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FOTO8 > online > Blogs > What is their ground is his figure: Eric Gottesman on collaboration
What is their ground is his figure: Eric Gottesman on collaboration
Collaborative photographic projects occupy a kind of mirror world to what we might call "conventional" documentary photography projects. The reasons and the concerns are often very similar, yet everything else is very different. They come from different places and they go to different places.
I've recently come to know the work of Eric Gottesman and his collaborators on the stigma of HIV/AIDS in Ethiopia , and wanted to share a statement that he wrote at my request. Eric has worked in Lebanon, in the United States and, now, in Northern Labrador, but his most ambitious project has been in Ethiopia. This work, and his thoughtful words about it, not only served to demystify collaborative photography for me, but also articulated some very exciting possibilities, and poses questions that will be relevant to any documentary photographer.
Eric Gottesman's project follows in the tradition of collaborative photography, in which a photographer guides a particular population through the use of equipment and visual language. Photography becomes available as a means to engage with the world, and to tell one's own stories about it. Wendy Ewald is probably the best known and most important figure in the development of strategies to use photography to enable self-realization and literacy among children. The film Born into Brothels describes Zana Briski's work on such a project.
Eric's work is distinctive in that the pictures that were produced by the children who he worked with- children who had lost parents to AIDS- were purposed towards a larger project of addressing the stigmas associated with HIV/AIDS in society at large head on.
The project traveled through Ethiopia in an installation referencing a traditional Ethiopian coffee ceremony. Images by the children describing their lives and their aspirations were accompanied by letters that they wrote, directed towards their absent parents. Together these filled the space within metal screens from which images were hung.
The name of the ceremony, Abul Thona Baraka, in Amharic, names three progressively stronger cups of coffee. The three words signify "meeting", "falling in love" and "parting ways".
The continuation of the project has involved children in making videos. These videos are, like legends, fiction in the sense that they are written and performed, truthful in that they emerge from lived experience.
Along with the impact that this project has made in changing cultural perceptions surrounding "secondary victims" of HIV/AIDS, Eric's work is important for several reasons that will be of interest to any documentary photographer.
First, the work of Eric and his collaborators follows in the tradition of concerned photography, but does so by completely reinventing the production and circulation processes, as well as redefining what constitutes the body of work itself. The production has moved from each stage to each stage organically and found its form and its audience at each moment, the form that is most effective for speaking to the audience that is most important. It's not just that the project lacks vanity. It's more than this; there is a humility in Gottesman and Co.'s decision to foreground the activity surrounding the images rather than the images themselves. That is, it's not enough to make the pictures, to bear witness; there must be a strategy to make the pictures work. In this case, the strategy is something entirely new.
Second, like other collaborative projects, it emphasizes process and practice; the photographs themselves are in some respects secondary to the process of the children learning to make pictures in their own visual idioms. Except that the photographs are not secondary at all; the pictures can go on to have a second life traveling through Ethiopia, and a third life traveling through the Western world.
Finally, as Eric describes below, collaborative engagement builds out what is possible with photography, encouraging new ways of communicating visually, and hybrid aesthetics, the possibility that something new and beautiful may emerge. This is not at the expense of, but rather as a result of political and activist engagement.
Eric's response to my questions was very rich and with his permission I have included an edited version below. Please bear in mind that the statement only covers the issues that I asked him about, representing only certain facets of this project. Also, the comments above are my own thoughts.
By the way, this project will soon enter its third or fourth life as he is working on a book, May the Finest in the World Always Accompany You!
Leo Hsu
Here is Eric's statement:
Notes on Negotiation and Collaboration:
I went to Ethiopia in 1999 for the Hart Fellowship from Duke and spent a year there. I found a local NGO with whom to work. At the time, it was one of the only Ethiopian organizations working on the issue of HIV/AIDS. AIDS was highly stigmatized then and there was a sense that something was going on but no one was talking about it. I started visiting social service agencies and made a series of pictures that, along with the pictures and letters made by a group of six children that I met, became the first photographic exhibition about HIV/AIDS in Ethiopia's history.
These first pictures that I exhibited were entirely anonymous because the subjects of my photographs would not allow me to photograph their faces, or even to use a 35mm camera because they were afraid that I would use their images in ways that might put them at risk. I switched over to using a Polaroid process so that we could look at the images together. If they disapproved, we destroyed the negatives immediately. This process opened me up to the idea of shifting the balance of agency from me (photographer) to the subject, not only for political reasons but because that shift indicates the possibility of a new vision, a new aesthetic, the creation of a collective masterpiece.
At that same time, I met a woman named Yewoinshet Masresha, who is now one of my closest friends. She was working with children affected by the epidemic. She introduced me to six children in Addis Ababa all living together, in a home she had set up, as brothers and sisters even though they were not related by blood. I went there one day and explained very vaguely my ideas for this project. They listened politely and told me to come back a few days later for an answer. When I did, they agreed to work with me on the condition that their work would be used to help other kids like them; they defined their audience very early on in the project. And so Sudden Flowers , the collective that these children later named, was formed.
I began going over to their house and hanging around, teaching them to use the same Polaroid ProPack Cameras and 665 Black and White Positive-Negative Film that I was using. I dropped by every couple of days and played cards, ate injera, drank coffee. I picked up the negatives that they had shot and dropped into the bucket of sodium sulfite I left for them. We looked together at the positives and talked about the pictures. Sometimes I would give assignments.
At first, I thought they were acting as typical kids playing with cameras: snapshots, mugging. It was not until I saw this one image, the one of the dream of the house catching on fire, that I realized that something more profound was happening. I realized this because that image was made using a double exposure technique, something which I had not taught them. When I saw that picture, and after I learned more about Ethiopian art and culture, I came to understand that they were learning to master the medium of expression that I brought to them. They understood how to use the camera, and the results were beyond the representations of Ethiopians, of Africans, that I had previously seen.
We found different ways of collaborating: sometimes they took the pictures, sometimes I did, sometimes they would direct it like a scene of a film and then I would trip the shutter on the camera (this process led into how we make videos as well).
