisation; protection; radiation; radiographers
8.  Evaluating the quality of informed consent and contemporary clinical practices by medical doctors in South Africa: An empirical study 
BMC Medical Ethics  2013;14(Suppl 1):S3.
Background
Informed consent is a legal and ethical doctrine derived from the principle of respect for autonomy. Generally two rights derived from autonomy are accorded legal protection. The constitutional right to bodily integrity followed by the right to bodily well-being, protected by professional negligence rules. Therefore healthcare professionals treating patients' without valid consent may be guilty of infringing patients' rights. Many challenges are experienced by doctors obtaining informed consent in complex multicultural societies like South Africa. These include different cultural ethos, multilingualism, poverty, education, unfamiliarity with libertarian rights based autonomy, and power asymmetry between doctors and patients. All of which could impact on the ability of doctors to obtain legally valid informed consent.
Methods
The objective of this study was to evaluate whether the quality of informed consent obtained by doctors practicing in South Africa is consistent with international ethical standards and local regulations. Responses from 946 participants including doctors, nurses and patients was analyzed, using a semi-structured self-administered questionnaire and person triangulation in selected public hospitals in Durban, KwaZulu-Natal, South Africa.
Results
The median age of 168 doctors participating was 30 years with 51% females, 28% interns, 16% medical officers, 26% registrars, 30% consultant/specialists. A broad range of clinical specialties were represented. Challenges to informed consent practice include language difficulties, lack of interpreters, workload, and time constraints. Doctors spent 5-10 minutes on consent, disclosed most information required to patients, however knowledge of essential local laws was inadequate. Informed consent aggregate scores (ICAS) showed that interns/registrars scored lower than consultants/specialists. ICAS scores were statistically significant by specialty (p = 0.005), with radiologists and anaesthetists scoring lowest, while internists, GPs and obstetricians/gynaecologists scored highest. Comparative ICAS scores showed that professional nurses scored significantly lower than doctors (p ≤ 0.001).
Conclusions
This study shows that though doctors had general knowledge of informed consent requirements, execution in practice was inadequate, with deficiency in knowledge of basic local laws and regulations. Remedying identified deficiencies may require a 'corps' of interpreters in local hospitals to assist doctors in dealing with language difficulties, and continuing education in medical law and ethics to improve informed consent practices and overall quality of healthcare service delivery.
doi:10.1186/1472-6939-14-S1-S3
PMCID: PMC3878312  PMID: 24564932
Africa; Autonomy; Patients' rights; Informed consent; Doctors; Empirical ethics; Nurses; Laws; Regulations
9.  Status of radiation protection at different hospitals in Nepal 
Nepal has a long history of medical radiology since1923 but unfortunately, we still do not have any Radiation Protection Infrastructure to control the use of ionizing radiations in the various fields. The objective of this study was an assessment of the radiation protection in medical uses of ionizing radiation. Twenty-eight hospitals with diagnostic radiology facility were chosen for this study according to patient loads, equipment and working staffs. Radiation surveys were also done at five different radiotherapy centers. Questionnaire for radiation workers were used; radiation dose levels were measured and an inventory of availability of radiation equipment made. A corollary objective of the study was to create awareness in among workers on possible radiation health hazard and risk. It was also deemed important to know the level of understanding of the radiation workers in order to initiate steps towards the establishment of Nepalese laws, regulation and code of radiological practice in this field. Altogether, 203 Radiation workers entertained the questionnaire, out of which 41 are from the Radiotherapy and 162 are from diagnostic radiology. The radiation workers who have participated in the questionnaire represent more than 50% of the radiation workers working in this field in Nepal. Almost all X-ray, CT and Mammogram installations were built according to protection criteria and hence found safe. Radiation dose level at the reference points for all the five Radiotherapy centers are within safe limit. Around 65% of the radiation workers have never been monitored for radiation. There is no quality control program in any of the surveyed hospitals except radiotherapy facilities.
doi:10.4103/0971-6203.103611
PMCID: PMC3532754  PMID: 23293457
Dose limit; personnel monitoring; quality control; workload
10.  The Outer Surface Lipoprotein VolA Mediates Utilization of Exogenous Lipids by Vibrio cholerae 
mBio  2013;4(3):e00305-13.
