The provision of a time-critical elective surgical service during the COVID-19 Crisis: a UK experience.

INTRODUCTION: With the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic. MATERIALS AND METHODS: A protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 'clean' site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff. RESULTS: A total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive. CONCLUSION: This study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.

Characterization of a novel allele, HLA-C*02:135N, by full-length gene sequencing in a bone marrow donor.

A frameshift because of a two-nucleotide deletion results in an HLA-C null allele, HLA-C*02:135N.

Towards understanding and predicting suicidality in women: biomarkers and clinical risk assessment.

Women are under-represented in research on suicidality to date. Although women have a lower rate of suicide completion than men, due in part to the less-violent methods used, they have a higher rate of suicide attempts. Our group has previously identified genomic (blood gene expression biomarkers) and clinical information (apps) predictors for suicidality in men. We now describe pilot studies in women. We used a powerful within-participant discovery approach to identify genes that change in expression between no suicidal ideation (no SI) and high suicidal ideation (high SI) states (n=12 participants out of a cohort of 51 women psychiatric participants followed longitudinally, with diagnoses of bipolar disorder, depression, schizoaffective disorder and schizophrenia). We then used a Convergent Functional Genomics (CFG) approach to prioritize the candidate biomarkers identified in the discovery step by using all the prior evidence in the field. Next, we validated for suicidal behavior the top-ranked biomarkers for SI, in a demographically matched cohort of women suicide completers from the coroner's office (n=6), by assessing which markers were stepwise changed from no SI to high SI to suicide completers. We then tested the 50 biomarkers that survived Bonferroni correction in the validation step, as well as top increased and decreased biomarkers from the discovery and prioritization steps, in a completely independent test cohort of women psychiatric disorder participants for prediction of SI (n=33) and in a future follow-up cohort of psychiatric disorder participants for prediction of psychiatric hospitalizations due to suicidality (n=24). Additionally, we examined how two clinical instruments in the form of apps, Convergent Functional Information for Suicidality (CFI-S) and Simplified Affective State Scale (SASS), previously tested in men, perform in women. The top CFI-S item distinguishing high SI from no SI states was the chronic stress of social isolation. We then showed how the clinical information apps combined with the 50 validated biomarkers into a broad predictor (UP-Suicide), our apriori primary end point, predicts suicidality in women. UP-Suicide had a receiver-operating characteristic (ROC) area under the curve (AUC) of 82% for predicting SI and an AUC of 78% for predicting future hospitalizations for suicidality. Some of the individual components of the UP-Suicide showed even better results. SASS had an AUC of 81% for predicting SI, CFI-S had an AUC of 84% and the combination of the two apps had an AUC of 87%. The top biomarker from our sequential discovery, prioritization and validation steps, BCL2, predicted future hospitalizations due to suicidality with an AUC of 89%, and the panel of 50 validated biomarkers (BioM-50) predicted future hospitalizations due to suicidality with an AUC of 94%. The best overall single blood biomarker for predictions was PIK3C3 with an AUC of 65% for SI and an AUC of 90% for future hospitalizations. Finally, we sought to understand the biology of the biomarkers. BCL2 and GSK3B, the top CFG scoring validated biomarkers, as well as PIK3C3, have anti-apoptotic and neurotrophic effects, are decreased in expression in suicidality and are known targets of the anti-suicidal mood stabilizer drug lithium, which increases their expression and/or activity. Circadian clock genes were overrepresented among the top markers. Notably, PER1, increased in expression in suicidality, had an AUC of 84% for predicting future hospitalizations, and CSNK1A1, decreased in expression, had an AUC of 96% for predicting future hospitalizations. Circadian clock abnormalities are related to mood disorder, and sleep abnormalities have been implicated in suicide. Docosahexaenoic acid signaling was one of the top biological pathways overrepresented in validated biomarkers, which is of interest given the potential therapeutic and prophylactic benefits of omega-3 fatty acids. Some of the top biomarkers from the current work in women showed co-directionality of change in expression with our previous work in men, whereas others had changes in opposite directions, underlying the issue of biological context and differences in suicidality between the two genders. With this study, we begin to shed much needed light in the area of female suicidality, identify useful objective predictors and help understand gender commonalities and differences. During the conduct of the study, one participant committed suicide. In retrospect, when the analyses were completed, her UP-Suicide risk prediction score was at the 100 percentile of all participants tested.

Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach.

Worldwide, one person dies every 40 seconds by suicide, a potentially preventable tragedy. A limiting step in our ability to intervene is the lack of objective, reliable predictors. We have previously provided proof of principle for the use of blood gene expression biomarkers to predict future hospitalizations due to suicidality, in male bipolar disorder participants. We now generalize the discovery, prioritization, validation, and testing of such markers across major psychiatric disorders (bipolar disorder, major depressive disorder, schizoaffective disorder, and schizophrenia) in male participants, to understand commonalities and differences. We used a powerful within-participant discovery approach to identify genes that change in expression between no suicidal ideation and high suicidal ideation states (n=37 participants out of a cohort of 217 psychiatric participants followed longitudinally). We then used a convergent functional genomics (CFG) approach with existing prior evidence in the field to prioritize the candidate biomarkers identified in the discovery step. Next, we validated the top biomarkers from the prioritization step for relevance to suicidal behavior, in a demographically matched cohort of suicide completers from the coroner's office (n=26). The biomarkers for suicidal ideation only are enriched for genes involved in neuronal connectivity and schizophrenia, the biomarkers also validated for suicidal behavior are enriched for genes involved in neuronal activity and mood. The 76 biomarkers that survived Bonferroni correction after validation for suicidal behavior map to biological pathways involved in immune and inflammatory response, mTOR signaling and growth factor regulation. mTOR signaling is necessary for the effects of the rapid-acting antidepressant agent ketamine, providing a novel biological rationale for its possible use in treating acute suicidality. Similarly, MAOB, a target of antidepressant inhibitors, was one of the increased biomarkers for suicidality. We also identified other potential therapeutic targets or biomarkers for drugs known to mitigate suicidality, such as omega-3 fatty acids, lithium and clozapine. Overall, 14% of the top candidate biomarkers also had evidence for involvement in psychological stress response, and 19% for involvement in programmed cell death/cellular suicide (apoptosis). It may be that in the face of adversity (stress), death mechanisms are turned on at a cellular (apoptosis) and organismal level. Finally, we tested the top increased and decreased biomarkers from the discovery for suicidal ideation (CADM1, CLIP4, DTNA, KIF2C), prioritization with CFG for prior evidence (SAT1, SKA2, SLC4A4), and validation for behavior in suicide completers (IL6, MBP, JUN, KLHDC3) steps in a completely independent test cohort of psychiatric participants for prediction of suicidal ideation (n=108), and in a future follow-up cohort of psychiatric participants (n=157) for prediction of psychiatric hospitalizations due to suicidality. The best individual biomarker across psychiatric diagnoses for predicting suicidal ideation was SLC4A4, with a receiver operating characteristic (ROC) area under the curve (AUC) of 72%. For bipolar disorder in particular, SLC4A4 predicted suicidal ideation with an AUC of 93%, and future hospitalizations with an AUC of 70%. SLC4A4 is involved in brain extracellular space pH regulation. Brain pH has been implicated in the pathophysiology of acute panic attacks. We also describe two new clinical information apps, one for affective state (simplified affective state scale, SASS) and one for suicide risk factors (Convergent Functional Information for Suicide, CFI-S), and how well they predict suicidal ideation across psychiatric diagnoses (AUC of 85% for SASS, AUC of 89% for CFI-S). We hypothesized a priori, based on our previous work, that the integration of the top biomarkers and the clinical information into a universal predictive measure (UP-Suicide) would show broad-spectrum predictive ability across psychiatric diagnoses. Indeed, the UP-Suicide was able to predict suicidal ideation across psychiatric diagnoses with an AUC of 92%. For bipolar disorder, it predicted suicidal ideation with an AUC of 98%, and future hospitalizations with an AUC of 94%. Of note, both types of tests we developed (blood biomarkers and clinical information apps) do not require asking the individual assessed if they have thoughts of suicide, as individuals who are truly suicidal often do not share that information with clinicians. We propose that the widespread use of such risk prediction tests as part of routine or targeted healthcare assessments will lead to early disease interception followed by preventive lifestyle modifications and proactive treatment.