I think I started with 100 packs of PN665 film.. Overall, we probably shot about 3000 images on that film. In addition to looking fantastic, Polaroid is really wonderful for this kind of work. The subject and the photographer get to see the image at the same exact time, there is a tangible photograph, and the high cost of the film forces young photographers to slow down and consider their images
Some of the kids I have been working with have shot on digital with varying degrees of success, but I have very rarely seen a good "participatory" project shot on digital. The images become deleteable, disposable…much like the projects that used to be done on disposable cameras. Some of the less successful collaborative projects are based on the idea that "poor kids can take good pictures too!"…but this approach to me does not fully anticipate the potential of the collaborative process. The idea is not just to change who is pressing the button on the camera, it is to change what "good pictures" are, to change the kinds of images we see, value, learn from.
I have often seen images from these projects that undercut the good intentions of the projects' initiators by falling back into the old stereotypes and power dynamics that the collaborative process intends to avoid. There are questions like: Who is editing this material? Where is it being shown? For what purpose? It bothers me when these projects use a pseudo-democratic rhetoric to describe the act of handing out cameras, as though distributing cameras alone is "empowerment" or "giving voice to the voiceless." When I see this kind of stuff, I become listless; the process is so much more complicated than that.
First of all, the dissemination of the machine itself is not the point, unless you work for Canon or Nikon; the point is that through this process, as through other artistic processes, another kind of truth might emerge, a new vision that contributes to the world.
Secondly, from a political point of view, there are systems of power that are constructed above the individual that must be strategically navigated in order for an individual's voice to carry any kind of political import. The fact that more people in Ethiopia take photographs, as with the fact that more people vote, alone does not mean people are empowered. What is done with those photographs, or votes, must also be considered. I think of the disputed 2005 election in Ethiopia and wonder if there is an analogy to be drawn.
Returning to our project, the children of our collective and I talk a lot about who the audience for this work is (primarily an Ethiopian audience, as with the OSI show and other exhibits we've had in Ethiopia at Addis Ababa City Hall and other places; secondarily for an outside audience). One of the concerns has always been the stigma surrounding HIV/AIDS.
The members of Sudden Flowers go back and forth on this. Sometimes they want to show their faces and share their feelings (in order to stand up for their parents, to represent their parents' suffering to society), sometimes they want to remain anonymous (out of fear of stigmatization or out of anger). I think it is an interesting tension and one of the major ways in which the collaborative process plays out and reveals something more interesting than I could produce on my own as a Western documentarian or journalist.
I think photojournalists are athletes, masters at what they do and they often have very good social intentions. The goal for them is to witness and "tell the story." I am not interested in objecting to this approach but only in commenting that the way in which they tell the story is all about the technical composition of the image [the formal characteristics]. The question of "good" or "right" imagery is one that absolutely applies to their work, and this has become increasingly the case as photographic technique becomes more widely disseminated and viewers demand more professional imagery.
But the implications of this kind of imagery, or of why viewers demand this kind of imagery are rarely questioned in photo-documentary work.
In our project, the children talked less about making "good" or "right" pictures than they did about what the process means to them. The images and texts that come out of this project are very personal, very embodied in lived experience, unlike the "witnessed" images of photojournalism. As a result, the children talk about the psychological impact of this project on them. As well, they express their desires to see the process change as they change, to incorporate, for instance, images of them laughing as well as representations of them mourning.
Despite this elevation of process over product, they are participating in the editing of the images for the exhibitions and publications that we have put out. They do care about what they produce. So they are making choices about which images they like…They are not necessarily the ones I would pick, but I have not really pushed them to explain why they picked the ones they picked…I just assumed that I needed to look longer at the ones they chose and educate myself about what I am missing.
-Eric Gottesman
The Work of Eric Gottesman and his collaborators
Sudden Flowers
Hope for Children Organization in Ethiopia
Wendy Ewald on Children and Photography
(Eric Gottesman's work has been supported by an OSI Distribution Grant, the CDS at Duke, and the John Cohen and Mary Louise Phillips Opportunity Fun.)
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April 2000, VOLUME105 /ISSUE 4
Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip
Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip
Developmental dysplasia of the hipis the preferred term to describe the condition in which the femoral head has an abnormal relationship to the acetabulum. Developmental dysplasia of the hip includes frank dislocation (luxation), partial dislocation (subluxation), instability wherein the femoral head comes in and out of the socket, and an array of radiographic abnormalities that reflect inadequate formation of the acetabulum. Because many of these findings may not be present at birth, the termdevelopmental more accurately reflects the biologic features than does the term congenital. The disorder is uncommon. The earlier a dislocated hip is detected, the simpler and more effective is the treatment. Despite newborn screening programs, dislocated hips continue to be diagnosed later in infancy and childhood,1–11 in some instances delaying appropriate therapy and leading to a substantial number of malpractice claims. The objective of this guideline is to reduce the number of dislocated hips detected later in infancy and childhood. The target audience is the primary care provider. The target patient is the healthy newborn up to 18 months of age, excluding those with neuromuscular disorders, myelodysplasia, or arthrogryposis.
DDH =
developmental dysplasia of the hip •
AVN =
avascular necrosis of the hip
BIOLOGIC FEATURES AND NATURAL HISTORY
Understanding the developmental nature of developmental dysplasia of the hip (DDH) and the subsequent spectrum of hip abnormalities requires a knowledge of the growth and development of the hip joint.12 Embryologically, the femoral head and acetabulum develop from the same block of primitive mesenchymal cells. A cleft develops to separate them at 7 to 8 weeks' gestation. By 11 weeks' gestation, development of the hip joint is complete. At birth, the femoral head and the acetabulum are primarily cartilaginous. The acetabulum continues to develop postnatally. The growth of the fibrocartilaginous rim (the labrum) that surrounds the bony acetabulum deepens the socket. Development of the femoral head and acetabulum are intimately related, and normal adult hip joints depend on further growth of these structures. Hip dysplasia may occur in utero, perinatally, or during infancy and childhood.