ABSTRACT
Previous work from our laboratory showed that the Gram-negative aquatic pathogen Vibrio cholerae can take up a much wider repertoire of fatty acids than other Gram-negative organisms. The current work elaborated on the ability of V. cholerae to exploit an even more diverse pool of lipid nutrients from its environment. We have demonstrated that the bacterium can use lysophosphatidylcholine as a metabolite for growth. Using a combination of thin-layer chromatography and mass spectrometry, we also showed that lysophosphatidylcholine-derived fatty acid moieties can be used for remodeling the V. cholerae membrane architecture. Furthermore, we have identified a lysophospholipase, VolA (Vibrio outer membrane lysophospholipase A), required for these activities. The enzyme is well conserved in Vibrio species, is coexpressed with the outer membrane fatty acid transporter FadL, is one of very few surface-exposed lipoprotein enzymes to be identified in Gram-negative bacteria and the first instance of a surface lipoprotein phospholipase. We propose a model whereby the bacterium efficiently couples the liberation of fatty acid from lysophosphatidylcholine to its subsequent metabolic uptake. An expanded ability to scavenge diverse environmental lipids at the bacterial surface increases overall bacterial fitness and promotes homeoviscous adaptation through membrane remodeling.
IMPORTANCE
Our understanding of how bacteria utilize environmental lipid sources has been limited to lipids such as fatty acids and cholesterol. This narrow scope may be attributed to both the intricate nature of lipid uptake mechanisms and the diversity of lipid substrates encountered within an ecological niche. By examining the ability of the pathogen Vibrio cholerae to utilize exogenous lipids, we uncovered a surface-exposed lipoprotein (VolA) that is required for processing the prevalent host lipid lysophosphatidylcholine. VolA functions as a lipase liberating a fatty acid from exogenous lysophospholipids. The freed fatty acid is then transported into the cell, serving as a carbon source, or shunted into phospholipid synthesis for membrane assembly. A limited number of surface-exposed lipoproteins have been found in Gram-negative organisms, and few have enzymatic function. This work highlights the ability of bacteria to exploit exogenous lipids for both maintenance of the membrane and carbon source acquisition.
doi:10.1128/mBio.00305-13
PMCID: PMC3656444  PMID: 23674613
11.  A transmissible avian neoplasm. (Sarcoma of the common fowl) by Peyton Rous, M.D., Experimental Medicine for Sept. 1, 1910, vol. 12, pp.696- 705 
In this paper is reported the first avian tumor that has proved transplantable to other individuals. It is a spindle-celled sarcoma of the hen, which thus far has been propagated into its fourth tumor generation. This was accomplished by the use of fowls of pure blood from the small, intimately related stock in which the growth occurred. Market-bought fowls of similar variety have shown themselves insusceptible, as have fowls of mixed breed, pigeons and guinea-pigs. The percentage of successful transplantations has been small, but in the individuals developing a tumor its growth has been fairly rapid. Young chickens are more susceptible than adults. The reinoculation of negative fowls has never resulted in a growth. Throughout, the sarcoma has remained true to type. It is infiltrative and destructive. Metastasis has been observed once (to the heart). Experiments to determine whether the growth may be transmitted by cell-fragments have not yet been made. Repeated bacteriological examinations have yielded negative results. In its general behavior, so far as tested, this avian tumor closely resembles the typical mammalian neoplasms that are transplantable.
PMCID: PMC2185676  PMID: 229185
12.  VolRoverN: Enhancing surface and volumetric reconstruction for realistic dynamical simulation of cellular and subcellular function 
Neuroinformatics  2014;12(2):277-289.