Physicians knowledge and attitude of opioid availability, accessibility and use in pain management in Bangladesh.

This survey was conducted on 1000 physicians with pain management responsibilities practicing in 47 districts in Bangladesh. The response rate was 58.3%. The physicians had a mean of 21 years in practice. It was notable that 66% of the physicians had seen cancer patients in the last 12 months and 63% had seen patients with advanced stage cancer where opioids are considered as the mainstay of treatment. It was discouraging that 85% of the physicians preferred to prescribe pethidine, when patients needed opioids for severe pain. 53% of the physicians were not aware of the 'Bangladesh Narcotics law, 1990'. 89% of the physicians would restrict opioid dosage in pain management to prevent drug tolerance or addiction. Oncology physicians displayed significantly higher knowledge scores. The results demonstrated physicians' poor knowledge, attitude and perceived barriers regarding opioids. Effective education strategies need to be addressed using the study result.

What are the costs and benefits of patient notification exercises following poor infection control practices in dentistry?

BACKGROUND: Allegations of serious failures in infection control practice were made against a dentist practicing in the South West of England. The dentist (who tested negative for Blood Borne Viruses (BBVs)) was immediately suspended. METHODS: Because inadequate infection control presents a potential risk of transmitting BBVs between patients, a notification exercise was undertaken. Of 7625 patients contacted, 2780 (37%) were tested. RESULTS: Nine cases of Hepatitis B (HBV) and four cases of Hepatitis C (HCV) were identified, of which seven were previously diagnosed. None of these were children. All of the six newly diagnosed cases had recognized risk factors for BBVs. The costs of the notification exercise were estimated at £311,500 of which £165,000 was staff costs, (£51,916 per newly diagnosed case). CONCLUSION: This study did not demonstrate any patient-to-patient transmission of blood-borne viruses but the response rate was relatively low. There are significant costs associated with undertaking notification exercises. These findings should inform future recommendations and practice in this area.

Breastfeeding and cognitive development of children: assessment at one year of age.

Breastfeeding is the fundamental component of child survival strategy. It significantly influences neurological development of children. The study was conducted to assess whether exclusive and prolonged breastfeeding improves children's cognitive development, including low birth weight (LBW) babies, in a developing country setting like Bangladesh. This observational study was done on a cohort of newborn infants who were discharged from the special care baby unit of Dhaka Shishu Hospital during January 2006 to December 2008 with proper counseling about exclusive and prolonged breastfeeding. Their neuro-developmental follow-up was started at 4 weeks postnatal age and continued at 3-monthly intervals up to 1 year of age. At each visit, cognitive development was assessed using the Bayley Scales of Infant Development (BSID II). Cognitive development was compared between the babies of exclusive vs. non exclusive breastfeeding, normal weight vs. low birth weight and male vs. female babies. A total of 105 cases were successfully followed-up during this period. Out of these 47(44.8%) babies were exclusively breastfed up to 6 month of age and 58(55.2%) were in nonexclusive group. Overall Psychomotor Development Index (PDI) was slightly more (108.40 ± 23.06 vs. 103.23 ± 19.87) in the exclusive breast fed babies in comparison to nonexclusive breast fed babies, but was significantly more in babies having birth weight >2.5 kg in comparison to those having birth weight of <2.5 kg. Other parameters of cognitive development were more or less same in both normal and LBW groups. Mental and motor development was same in both boys and girls. In behavior ratings, cooperation was significantly high (5.89 ± 2.54 vs. 4.71 ± 3.13, p=0.05) and vocalization (5.89 ± 1.07 vs. 4.58 ± 1.16) was also high, though not significant, in girls than boys.

Assessment of fidelity and utility of the whole-genome amplification for the clinical tests offered in a histocompatibility and immunogenetics laboratory.