The acronym DDH includes hips that are unstable, subluxated, dislocated (luxated), and/or have malformed acetabula. A hip isunstable when the tight fit between the femoral head and the acetabulum is lost and the femoral head is able to move within (subluxated) or outside (dislocated) the confines of the acetabulum. Adislocation is a complete loss of contact of the femoral head with the acetabulum. Dislocations are divided into 2 types: teratologic and typical.12 Teratologic dislocations occur early in utero and often are associated with neuromuscular disorders, such as arthrogryposis and myelodysplasia, or with various dysmorphic syndromes. The typical dislocationoccurs in an otherwise healthy infant and may occur prenatally or postnatally.
During the immediate newborn period, laxity of the hip capsule predominates, and, if clinically significant enough, the femoral head may spontaneously dislocate and relocate. If the hip spontaneously relocates and stabilizes within a few days, subsequent hip development usually is normal. If subluxation or dislocation persists, then structural anatomic changes may develop. A deep concentric position of the femoral head in the acetabulum is necessary for normal development of the hip. When not deeply reduced (subluxated), the labrum may become everted and flattened. Because the femoral head is not reduced into the depth of the socket, the acetabulum does not grow and remodel and, therefore, becomes shallow. If the femoral head moves further out of the socket (dislocation), typically superiorly and laterally, the inferior capsule is pulled upward over the now empty socket. Muscles surrounding the hip, especially the adductors, become contracted, limiting abduction of the hip. The hip capsule constricts; once this capsular constriction narrows to less than the diameter of the femoral head, the hip can no longer be reduced by manual manipulative maneuvers, and operative reduction usually is necessary.
The hip is at risk for dislocation during 4 periods: 1) the 12th gestational week, 2) the 18th gestational week, 3) the final 4 weeks of gestation, and 4) the postnatal period. During the 12th gestational week, the hip is at risk as the fetal lower limb rotates medially. A dislocation at this time is termed teratologic. All elements of the hip joint develop abnormally. The hip muscles develop around the 18th gestational week. Neuromuscular problems at this time, such as myelodysplasia and arthrogryposis, also lead to teratologic dislocations. During the final 4 weeks of pregnancy, mechanical forces have a role. Conditions such as oligohydramnios or breech position predispose to DDH.13 Breech position occurs in ∼3% of births, and DDH occurs more frequently in breech presentations, reportedly in as many as 23%. The frank breech position of hip flexion and knee extension places a newborn or infant at the highest risk. Postnatally, infant positioning such as swaddling, combined with ligamentous laxity, also has a role.
The true incidence of dislocation of the hip can only be presumed. There is no "gold standard" for diagnosis during the newborn period. Physical examination, plane radiography, and ultrasonography all are fraught with false-positive and false-negative results. Arthrography (insertion of contrast medium into the hip joint) and magnetic resonance imaging, although accurate for determining the precise hip anatomy, are inappropriate methods for screening the newborn and infant.
The reported incidence of DDH is influenced by genetic and racial factors, diagnostic criteria, the experience and training of the examiner, and the age of the child at the time of the examination. Wynne-Davies14 reported an increased risk to subsequent children in the presence of a diagnosed dislocation (6% risk with healthy parents and an affected child, 12% risk with an affected parent, and 36% risk with an affected parent and 1 affected child). DDH is not always detectable at birth, but some newborn screening surveys suggest an incidence as high as 1 in 100 newborns with evidence of instability, and 1 to 1.5 cases of dislocation per 1000 newborns. The incidence of DDH is higher in girls. Girls are especially susceptible to the maternal hormone relaxin, which may contribute to ligamentous laxity with the resultant instability of the hip. The left hip is involved 3 times as commonly as the right hip, perhaps related to the left occiput anterior positioning of most nonbreech newborns. In this position, the left hip resides posteriorly against the mother's spine, potentially limiting abduction.
DDH is an evolving process, and its physical findings on clinical examination change.12 ,15 ,16 The newborn must be relaxed and preferably examined on a firm surface. Considerable patience and skill are required. The physical examination changes as the child grows older. No signs are pathognomonic for a dislocated hip. The examiner must look for asymmetry. Indeed, bilateral dislocations are more difficult to diagnose than unilateral dislocations because symmetry is retained. Asymmetrical thigh or gluteal folds, better observed when the child is prone, apparent limb length discrepancy, and restricted motion, especially abduction, are significant, albeit not pathognomonic signs. With the infant supine and the pelvis stabilized, abduction to 75° and adduction to 30° should occur readily under normal circumstances.
The 2 maneuvers for assessing hip stability in the newborn are the Ortolani and Barlow tests. The Ortolani elicits the sensation of the dislocated hip reducing, and the Barlow detects the unstable hip dislocating from the acetabulum. The Ortolani is performed with the newborn supine and the examiner's index and middle fingers placed along the greater trochanter with the thumb placed along the inner thigh. The hip is flexed to 90° but not more, and the leg is held in neutral rotation. The hip is gently abducted while lifting the leg anteriorly. With this maneuver, a "clunk" is felt as the dislocated femoral head reduces into the acetabulum. This is a positive Ortolani sign. The Barlow provocative test is performed with the newborn positioned supine and the hips flexed to 90°. The leg is then gently adducted while posteriorly directed pressure is placed on the knee. A palpable clunk or sensation of movement is felt as the femoral head exits the acetabulum posteriorly. This is a positive Barlow sign. The Ortolani and Barlow maneuvers are performed 1 hip at a time. Little force is required for the performance of either of these tests. The goal is not to prove that the hip can be dislocated. Forceful and repeated examinations can break the seal between the labrum and the femoral head. These strongly positive signs of Ortolani and Barlow are distinguished from a large array of soft or equivocal physical findings present during the newborn period. High-pitched clicks are commonly elicited with flexion and extension and are inconsequential. A dislocatable hip has a rather distinctive clunk, whereas a subluxable hip is characterized by a feeling of looseness, a sliding movement, but without the true Ortolani and Barlow clunks. Separating true dislocations (clunks) from a feeling of instability and from benign adventitial sounds (clicks) takes practice and expertise. This guideline recognizes the broad range of physical findings present in newborns and infants and the confusion of terminology generated in the literature. By 8 to 12 weeks of age, the capsule laxity decreases, muscle tightness increases, and the Barlow and Ortolani maneuvers are no longer positive regardless of the status of the femoral head. In the 3-month-old infant, limitation of abduction is the most reliable sign associated with DDH. Other features that arouse suspicion include asymmetry of thigh folds, a positive Allis or Galeazzi sign (relative shortness of the femur with the hips and knees flexed), and discrepancy of leg lengths. These physical findings alert the examiner that abnormal relationships of the femoral head to the acetabulum (dislocation and subluxation) may be present.