Establishing meaningful relationships between cellular structure and function requires accurate morphological reconstructions. In particular, there is an unmet need for high quality surface reconstructions to model subcellular and synaptic interactions among neurons at nanometer resolution. We address this need with VolRoverN, a software package that produces accurate, efficient, and automated 3D surface reconstructions from stacked 2D contour tracings. While many techniques and tools have been developed in the past for 3D visualization of cellular structure, the reconstructions from VolRoverN meet specific quality criteria that are important for dynamical simulations. These criteria include manifoldness, water-tightness, lack of self- and object-object-intersections, and geometric accuracy. These enhanced surface reconstructions are readily extensible to any cell type (including glia) and are used here on complex spiny dendrites and axons from mature rat hippocampal area CA1. Both spatially realistic surface reconstructions and reduced skeletonizations are produced and formatted by VolRoverN for easy input into analysis software packages for neurophysiological simulations at multiple spatial and temporal scales ranging from ion electro-diffusion to electrical cable models.
doi:10.1007/s12021-013-9205-2
PMCID: PMC4033674  PMID: 24100964
13.  Erratum Vol. 4, No. 1 
In the article, "Emerging Infectious Diseases Brazil," by Hooman Momen, on page 3 the last sentence of the next-to-the-last paragraph should read, "The existing, generally passive epidemiologic surveillance system produces information that arrives too late to be effective; however, a number of measures, if implemented immediately, can mitigate the impact of any future epidemic: a containment laboratory (biosafety level 4) that can handle known and unknown microbes of high virulence; at least one infirmary, properly designed and fully equipped, to treat highly contagious and virulent diseases (the current lack of this facility poses a great danger to the population should an outbreak of such a disease occur); and a mobile multidisciplinary task force, including epidemiologists, microbiologists, entomologists, and clinicians, ready to investigate suspected disease outbreaks on short notice.
PMCID: PMC2640140  PMID: 9680508
14.  Fact-finding Survey of Nosocomial Infection Control in Hospitals in Kathmandu, Nepal—A Basis for Improvement 
Tropical Medicine and Health  2013;41(3):113-119.
The purpose of this study was to investigate the actual conditions of nosocomial infection control in Kathmandu City, Nepal as a basis for the possible contribution to its improvement. The survey was conducted at 17 hospitals and the methods included a questionnaire, site visits and interviews. Nine hospitals had manuals on nosocomial infection control, and seven had an infection control committee (ICC). The number of hospitals that met the required amount of personal protective equipment preparation was as follows: gowns (13), gloves (13), surgical masks (12). Six hospitals had carried out in-service training over the past one year, but seven hospitals responded that no staff had been trained. Eight hospitals were conducting surveillance based on the results of bacteriological testing. The major problems included inadequate management of ICC, insufficient training opportunities for hospital staff, and lack of essential equipment. Moreover, increasing bacterial resistance to antibiotics was recognized as a growing issue. In comparison with the results conducted in 2003 targeting five governmental hospitals, a steady improvement was observed, but further improvements are needed in terms of the provision of high quality medical care. Particularly, dissemination of appropriate manuals, enhancement of basic techniques, and strengthening of the infection control system should be given priority.
doi:10.2149/tmh.2013-03
PMCID: PMC3798410  PMID: 24155652
Fact finding survey; nosocomial infection control; Kathmandu; Nepal
15.  Radiation management and credentialing of fluoroscopy users 
Pediatric Radiology  2006;36(Suppl 2):182-184.
During the last 15 years, developments in X-ray technologies have substantially improved the ability of practitioners to treat patients using fluoroscopically guided interventional techniques. Many of these procedures require a greater use of fluoroscopy and more recording of images. This increases the potential for radiation-induced dermatitis and epilation, as well as severe radiation-induced burns to patients. Many fluoroscope operators are untrained in radiation management and do not realize that these procedures increase the risk of radiation injury and radiation-induced cancer in personnel as well as patients. The hands of long-time fluoroscope operators in some cases exhibit radiation damage—especially when sound radiation protection practices have not been followed. In response, the Center for Devices and Radiological Health of the United States Food and Drug Administration has issued an Advisory calling for proper training of operators. Hospitals and administrators need to support and enforce the need for this training by requiring documentation of credentials in radiation management as a prerequisite for obtaining fluoroscopy privileges. A concerted effort on the part of professional medical organizations and regulatory agencies will be required to train fluoroscopy users to prevent physicians from unwittingly imparting serious radiation injuries to their patients.
doi:10.1007/s00247-006-0209-z
PMCID: PMC2663635  PMID: 16862411
Credentialing fluoroscopist; Fluoroscopist radiation dose
16.  Comparative cost-efficiency of the EVOTECH endoscope cleaner and reprocessor versus manual cleaning plus automated endoscope reprocessing in a real-world Canadian hospital endoscopy setting 
BMC Gastroenterology  2011;11:105.