Increasing emphasis on the use of molecular tests in a histocompatibility and immunogenetics laboratory (HIL) poses a potential problem of lack of sufficient DNA to perform multiple genetic analyses. In this study, we report the feasibility, fidelity and utility of multiple displacement amplification (MDA) method to perform whole-genome amplification (WGA) to generate DNA specimens that can be analyzed by multiple molecular techniques and can be used for different clinical tests offered by an HIL. The MDA-generated DNA when compared with the native DNA showed 100% congruency in genotyping of 37 genes/loci using multiple downstream molecular techniques: sequence-based typing and sequence-specific primer-based typing for 5 human leukocyte antigen (HLA) class I and II genes (HLA-A, B, C, DRB1 and DQB1), luminex-based sequence-specific oligonucleotide (SSO) genotyping for a panel of 16 killer immunoglobulin-like receptor (KIR) genes and automated fragment size analysis for a panel of 15 short tandem repeat (STR) loci and amelogenin gene. For post-allogeneic hematopoietic cell transplantation (HCT) chimerism analysis, MDA-generated DNA appeared useful for enriching pre-transplant DNA but not for enriching post-transplant chimeric DNA. Overall, our results show that MDA-based WGA could generate DNA of high yield and fidelity that can be used for various clinical tests and research purposes.

Factors influencing the choice of anesthesia as a career in a developing country.

Career choice in medicine is influenced by several factors. Our aim was to look at reasons for choice of anesthesia as a career in a cohort of doctors applying for the residency training in a university hospital in a developing country. A semi-structured interview form is used in our department and includes a question related to career choice. Each applicant is interviewed by two faculty members independently. All interview forms between 1992 to 2004 were reviewed and the reason for choosing anesthesia was coded in different categories. The sample consisted of 167 applicants and 334 forms. There were 29 females and 138 males. The mean age of the applicants was 28 years. Sixty two percent chose anesthesia because of general interest and nature of the specialty, 24% of these mentioned had no specific reasons, 17% thought the specialty was intellectually challenging, 8% liked the technical aspect, 5% were interested in physiology and pharmacology, 2% liked the operating room environment, and 6% liked the immediate results. The second major group (36%) cited the reason as better economic opportunities. Sixteen percent were influenced by friends or relatives in their choice. Twenty six percent chose anesthesia primarily because of their interest in critical care, pain management or emergency management. Our data indicates that selection of career in anesthesia in our county is strongly related to the nature of specialty and future employment opportunities. A significant number were influenced by family and friends. This pattern is different from that reported from Australia and United States.

Customer focused incident monitoring in anaesthesia.

The database of incident forms relating to anaesthesia services in an institutional risk management programme were reviewed for 2003-2005, the aim being to identify any recurring patterns. Incidents were prospectively categorised as relating to attitude/behaviour, communication breakdown, delay in service, or were related to care, cost, environment, equipment, security, administrative process, quality of service or miscellaneous. The total number of anaesthesia-related incidents reported during the period was 287, which related to 0.44% of the total number of anaesthetics administered during the time period. In all, 170 incidents were reported by the department, 96 by internal customers and 21 by external customers. Only 30% of the complaints came from the operating room. Thirty-four per cent of all incidents related to communication, behaviour and delay in service. A requirement to teach communication skills and stress handling formally in anaesthesia training programmes, and at the time of induction of staff into the department, has been identified.

Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan.

A survey of smoking prevalence and attitudes was made among medical students randomly selected from classes at the Aga Khan University, Karachi, Pakistan. Of 271 respondents, 14.4% were current smokers (22.0% male and 3.8% females) and 3.3% ex-smokers. A majority of students recognized the dangers associated with active as well as passive smoking although only 55% of current smokers planned to quit in the near future. Most smokers (96%) believed that they as well as other health professionals needed training on smoking cessation and 95% of all students believed that doctors should play a role model in smoking cessation by not smoking themselves. Specific training and counselling should be a part of the required curriculum at medical schools.

Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan

A survey of smoking prevalence and attitudes was made among medical students randomly selected from classes at the Aga Khan University, Karachi, Pakistan. Of 271 respondents, 14.4% were current smokers [22.0% male and 3.8% females] and 3.3% ex-smokers. A majority of students recognized the dangers associated with active as well as passive smoking although only 55% of current smokers planned to quit in the near future. Most smokers [96%] believed that they as well as other health professionals needed training on smoking cessation and 95% of all students believed that doctors should play a role model in smoking cessation by not smoking themselves. Specific training and counselling should be a part of the required curriculum at medical schools

Low cost quality control human serum: method of preparation, validation of values and its comparison with the commercial control serum.

OBJECTIVE: To prepare low-cost quality controls (QC) human serum and scientifically evaluate its advantages/disadvantages when compared with commercially available sera. METHODS: The home made QC serum was prepared as per WHO recommended protocol from four healthy volunteers. It was screened for HIV, HCV and HBV, pooled together and stabilized with ethylene glycol. The initial 40 values were used for calculation of means, SDs and CVs for seventeen routinely measured analytes and results were compared with those of commercially available lyophilized human sera. RESULTS: The average concentrations of seventeen commonly analyzed constituents were found to be near the middle of the physiological range of healthy subjects and the home made serum could be a good substitute for the commercial serum of normal range. The narrower CVs of the analytes imply a lesser vial to vial variation in the home made sera. Additional advantages include easy preparation, no need for reconstitution and lower cost. CONCLUSION: Home made serum is a good substitute for the commercial serum of the normal range especially in developing countries like Pakistan.

Evaluation of a combined laser Doppler flowmetry and iontophoresis technique for the assessment of equine cutaneous microvascular function.

A combined laser Doppler flowmetry and iontophoresis (LDFI) technique, used routinely to assess human microvascular function, was evaluated as a noninvasive technique for assessment of equine microvascular function, to facilitate the study of diseases such as laminitis. Baseline and vasoactive agonist-induced (acetylcholine and nitroprusside) microvascular flux was quantified at 2 sites (on the dorsal pastern adjacent to the coronary band and over the gluteals) in 6 clinically normal horses on 5 or 6 separate occasions under standardised conditions. Both agonists significantly increased microvascular flux. Skin pigmentation significantly attenuated the baseline flux, but not the magnitude of the agonist-mediated vasodilatory response. While LDFI was simple to perform, its value as a clinical and research tool for assessing the equine cutaneous microcirculation is limited by its poor reliability, as indicated by the marked intra- and intersubject variability in baseline and agonist-mediated microvascular flux.

Assessment of microvascular endothelial function in human skin.

Endothelial dysfunction is an important factor in many cardiovascular diseases, and is commonly associated with impaired endothelium-mediated vasodilatation. Information about the mechanisms behind this dysfunction has come largely from animal studies or, in humans, through invasive techniques that are not specific to one vascular bed. We have developed protocols to assess endothelial function non-invasively in the cutaneous microcirculation by measuring blood flow responses to four receptor-specific vasoactive compounds. Cumulative doses of acetylcholine, methacholine, bradykinin and substance P were administered iontophoretically to the forearm skin of healthy volunteers on two to three occasions. Dose-dependent increases in skin microvascular blood flow in response to these drugs were measured with laser Doppler imaging. Vascular responses to acetylcholine and methacholine were reasonably consistent, with coefficients of variation of approx. 17%. The coefficients of variation for bradykinin and substance P were much poorer, as high as 70% for some doses. This might partly be a consequence of the more unpredictable effects of histamine release in the vasoactive behaviour of these two agonists. Although it might be advantageous to find other agonists with which to test the function of different receptor pathways, we have shown that just acetylcholine and methacholine can currently be used with iontophoresis to allow sensitive and reproducible assessment of endothelial function.

A comparison of OHIP 14 and OIDP as interviews and questionnaires.