Maldevelopments of the acetabulum alone (acetabular dysplasia) can be determined only by imaging techniques. Abnormal physical findings may be absent in an infant with acetabular dysplasia but no subluxation or dislocation. Indeed, because of the confusion, inconsistencies, and misuse of language in the literature (eg, an Ortolani sign called a click by some and a clunk by others), this guideline uses the following definitions.
A positive examination result for DDH is the Barlow or Ortolani sign. This is the clunk of dislocation or reduction.
An equivocal examination or warning signs include an array of physical findings that may be found in children with DDH, in children with another orthopaedic disorder, or in children who are completely healthy. These physical findings include asymmetric thigh or buttock creases, an apparent or true short leg, and limited abduction. These signs, used singly or in combination, serve to raise the pediatrician's index of suspicion and act as a threshold for referral. Newborn soft tissue hip clicks are not predictive of DDH17but may be confused with the Ortolani and Barlow clunks by some screening physicians and thereby be a reason for referral.
Radiographs of the pelvis and hips have historically been used to assess an infant with suspected DDH. During the first few months of life when the femoral heads are composed entirely of cartilage, radiographs have limited value. Displacement and instability may be undetectable, and evaluation of acetabular development is influenced by the infant's position at the time the radiograph is performed. By 4 to 6 months of age, radiographs become more reliable, particularly when the ossification center develops in the femoral head. Radiographs are readily available and relatively low in cost.
Real-time ultrasonography has been established as an accurate method for imaging the hip during the first few months of life.15 18–25 With ultrasonography, the cartilage can be visualized and the hip can be viewed while assessing the stability of the hip and the morphologic features of the acetabulum. In some clinical settings, ultrasonography can provide information comparable to arthrography (direct injection of contrast into the hip joint), without the need for sedation, invasion, contrast medium, or ionizing radiation. Although the availability of equipment for ultrasonography is widespread, accurate results in hip sonography require training and experience. Although expertise in pediatric hip ultrasonography is increasing, this examination may not always be available or obtained conveniently. Ultrasonographic techniques include static evaluation of the morphologic features of the hip, as popularized in Europe by Graf,26 and a dynamic evaluation, as developed by Harcke20 that assesses the hip for stability of the femoral head in the socket, as well as static anatomy. Dynamic ultrasonography yields more useful information. With both techniques, there is considerable interobserver variability, especially during the first 3 weeks of life.7 ,27
Experience with ultrasonography has documented its ability to detect abnormal position, instability, and dysplasia not evident on clinical examination. Ultrasonography during the first 4 weeks of life often reveals the presence of minor degrees of instability and acetabular immaturity. Studies7 ,28 ,29 indicate that nearly all these mild early findings, which will not be apparent on physical examination, resolve spontaneously without treatment. Newborn screening with ultrasonography has required a high frequency of reexamination and results in a large number of hips being unnecessarily treated. One study23 demonstrates that a screening process with higher false-positive results also yields increased prevention of late cases. Ultrasonographic screening of all infants at 4 to 6 weeks of age would be expensive, requiring considerable resources. This practice is yet to be validated by clinical trial. Consequently, the use of ultrasonography is recommended as an adjunct to the clinical evaluation. It is the technique of choice for clarifying a physical finding, assessing a high-risk infant, and monitoring DDH as it is observed or treated. Used in this selective capacity, it can guide treatment and may prevent overtreatment.
PRETERM INFANTS
DDH may be unrecognized in prematurely born infants. When the infant has cardiorespiratory problems, the diagnosis and management are focused on providing appropriate ventilatory and cardiovascular support, and careful examination of the hips may be deferred until a later date. The most complete examination the infant receives may occur at the time of discharge from the hospital, and this single examination may not detect subluxation or dislocation. Despite the medical urgencies surrounding the preterm infant, it is critical to examine the entire child.
METHODS FOR GUIDELINE DEVELOPMENT
Our goal was to develop a practice parameter by using a process that would be based whenever possible on available evidence. The methods used a combination of expert panel, decision modeling, and evidence synthesis30 (see the Technical Report available on Pediatrics electronic pages at www.pediatrics.org). The predominant methods recommended for such evidence synthesis are generally of 2 types: a data-driven method and amodel-driven 31 ,32 method. In data-driven methods, the analyst finds the best data available and induces a conclusion from these data. A model-driven method, in contrast, begins with an effort to define the context for evidence and then searches for the data as defined by that context. Data-driven methods are useful when the quality of evidence is high. A careful review of the medical literature revealed that the published evidence about DDH did not meet the criteria for high quality. There was a paucity of randomized clinical trials.8 We decided, therefore, to use the model-driven method.
A decision model was constructed based on the perspective of practicing clinicians and determining the best strategy for screening and diagnosis. The target child was a full-term newborn with no obvious orthopaedic abnormalities. We focused on the various options available to the pediatrician* for the detection of DDH, including screening by physical examination, screening by ultrasonography, and episodic screening during health supervision. Because the detection of a dislocated hip usually results in referral by the pediatrician, and because management of DDH is not in the purview of the pediatrician's care, treatment options are not included. We also included in our model a wide range of options for detecting DDH during the first year of life if the results of the newborn screen are negative.