Background
Reprocessing of endoscopes generally requires labour-intensive manual cleaning followed by high-level disinfection in an automated endoscope reprocessor (AER). EVOTECH Endoscope Cleaner and Reprocessor (ECR) is approved for fully automated cleaning and disinfection whereas AERs require manual cleaning prior to the high-level disinfection procedure. The purpose of this economic evaluation was to determine the cost-efficiency of the ECR versus AER methods of endoscopy reprocessing in an actual practice setting.
Methods
A time and motion study was conducted at a Canadian hospital to collect data on the personnel resources and consumable supplies costs associated with the use of EVOTECH ECR versus manual cleaning followed by AER with Medivators DSD-201. Reprocessing of all endoscopes was observed and timed for both reprocessor types over three days. Laboratory staff members were interviewed regarding the consumption and cost of all disposable supplies and equipment. Exact Wilcoxon rank sum test was used for assessing differences in total cycle reprocessing time.
Results
Endoscope reprocessing was significantly shorter with the ECR than with manual cleaning followed by AER. The differences in median time were 12.46 minutes per colonoscope (p < 0.0001), 6.31 minutes per gastroscope (p < 0.0001), and 5.66 minutes per bronchoscope (p = 0.0040). Almost 2 hours of direct labour time was saved daily with the ECR. The total per cycle cost of consumables and labour for maintenance was slightly higher for EVOTECH ECR versus manual cleaning followed by AER ($8.91 versus $8.31, respectively). Including the cost of direct labour time consumed in reprocessing scopes, the per cycle and annual costs of using the EVOTECH ECR was less than the cost of manual cleaning followed by AER disinfection ($11.50 versus $11.88).
Conclusions
The EVOTECH ECR was more efficient and less costly to use for the reprocessing of endoscopes than manual cleaning followed by AER disinfection. Although the cost of consumable supplies required to reprocess endoscopes with EVOTECH ECR was slightly higher, the value of the labour time saved with EVOTECH ECR more than offset the additional consumables cost. The increased efficiency with EVOTECH ECR could lead to even further cost-savings by shifting endoscopy laboratory personnel responsibilities but further study is required.
doi:10.1186/1471-230X-11-105
PMCID: PMC3198958  PMID: 21967345
17.  Primary Care Research Team Assessment (PCRTA): development and evaluation. 
BACKGROUND: Since the early 1990s the United Kingdom (UK) Department of Health has explicitly promoted a research and development (R&D) strategy for the National Health Service (NHS). General practitioners (GPs) and other members of the primary care team are in a unique position to undertake research activity that will complement and inform the research undertaken by basic scientists and hospital-based colleagues and lead directly to a better evidence base for decision making by primary care professionals. Opportunities to engage in R&D in primary care are growing and the scope for those wishing to become involved is finally widening. Infrastructure funding for research-active practices and the establishment of a range of support networks have helped to improve the research capacity and blur some of the boundaries between academic departments and clinical practice. This is leading to a supportive environment for primary care research. There is thus a need to develop and validate nationally accepted quality standards and accreditation of performance to ensure that funders, collaborators and primary care professionals can deliver high quality primary care research. Several strategies have been described in national policy documents in order to achieve an improvement in teaching and clinical care, as well as enhancing research capacity in primary care. The development of both research practices and primary care research networks has been recognised as having an important contribution to make in enabling health professionals to devote more protected time to undertake research methods training and to undertake research in a service setting. The recognition and development of primary care research has also brought with it an emphasis on quality and standards, including an approach to the new research governance framework. PRIMARY CARE RESEARCH TEAM ASSESSMENT: In 1998, the NHS Executive South and West, and later the London Research and Development Directorate, provided funding for a pilot project based at the Royal College of General Practitioners (RCGP) to develop a scheme to accredit UK general practices undertaking primary care R&D. The pilot began with initial consultation on the development of the process, as well as the standards and criteria for assessment. The resulting assessment schedule allowed for assessment at one of two levels: Collaborative Research Practice (Level I), with little direct experience of gaining project or infrastructure funding Established Research Practice (Level II), with more experience of research funding and activity and a sound infrastructure to allow for growth in capacity. The process for assessment of practices involved the assessment of written documentation, followed by a half-day assessment visit by a multidisciplinary team of three assessors. IMPLEMENTATION--THE PILOT PROJECT: Pilot practices were sampled in two regions. Firstly, in the NHS Executive South West Region, where over 150 practices expressed an interest in participating. From these a purposive sample of 21 practices was selected, providing a range of research and service activity. A further seven practices were identified and included within the project through the East London and Essex Network of Researchers (ELENoR). Many in this latter group received funding and administrative support and advice from ELENoR in order