OBJECTIVE: To assess the completion rates and concurrent validity of the Oral Impacts on Daily Performance (OIDP) and the short form of the Oral Health Impact Profile (OHIP 14) in both questionnaire and interview formats. BASIC RESEARCH DESIGN: Cross sectional social and clinical study. Clinical setting Dental teaching hospital primary care department in London UK. Participants Two week consecutive sample of 183 patients attending setting. PARTICIPANTS: came from 19 ethnic groups, 53% were men and 32% had attended for a dental emergency. MAIN OUTCOME MEASURES: Completion rates and concurrent validity for each instrument and in each format. RESULTS: Completion rates for OHIP 14 and OIDP were similar in interview format. In questionnaire format usable data were provided on 92.9% of the OHIP 14 but only 86.5% of the OIDP questionnaires. Completion of both questionnaires was related to ethnicity. The number of impacts for both measures and total impact scores for OHIP 14 were related to the age of the participants, the presence of oral disease and the order of administration of the instruments. Analysis of the total score for OIDP was weakened by the severe skewness of these data. CONCLUSIONS: The psychometric properties of OHIP 14 and OIDP were not related to the method of administration. However, the use of OIDP in this questionnaire format may result in loss of data, particularly from people who are not White English.

A prospective survey of intra-operative critical incidents in a teaching hospital in a developing country.

Critical incident monitoring has the advantage of identifying a potential risk to the patient without it necessarily resulting in morbidity. An added advantage in developing countries is the low cost involved in introducing the programme. This paper analyses the incidents reported from the operating room suite in a teaching hospital in a developing country from August 1997 to 31 December 1999. During the period, 20 819 anaesthetics were administered and 329 incidents were reported (1.58% of the cases). Seventy-three per cent of the incidents were reported in patients of ASA grade 1 or 2. Thirty-nine per cent occurred during induction, 51% during maintenance and 10% during emergence. Human error was the cause in 41%, equipment error in 50% and system error in 8.5%. Twenty-two per cent of the incidents resulted in minor, and 13% in major physiological disturbance. The technique has been found useful in identifying trends and selecting issues to be discussed in departmental quality assurance meetings, but requires persistent motivation of the reporting staff.

Self-assessed oral health status of ethnic minority residents of South London.

OBJECTIVE: To determine the self-assessed oral health status of individuals from minority ethnic communities living in South London. METHOD: A sample of 1,057 individuals from minority ethnic communities (as defined by Office of Censuses and Surveys categories) resident in South London were asked to complete measures of their oral and facial symptoms, the impact of their oral health on their daily functioning and of their satisfaction with the appearance of their teeth and gums. MEASURES: Self-assessed oral health status was determined by means of two short scales addressing oral symptoms and the impact of oral health on activities of daily living. Satisfaction with the appearance of the teeth and gums was also assessed. FINDINGS: No significant differences were found between minority ethnic communities in the number of symptoms reported, in the level of impact which such symptoms cause, or in their dissatisfaction with the appearance of their teeth and gums. Reporting of symptoms and impact were mildly though significantly correlated with dissatisfaction. CONCLUSIONS: There appears to be little difference between ethnic communities in their reporting of oral and facial symptoms, though these groups report higher levels of dissatisfaction with the appearance of their teeth and gums. Social and demographic factors play an important role in determining perceptions of oral health. The findings should be interpreted with caution given the difficulty of sampling minority ethnic communities and the subsequent limited representativeness of the sample.

Recommendations for water supply in arsenic mitigation: a case study from Bangladesh.

Arsenic problems have been observed in several countries around the world. The challenges of arsenic mitigation are more difficult for developing and poor countries due to resource and other limitations. Bangladesh is experiencing the worst arsenic problem in the world, as about 30 million people are possibly drinking arsenic contaminated water. Lack of knowledge has hampered the mitigation initiatives. This paper presents experience gained during an action research on water supply in arsenic mitigation in rural Singair, Bangladesh. The mitigation has been implemented there through integrated research and development of appropriate water supply options and its use through community participation. Political leaders and women played key roles in the success of the mitigation. More than one option for safe water has been developed and/or identified. The main recommendations include: integration of screening of tubewells and supply of safe water, research on technological and social aspects, community, women and local government participation, education and training of all stakeholders, immediate and appropriate use of the available knowledge, links between intermediate/immediate and long term investment, effective coordination and immediate attention by health, nutrition, agriculture, education, and other programs to this arsenic issue.