The outcomes on which we focused were a dislocated hip at 1 year of age as the major morbidity of the disease and avascular necrosis of the hip (AVN) as the primary complication of DDH treatment. AVN is a loss of blood supply to the femoral head resulting in abnormal hip development, distortion of shape, and, in some instances, substantial morbidity. Ideally, a gold standard would be available to define DDH at any point in time. However, as noted, no gold standard exists except, perhaps, arthrography of the hip, which is an inappropriate standard for use in a detection model. Therefore, we defined outcomes in terms of theprocess of care. We reviewed the literature extensively. The purpose of the literature review was to provide the probabilities required by the decision model since there were no randomized clinical trials. The article or chapter title and the abstracts were reviewed by 2 members of the methodology team and members of the subcommittee. Articles not rejected were reviewed, and data were abstracted that would provide evidence for the probabilities required by the decision model. As part of the literature abstraction process, the evidence quality in each article was assessed. A computer-based literature search, hand review of recent publications, or examination of the reference section for other articles ("ancestor articles") identified 623 articles; 241 underwent detailed review, 118 of which provided some data. Of the 100 ancestor articles, only 17 yielded useful articles, suggesting that our accession process was complete. By traditional epidemiologic standards,33 the quality of the evidence in this set of articles was uniformly low. There were few controlled trials and few studies of the follow-up of infants for whom the results of newborn examinations were negative. When the evidence was poor or lacking entirely, extensive discussions among members of the committee and the expert opinion of outside consultants were used to arrive at a consensus. No votes were taken. Disagreements were discussed, and consensus was achieved.
The available evidence was distilled in 3 ways. First, estimates were made of DDH at birth in infants without risk factors. These estimates constituted the baseline risk. Second, estimates were made of the rates of DDH in the children with risk factors. These numbers guide clinical actions: rates that are too high might indicate referral or different follow-up despite negative physical findings. Third, each screening strategy (pediatrician-based, orthopaedist-based, and ultrasonography-based) was scored for the estimated number of children given a diagnosis of DDH at birth, at mid-term (4–12 months of age), and at late-term (12 months of age and older) and for the estimated number of cases of AVN incurred, assuming that all children given a diagnosis of DDH would be treated. These numbers suggest the best strategy, balancing DDH detection with incurring adverse effects.
The baseline estimate of DDH based on orthopaedic screening was 11.5/1000 infants. Estimates from pediatric screening were 8.6/1000 and from ultrasonography were 25/1000. The 11.5/1000 rate translates into a rate for not-at-risk boys of 4.1/1000 boys and a rate for not-at-risk girls of 19/1000 girls. These numbers derive from the facts that the relative risk—the rate in girls divided by the rate in boys across several studies—is 4.6 and because infants are split evenly between boys and girls, so .5 × 4.1/1000 + .5 × 19/1000 = 11.5/1000.34 ,35 We used these baseline rates for calculating the rates in other risk groups. Because the relative risk of DDH for children with a positive family history (first-degree relatives) is 1.7, the rate for boys with a positive family history is 1.7 × 4.1 = 6.4/1000 boys, and for girls with a positive family history, 1.7 × 19 = 32/1000 girls. Finally, the relative risk of DDH for breech presentation (of all kinds) is 6.3, so the risk for breech boys is 7.0 × 4.1 = 29/1000 boys and for breech girls, 7.0 × 19 = 133/1000 girls. These numbers are summarized in Table 1.
Relative and Absolute Risks for Finding a Positive Examination Result at Newborn Screening by Using the Ortolani and Barlow Signs
These numbers suggest that boys without risk or those with a family history have the lowest risk; girls without risk and boys born in a breech presentation have an intermediate risk; and girls with a positive family history, and especially girls born in a breech presentation, have the highest risks. Guidelines, considering the risk factors, should follow these risk profiles. Reports of newborn screening for DDH have included various screening techniques. In some, the screening clinician was an orthopaedist, in others, a pediatrician, and in still others, a physiotherapist. In addition, screening has been performed by ultrasonography. In assessing the expected effect of each strategy, we estimated the newborn DDH rates, the mid-term DDH rates, and the late-term DDH rates for each of the 3 strategies, as shown inTable 2. We also estimated the rate of AVN for DDH treated before 2 months of age (2.5/1000 treated) and after 2 months of age (109/1000 treated). We could not distinguish the AVN rates for children treated between 2 and 12 months of age from those treated later. Table 2 gives these data. The total cases of AVN per strategy are calculated, assuming that all infants with positive examination results are treated.
Newborn Strategy*
Table 2 shows that a strategy using pediatricians to screen newborns would give the lowest newborn rate but the highest mid- and late-term DDH rates. To assess how much better an ultrasonography-only screening strategy would be, we could calculate a cost-effectiveness ratio. In this case, the "cost" of ultrasonographic screening is the number of "extra" newborn cases that probably include children who do not need to be treated. (The cost from AVN is the same in the 2 strategies.) By using these cases as the cost and the number of later cases averted as the effect, a ratio is obtained of 71 children treated neonatally because of a positive ultrasonographic screen for each later case averted. Because this number is high, and because the presumption of better late-term efficacy is based on a single study, we do not recommend ultrasonographic screening at this time.
RECOMMENDATIONS AND NOTES TO ALGORITHM (Fig 1)
Screening for developmental hip dysplasia—clinical algorithm.