to prepare written submissions for assessment. Some sample loss was encountered within the pilot project, which was attributable largely to conflicting demands on participants' time. Indeed, the preparation of written submissions within the South West coincided with the introduction of primary care groups (PCGs) in April 1999, which several practices cited as having a major impact on their participation in the pilot project. A final sample of 15 practices (nine in the South West and six through ELENoR) underwent assessment through the pilot project. EVALUATION: A formal evaluation of the Primary Care Research Team Assessment (PCRTA) pilot was undertaken by an independent researcher (FM). This was supplemented with feedback from the assessment team members. The qualitative aspect of the evaluation, which included face-to-face and telephone interviews with assessors, lead researchers and other practice staff within the pilot research practices, as well as members of the project management group, demonstrated a positive view of the pilot scheme. Several key areas were identified in relation to particular strengths of research practices and areas for development including: Strengths Level II practices were found to have a strong primary care team ethos in research. Level II practices tended to have a greater degree of strategic thinking in relation to research. Development areas Level I practices were found to lack a clear and explicit research strategy. Practices at both levels had scope to develop their communication processes for dissemination of research and also for patient involvement. Practices at both levels needed mechanisms for supporting professional development in research methodology. The evaluation demonstrated that practices felt that they had gained from their participation and assessors felt that the scheme had worked well. Some specific issues were raised by different respondents within the qualitative evaluation relating to consistency of interpretation of standards and also the possible overlap of the assessment scheme with other RCGP quality initiatives. NATIONAL IMPLEMENTATION OF THE PRIMARY CARE RESEARCH TEAM ASSESSMENT: The pilot project has been very successful and recommendations have been made to progress to a UK scheme. Management and review of the scheme will remain largely the same, with a few changes focusing on the assessment process and support for practices entering the scheme. Specific changes include: development of the support and mentoring role of the primary care research networks increased peer and external support and mentoring for research practices undergoing assessment development of assessor training in line with other schemes within the RCGP Assessment Network work to ensure consistency across RCGP accreditation schemes in relation to key criteria, thereby facilitating comparable assessment processes refinement of the definition of the two groups, with Level I practices referred to as Collaborators and Level II practices as Investigator-Led. The project has continued to generate much enthusiasm and support and continues to reflect current policy. Indeed, recent developments include the proposed new funding arrangements for primary care R&D, which refer to the RCGP assessment scheme and recognise it as a key component in the future R&D agenda. The assessment scheme will help primary care trusts (PCTs) and individual practices to prepare and demonstrate their approach to research governance in a systematic way. It will also provide a more explicit avenue for primary care trusts to explore local service and development priorities identified within health improvement programmes and the research priorities set nationally for the NHS.
PMCID: PMC2560501  PMID: 12049028
22.  Ultraviolet damage to the eye revisited: eye-sun protection factor (E-SPF®), a new ultraviolet protection label for eyewear 
Ultraviolet (UV) radiation potentially damages the skin, the immune system, and structures of the eye. A useful UV sun protection for the skin has been established. Since a remarkable body of evidence shows an association between UV radiation and damage to structures of the eye, eye protection is important, but a reliable and practical tool to assess and compare the UV-protective properties of lenses has been lacking. Among the general lay public, misconceptions on eye-sun protection have been identified. For example, sun protection is mainly ascribed to sunglasses, but less so to clear lenses. Skin malignancies in the periorbital region are frequent, but usual topical skin protection does not include the lids. Recent research utilized exact dosimetry and demonstrated relevant differences in UV burden to the eye and skin at a given ambient irradiation. Chronic UV effects on the cornea and lens are cumulative, so effective UV protection of the eyes is important for all age groups and should be used systematically. Protection of children’s eyes is especially important, because UV transmittance is higher at a very young age, allowing higher levels of UV radiation to reach the crystalline lens and even the retina. Sunglasses as well as clear lenses (plano and prescription) effectively reduce transmittance of UV radiation. However, an important share of the UV burden to the eye is explained by back reflection of radiation from lenses to the eye. UV radiation incident from an angle of 135°–150° behind a lens wearer is reflected from the back side of lenses. The usual antireflective coatings considerably increase reflection of UV radiation. To provide reliable labeling of the protective potential of lenses, an eye-sun protection factor (E-SPF®) has been developed. It integrates UV transmission as well as UV reflectance of lenses. The E-SPF® compares well with established skin-sun protection factors and provides clear messages to eye health care providers and to lay consumers.