1. All newborns are to be screened by physical examination. The evidence† for this recommendation is good. The expert consensus‡ is strong. Although initial screening by orthopaedists§ would be optimal (Table 2), it is doubtful that if widely practiced, such a strategy would give the same good results as those published from pediatric orthopaedic research centers. It is recommended that screening be done by a properly trained health care provider (eg, physician, pediatric nurse practitioner, physician assistant, or physical therapist). (Evidence for this recommendation is strong.) A number of studies performed by properly trained nonphysicians report results indistinguishable from those performed by physicians.36 The examination after discharge from the neonatal intensive care unit should be performed as a newborn examination with appropriate screening. Ultrasonography of all newborns is not recommended. (Evidence is fair; consensus is strong.) Although there is indirect evidence to support the use of ultrasonographic screening of all newborns, it is not advocated because it is operator-dependent, availability is questionable, it increases the rate of treatment, and interobserver variability is high. There are probably some increased costs. We considered a strategy of "no newborn screening." This arm is politically indefensible because screening newborns is inherent in pediatrician's care. The technical report details this limb through decision analysis. Regardless of the screening method used for the newborn, DDH is detected in 1 in 5000 infants at 18 months of age.3 The evidence and consensus for newborn screening remain strong.
Newborn Physical Examination and Treatment
2. If a positive Ortolani or Barlow sign is found in the newborn examination, the infant should be referred to an orthopaedist. Orthopaedic referral is recommended when the Ortolani sign is unequivocally positive (a clunk). Orthopaedic referral is not recommended for any softly positive finding in the examination (eg, hip click without dislocation). The precise time frame for the newborn to be evaluated by the orthopaedist cannot be determined from the literature. However, the literature suggests that the majority of "abnormal" physical findings of hip examinations at birth (clicks and clunks) will resolve by 2 weeks; therefore, consultation and possible initiation of treatment are recommended by that time. The data recommending that all those with a positive Ortolani sign be referred to an orthopaedist are limited, but expert panel consensus, nevertheless, was strong, because pediatricians do not have the training to take full responsibility and because true Ortolani clunks are rare and their management is more appropriately performed by the orthopaedist.
If the results of the physical examination at birth are "equivocally" positive (ie, soft click, mild asymmetry, but neither an Ortolani nor a Barlow sign is present), then a follow-up hip examination by the pediatrician in 2 weeks is recommended. (Evidence is good; consensus is strong.) The available data suggest that most clicks resolve by 2 weeks and that these "benign hip clicks" in the newborn period do not lead to later hip dysplasia.9 ,17 ,28 ,37 Thus, for an infant with softly positive signs, the pediatrician should reexamine the hips at 2 weeks before making referrals for orthopaedic care or ultrasonography. We recognize the concern of pediatricians about adherence to follow-up care regimens, but this concern regards all aspects of health maintenance and is not a reason to request ultrasonography or other diagnostic study of the newborn hips.
3. If the results of the newborn physical examination are positive (ie, presence of an Ortolani or a Barlow sign), ordering an ultrasonographic examination of the newborn is not recommended. (Evidence is poor; opinion is strong.) Treatment decisions are not influenced by the results of ultrasonography but are based on the results of the physical examination. The treating physician may use a variety of imaging studies during clinical management. If the results of the newborn physical examination are positive, obtaining a radiograph of the newborn's pelvis and hips is not recommended(evidence is poor; opinion is strong), because they are of limited value and do not influence treatment decisions.
The use of triple diapers when abnormal physical signs are detected during the newborn period is not recommended. (Evidence is poor; opinion is strong.) Triple diaper use is common practice despite the lack of data on the effectiveness of triple diaper use; and, in instances of frank dislocation, the use of triple diapers may delay the initiation of more appropriate treatment (such as with the Pavlik harness). Often, the primary care pediatrician may not have performed the newborn examination in the hospital. The importance of communication cannot be overemphasized, and triple diapers may aid in follow-up as a reminder that a possible abnormal physical examination finding was present in the newborn.
2-Week Examination
4. If the results of the physical examination are positive (eg, positive Ortolani or Barlow sign) at 2 weeks, refer to an orthopaedist. (Evidence is strong; consensus is strong.) Referral is urgent but is not an emergency. Consensus is strong that, as in the newborn, the presence of an Ortolani or Barlow sign at 2 weeks warrants referral to an orthopaedist. An Ortolani sign at 2 weeks may be a new finding or a finding that was not apparent at the time of the newborn examination.
5. If at the 2-week examination the Ortolani and Barlow signs are absent but physical findings raise suspicions, consider referral to an orthopaedist or request ultrasonography at age 3 to 4 weeks. Consensus is mixed about the follow-up for softly positive or equivocal findings at 2 weeks of age (eg, adventitial click, thigh asymmetry, and apparent leg length difference). Because it is necessary to confirm the status of the hip joint, the pediatrician can consider referral to an orthopaedist or for ultrasonography if the constellation of physical findings raises a high level of suspicion. However, if the physical findings are minimal, continuing follow-up by the periodicity schedule with focused hip examinations is also an option, provided risk factors are considered. (See "Recommendations" 7 and 8.)
6. If the results of the physical examination are negative at 2 weeks, follow-up is recommended at the scheduled well-baby periodic examinations. (Evidence is good; consensus is strong.)
7. Risk factors. If the results of the newborn examination are negative (or equivocally positive), risk factors may be considered.13 ,21 38–41 Risk factors are a study of thresholds to act.42 Table 1 gives the risk of finding a positive Ortolani or Barlow sign at the time of the initial newborn screening. If this examination is negative, the absolute risk of there being a true dislocated hip is greatly reduced. Nevertheless, the data in Table 1 may influence the pediatrician to perform confirmatory evaluations. Action will vary based on the individual clinician. The following recommendations are made (evidence is strong; opinion is strong):
Girl (newborn risk of 19/1000). When the results of the newborn examination are negative or equivocally positive, hips should be reevaluated at 2 weeks of age. If negative, continue according to the periodicity schedule; if positive, refer to an orthopaedist or for ultrasonography at 3 weeks of age.
Infants with a positive family history of DDH (newborn risk for boys of 9.4/1000 and for girls, 44/1000). When the results of the newborn examination in boys are negative or equivocally positive, hips should be reevaluated at 2 weeks of age. If negative, continue according to the periodicity schedule; if positive, refer to an orthopaedist or for ultrasonography at 3 weeks of age. In girls, the absolute risk of 44/1000 may exceed the pediatrician's threshold to act, and imaging with an ultrasonographic examination at 6 weeks of age or a radiograph of the pelvis at 4 months of age is recommended.
Breech presentation (newborn risk for boys of 26/1000 and for girls, 120/1000). For negative or equivocally positive newborn examinations, the infant should be reevaluated at regular intervals (according to the periodicity schedule) if the examination results remain negative. Because an absolute risk of 120/1000 (12%) probably exceeds most pediatricians' threshold to act, imaging with an ultrasonographic examination at 6 weeks of age or with a radiograph of the pelvis and hips at 4 months of age is recommended. In addition, because some reports show a high incidence of hip abnormalities detected at an older age in children born breech, this imaging strategy remains an option for all children born breech, not just girls. These hip abnormalities are, for the most part, inadequate development of the acetabulum. Acetabular dysplasia is best found by a radiographic examination at 6 months of age or older. A suggestion of poorly formed acetabula may be observed at 6 weeks of age by ultrasonography, but the best study remains a radiograph performed closer to 6 months of age. Ultrasonographic newborn screening of all breech infants will not eliminate the possibility of later acetabular dysplasia.
8. Periodicity. The hips must be examined at every well-baby visit according to the recommended periodicity schedule for well-baby examinations (2–4 days for newborns discharged in less than 48 hours after delivery, by 1 month, 2 months, 4 months, 6 months, 9 months, and 12 months of age). If at any time during the follow-up period DDH is suspected because of an abnormal physical examination or by a parental complaint of difficulty diapering or abnormal appearing legs, the pediatrician must confirm that the hips are stable, in the sockets, and developing normally. Confirmation can be made by a focused physical examination when the infant is calm and relaxed, by consultation with another primary care pediatrician, by consultation with an orthopaedist, by ultrasonography if the infant is younger than 5 months of age, or by radiography if the infant is older than 4 months of age. (Between 4 and 6 months of age, ultrasonography and radiography seem to be equally effective diagnostic imaging studies.)
DDH is an important term because it accurately reflects the biologic features of the disorder and the susceptibility of the hip to become dislocated at various times. Dislocated hips always will be diagnosed later in infancy and childhood because not every dislocated hip is detectable at birth, and hips continue to dislocate throughout the first year of life. Thus, this guideline requires that the pediatrician follow a process of care for the detection of DDH. The process recommended for early detection of DDH includes the following:
Screen all newborns' hips by physical examination.
Examine all infants' hips according to a periodicity schedule and follow-up until the child is an established walker.
Record and document physical findings.
Be aware of the changing physical examination for DDH.
If physical findings raise suspicion of DDH, or if parental concerns suggest hip disease, confirmation is required by expert physical examination, referral to an orthopaedist, or by an age-appropriate imaging study.
When this process of care is followed, the number of dislocated hips diagnosed at 1 year of age should be minimized. However, the problem of late detection of dislocated hips will not be eliminated. The results of screening programs have indicated that 1 in 5000 children have a dislocated hip detected at 18 months of age or older.3
The Technical Report is available from the American Academy of Pediatrics from several sources. The Technical Report is published in full-text on Pediatrics electronic pages. It is also available in a compendium of practice guidelines that contains guidelines and evidence reports together. The objective was to create a recommendation to pediatricians and other primary care providers about their role as screeners for detecting DDH. The patients are a theoretical cohort of newborns. A model-based method using decision analysis was the foundation. Components of the approach include:
Perspective: primary care provider
Outcomes: DDH and AVN
Preferences: expected rates of outcomes
Model: influence diagram assessed from the subcommittee and from the methodology team with critical feedback from the subcommittee
Evidence sources: Medline and EMBase (detailed in "Methods" section)
Evidence quality: assessed on a custom, subjective scale, based primarily on the fit of the evidence in the decision model
The results are detailed in the "Methods" section. Based on the raw evidence and Bayesian hierarchical meta-analysis,34 ,35 estimates for the incidence of DDH based on the type of screener (orthopaedist vs pediatrician); the odds ratio for DDH given risk factors of sex, family history, and breech presentation; and estimates for late detection and AVN were determined and are detailed in the "Methods" section and in Tables 1 and 2.
The decision model (reduced based on available evidence) suggests that orthopaedic screening is optimal, but because orthopaedists in the published studies and in practice would differ in pediatric expertise, the supply of pediatric orthopaedists is relatively limited, and the difference between orthopaedists and pediatricians is statistically insignificant, we conclude that pediatric screening is to be recommended. The place for ultrasonography in the screening process remains to be defined because of the limited data available regarding late diagnosis in ultrasonography screening to permit definitive recommendations.
These data could be used by others to refine the conclusion based on costs, parental preferences, or physician style. Areas for research are well defined by our model-based method. All references are in the Technical Report.
The quality of the literature suggests many areas for research, because there is a paucity of randomized clinical trials and case-controlled studies. The following is a list of possibilities:
Minimum diagnostic abilities of a screener. Although there are data for pediatricians in general, few, if any, studies evaluated the abilities of an individual examiner. What should the minimum sensitivity and specificity be, and how should they be assessed?
Intercurrent screening. There were few studies on systemic processes for screening after the newborn period.2 ,43 ,44 Although several studies assessed postneonatal DDH, the data did not specify how many examinations were performed on each child before the abnormal result was found.
Trade-offs. Screening always results in falsepositive results, and these patients suffer the adverse effects of therapy. How many unnecessary AVNs are we—families, physicians, and society—willing to tolerate from a screening program for every appropriately treated infant in whom late DDH was averted? This assessment depends on people's values and preferences and is not strictly an epidemiologic issue.
Postneonatal DDH after ultrasonographic screening. Although we concluded that ultrasonographic screening did not result in fewer diagnoses of postneonatal DDH, that conclusion was based on only 1 study.36 Further study is needed.
Cost-effectiveness. If ultrasonographic screening reduces the number of postneonatal DDH diagnoses, then there will be a cost trade-off between the resources spent up front to screen everyone with an expensive technology, as in the case of ultrasonography, and the resources spent later to treat an expensive adverse event, as in the case of physical examination-based screening. The level at which the cost per case of postneonatal DDH averted is no longer acceptable is a matter of social preference, not of epidemiology.