doi:10.2147/OPTH.S46189
PMCID: PMC3872277  PMID: 24379652
back reflection; transmission; irradiation; solar irradiance; aging; risk reduction; prevention
23.  Practical Protective Tools for Occupational Exposure: 
Interventional Neuroradiology  2001;6(Suppl 1):33-42.
Summary
Two practical protective tools for occupational exposure for neurointerventional radiologists are presented. The first purpose of this study was to investigate the effectiveness of double focus spectacles for the aged with a highly refracted glass lens (special spectacles for the aged) for radiation protection of the crystalline lens of the eye in comparison with other spectacles on the market, based on the measurement of film density which was obtained by exposure of X-ray through those spectacles. As a result of the film densitometry mentioned above, the effectiveness of special spectacles for the aged in radiation protection was nearly equal to the effectiveness of a goggle type shield which is made with a 0.07 mm lead-equivalent plastic lens.
The second purpose of this study was to investigate the effectiveness of the protective barrier; which we remodeled for cerebral angiography or neuroendovascular therapy, for radiation exposure, based on the measurement in a simulated study with a head phantom, and on the measurement of radiation exposure in operaters during procedures of clinical cases. In the experimental study radiation exposure in supposed position of the crystalline lens was reduced to about one third and radiation exposure in supposed position of the gonadal glands was reduced to about one seventh, compared to radiation exposure without employing the barrier.
The radiation exposure was monitored at the left breast of three radiologists, in 215 cases of cerebral angiography. Employing the barrier in cerebral angiography, average equivalent dose at the left breast measured 1.49µ Sv during 10 min of fluoroscopy. In three kinds of neuroendovascular therapy in 40 cases, radiation exposure in an operator was monitored in the same fashion and the dose was recorded less than the result reported in previous papers in which any protective barrier have not been employed in the procedure1,2.
As a result, the two above mentioned protective tools are considered practical in clinical usage and very effective to reduce radiation exposure in an operator of interventional neuroradiolgy which may sometimes require many hours to complete the therapy under extended fluoroscopic time.
PMCID: PMC3685933  PMID: 20667219
occupational exposure, radiation protection, crystalline lens of eye, barrier against X-ray exposure, cerebral angiography, interventional neuroradiology
24.  Eurocan plus report: feasibility study for coordination of national cancer research activities 
Summary
The EUROCAN+PLUS Project, called for by the European Parliament, was launched in October 2005 as a feasibility study for coordination of national cancer research activities in Europe. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people, the largest Europe–wide consultation ever conducted in the field of cancer research.
Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
It is essential to include the patients’ voice in the establishment of priority areas in cancer research at the present time. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community is evident. A top priority should be the development of translational research (in its widest form), leading to the development of effective and innovative cancer treatments and preventive strategies. Translational research ranges from bench–to–bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
The EUROCAN+PLUS Project recommends the creation of a small, permanent and independent European Cancer Initiative (ECI). This should be a model structure and was widely supported at both General Assemblies of the project. The ECI should assume responsibility for stimulating innovative cancer research and facilitating processes, becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ organizations, European institutions, Member States, industry and small and medium enterprises (SMEs), putting into practice solutions aimed at alleviating barriers to collaboration and coordination of cancer research activities in the European Union, and dealing with legal and regulatory issues. The development of an effective ECI will require time, but this entity should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co–operation between comprehensive cancer centres and basic research laboratories throughout Europe and (3) networking between funding bodies at the European level.
The European Parliament and its instruments have had a major influence in cancer control in Europe, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
Executive Summary
Cancer is one of the biggest public health crises facing Europe in the 21st century—one for which Europe is currently not prepared nor preparing itself. Cancer is a major cause of death in Europe with two million casualties and three million new cases diagnosed annually, and the situation is set to worsen as the population ages.
These facts led the European Parliament, through the Research Directorate-General of the European Commission, to call for initiatives for better coordination of cancer research efforts in the European Union. The EUROCAN+PLUS Project was launched in October 2005 as a feasibility study for coordination of national cancer research activities. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people. In this respect, the Project became the largest Europe-wide consultation ever conducted in the field of cancer research, implicating researchers, cancer centres and hospitals, administrators, healthcare professionals, funding agencies, industry, patients’ organizations and patients.
The Project first identified barriers impeding research and collaboration in research in Europe. Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain the formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
In addition, there is a shortage of leadership, a multiplicity of institutions each focusing on its own agenda, sub–optimal contact with industry, inadequate training, non–existent career paths, low personnel mobility in research especially among clinicians and inefficient funding—all conspiring against efficient collaboration in cancer care and research. European cancer research today does not have a functional translational research continuum, that is the process that exploits biomedical research innovations and converts them into prevention methods, diagnostic tools and therapies. Moreover, epidemiological research is not integrated with other types of cancer research, and the implementation of the European Directives on Clinical Trials 1 and on Personal Data Protection 2 has further slowed the innovation process in Europe. Furthermore, large inequalities in health and research exist between the EU–15 and the New Member States.
The picture is not entirely bleak, however, as the European cancer research scene presents several strengths, such as excellent basic research and clinical research and innovative etiological research that should be better exploited.
When considering recommendations, several priority dimensions had to be retained. It is essential that proposals include actions and recommendations that can benefit all Member States of the European Union and not just States with the elite centres. It is also essential to have a broader patient orientation to help provide the knowledge to establish cancer control possibilities when we exhaust what can be achieved by the implementation of current knowledge. It is vital that the actions proposed can contribute to the Lisbon Strategy to make Europe more innovative and competitive in (cancer) research.
The Project participants identified six areas for which consensus solutions should be implemented in order to obtain better coordination of cancer research activities. The required solutions are as follows. The proactive management of innovation, detection, facilitation of collaborations and maintenance of healthy competition within the European cancer research community.The establishment of an exchange portal of information for health professionals, patients and policy makers.The provision of guidance for translational and clinical research including the establishment of a translational research platform involving comprehensive cancer centres and cancer research centres.The coordination of calls and financial management of cancer research projects.The construction of a ‘one–stop shop’ as a contact interface between the industry, small and medium enterprises, scientists and other stakeholders.The support of greater involvement of healthcare professionals in translational research and multidisciplinary training.
In the course of the EUROCAN+PLUS consultative process, several key collaborative projects emerged between the various groups and institutes engaged in the consultation. There was a collaboration network established with Europe’s leading Comprehensive Cancer Centres; funding was awarded for a closer collaboration of Owners of Cancer Registries in Europe (EUROCOURSE); there was funding received from FP7 for an extensive network of leading Biological Resource Centres in Europe (BBMRI); a Working Group identified the special needs of Central, Eastern and South–eastern Europe and proposed a remedy (‘Warsaw Declaration’), and the concept of developing a one–stop shop for dealing with academia and industry including the Innovative Medicines Initiative (IMI) was discussed in detail.
Several other dimensions currently lacking were identified. There is an absolute necessity to include the patients’ voice in the establishment of priority areas in cancer research at the present time. It was a salutary lesson when it was recognized that all that is known about the quality of life of the cancer patient comes from the experience of a tiny proportion of cancer patients included in a few clinical trials. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community was evident. A top priority should be the development of translational research (in its widest form) and the development of effective and innovative cancer treatments and preventative strategies in the European Union. Translational research ranges from bench-to-bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
Having taken note of the barriers and the solutions and having examined relevant examples of existing European organizations in the field, it was agreed during the General Assembly of 19 November 2007 that the EUROCAN+PLUS Project had to recommend the creation of a small, permanent and neutral ECI. This should be a model structure and was widely supported at both General Assemblies of the project. The proposal is based on the successful model of the European Molecular Biology Organisation (EMBO), and its principal aims include providing a forum where researchers from all backgrounds and from all countries can meet with members of other specialities including patients, nurses, clinicians, funders and scientific administrators to develop priority programmes to make Europe more competitive in research and more focused on the cancer patient.
The ECI should assume responsibility for: stimulating innovative cancer research and facilitating processes;becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ and organizations;European institutions, Member States, industry and small and medium enterprises;putting into practice the aforementioned solutions aimed at alleviating barriers and coordinating cancer research activities in the EU;dealing with legal and regulatory issues.
Solutions implemented through the ECI will lead to better coordination and collaboration throughout Europe, more efficient use of resources, an increase in Europe’s attractiveness to the biomedical industry and better quality of cancer research and education of health professionals.
The Project considered that European legal instruments currently available were inadequate for addressing many aspects of the barriers identified and for the implementation of effective, lasting solutions. Therefore, the legal environment that could shelter an idea like the ECI remains to be defined but should be done so as a priority. In this context, the initiative of the European Commission for a new legal entity for research infrastructure might be a step in this direction. The development of an effective ECI will require time, but this should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass: (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co-operation between comprehensive cancer centres and basic research laboratories throughout Europe; (3) networking between funding bodies at the European level. Another topic deserving immediate attention is the creation of a European database on cancer research projects and cancer research facilities.
Despite enormous progress in cancer control in Europe during the past two decades, there was an increase of 300,000 in the number of new cases of cancer diagnosed between 2004 and 2006. The European Parliament and its instruments have had a major influence in cancer control, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
doi:10.3332/ecancer.2011.84
PMCID: PMC3234055  PMID: 22274749
25.  “Prescribing sunshine”: a national, cross-sectional survey of 1,089 New Zealand general practitioners regarding their sun exposure and vitamin D perceptions, and advice provided to patients 
BMC Family Practice  2012;13:85.
Background
The health effects of ultraviolet radiation vary according to wavelength, timing and pattern of exposure, personal characteristics and practices. Negative effects include skin cancers, eye diseases and immune suppression; positive effects primarily relate to endogenous vitamin D production which protects against bone disease. Drafting comprehensive guidelines regarding appropriate sun protective behaviours and vitamin D sufficiency is challenging. Advice given by general practitioners is potentially influential because they are widely respected.
Methods
A survey instrument was developed, pre-tested and provided to practising GP’s, either by on-line link or mailed, reply paid hard-copy. Odds ratios, differences in means, or ratios of geometric means from regression models are reported for potential predictor variables with 95% confidence intervals.
Results
Data (demographic, training, practicing, information accessing, confidence in vitamin D knowledge) suitable for analysis were obtained from 1,089 GPs (32% participation). Many (43%) were ‘not at all confident’ about their vitamin D knowledge. Recent information led 29% to recommend less sun protection during winter months and 10% less all year. Confidence was positively associated with non-‘Western’ medical training, information sources read and practising in a metropolitan centre with a medical school. Reading the Melanoma Clinical Practice Guidelines was associated with lower estimates of the amount of summer sun exposure required to obtain adequate vitamin D. Increasing years in practice was negatively associated with provision of recommended advice about summer and winter sun protection. Greater concern about vitamin D than skin cancer was expressed by females and those in practice longer.
Conclusions
Concern about the potentially negative impact of skin cancer prevention on vitamin D status may undermine appropriate sun protective recommendations. Reading some educational resources was associated with confidence about vitamin D knowledge and a perception that significantly less summer sun exposure was required for those with high sun sensitivity to achieve adequate vitamin D, suggesting a potentially positive impact of such resources. Education could be targeted towards groups least likely to promote existing recommendations. Authoritative guidelines about vitamin D and sun protection would be a valued resource among GPs. Study findings are potentially valuable to help guide public policy and target interventions.
doi:10.1186/1471-2296-13-85
PMCID: PMC3460728  PMID: 22901028
Vitamin D; Skin cancer; Sun exposure; Primary care

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