We acknowledge and appreciate the help of our methodology team, Richard Hinton, MD, Paola Morello, MD, and Jeanne Santoli, MD, who diligently participated in the literature review and abstracting the articles into evidence tables, and the subcommittee on evidence analysis.
We would also like to thank Robert Sebring, PhD, for assisting in the management of this process; Bonnie Cosner for managing the workflow; and Chris Kwiat, MLS, from the American Academy of Pediatrics Bakwin Library, who performed the literature searches.
Committee on Quality Improvement, 1999–2000
Charles J. Homer, MD, MPH, Chairperson
Richard D. Baltz, MD
Gerald B. Hickson, MD
Paul V. Miles, MD
Thomas B. Newman, MD, MPH
Joan E. Shook, MD
William M. Zurhellen, MD
Betty A. Lowe, MD, Liaison, National Association of Children's Hospitals and Related Institutions (NACHRI)
Ellen Schwalenstocker, MBA, Liaison, NACHRI
Michael J. Goldberg, MD, Liaison, Council on Sections
Richard Shiffman, MD, Liaison, Section on Computers and Other Technology
Jan Ellen Berger, MD, Liaison, Committee on Medical Liability
F. Lane France, MD, Committee on Practice and Ambulatory Medicine
Subcommittee on Developmental Dysplasia of the Hip, 1999–2000
Michael J. Goldberg, MD, Chairperson
Section on Orthopaedics
Theodore H. Harcke, MD
Section on Radiology
Anthony Hirsch, MD
Harold Lehmann, MD, PhD
Section on Epidemiology
Dennis R. Roy, MD
Philip Sunshine, MD
Section on Perinatology
Carol Dezateux, MB, MPH
ADDENDUM TO REFERENCES FOR THE DDH GUIDELINE
New information is generated constantly. Specific details of this report must be changed over time.
New articles (additional articles 1–7) have been published since the completion of our literature search and construction of this Guideline. These articles taken alone might seem to contradict some of the Guideline's estimates as detailed in the article and in the Technical Report. However, taken in context with the literature synthesis carried out for the construction of this Guideline, our estimates remain intact and no conclusions are obviated.
The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
The Practice Guideline, "Early Detection of Developmental Dysplasia of the Hip," was reviewed by appropriate committees and sections of the American Academy of Pediatrics (AAP) including the Chapter Review Group, a focus group of office-based pediatricians representing each AAP District: Gene R. Adams, MD; Robert M. Corwin, MD; Diane Fuquay, MD; Barbara M. Harley, MD; Thomas J. Herr, MD, Chair; Kenneth E. Matthews, MD; Robert D. Mines, MD; Lawrence C. Pakula, MD; Howard B. Weinblatt, MD; and Delosa A. Young, MD. The Practice Guideline was also reviewed by relevant outside medical organizations as part of the peer review process.
* In this guideline, the term pediatricianincludes the range of pediatric primary care providers, eg, family practitioners and pediatric nurse practitioners.
† In this guideline, evidence is listed as good, fair, or poor based on the methodologist's evaluation of the literature quality. (See the Technical Report.)
‡ Opinion or consensus is listed as strong if opinion of the expert panel was unanimous or mixed if there were dissenting points of view.
§ In this guideline, the term orthopaedistrefers to an orthopaedic surgeon with expertise in pediatric orthopaedic conditions.
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Home GCA Member Announcements Emergent BioSolutions, a Global Biotechnology Company, Appoints GCA Game Changer Richard Lindahl...
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Emergent BioSolutions, a Global Biotechnology Company, Appoints GCA Game Changer Richard Lindahl as Executive Vice President and Chief Financial Officer
EMERGENT BIOSOLUTIONS ANNOUNCES EXECUTIVE MANAGEMENT CHANGES THAT ENHANCE EXECUTION OF COMPANY'S GROWTH STRATEGY
GAITHERSBURG, MD., March 26, 2018 (via Globe Newswire) – Emergent BioSolutions Inc. (NYSE: EBS) today announced executive management changes that continue to align its organizational structure to its long-term strategy and to the achievement of its near- and long-term growth objectives. Specifically, effective today, the company's board of directors promoted Robert G. Kramer Sr. to the newly-created position of president and chief operating officer, and appointed Richard S. Lindahl as the company's new executive vice president and chief financial officer.
As president and COO, Kramer will have responsibility for the company's day-to-day operations and the successful execution of the company's stated growth plan. He will report directly to the company's chief executive officer, Daniel J. Abdun-Nabi. Kramer joined the company in early 1999 shortly after its founding. Over the years, he has held a variety of executive level positions, including president of Emergent's Lansing, Michigan manufacturing site and, most recently, executive vice president, administration and chief financial officer.
Rich Lindahl
Lindahl joins the company with responsibility for financial operations, investor relations, and information technology. He will also report to Abdun-Nabi. Lindahl most recently served as CFO at CEB Inc., a best practice insight and technology company, where he developed the finance organization to effectively support the company's growth resulting in a four-fold increase in market capitalization over his eight-year tenure. Prior to CEB, he served as senior vice president and treasurer of Sprint Nextel Corporation, vice president and treasurer of Nextel Communications, Inc., and in progressive finance and management positions at Nextel, Pocket Communications, Inc., MCI Communications Corp., Deloitte & Touche LLP, and Casher Associates, Inc.
"These management changes enhance the company's ability to execute on its overall strategy by ensuring an aligned and scalable organizational structure and a strong and deep leadership bench to drive future growth," said Abdun-Nabi. "The board and I have long valued Bob's leadership and extensive company knowledge, which position him well in his new role of overseeing our global operations. Bob's sound business acumen, strategic thinking, and focus on financial discipline have contributed to the company's growth over the years. Additionally, we are pleased to welcome Rich to the Emergent team. With more than 20 years serving in finance leadership roles in large, growth-oriented public companies, we are confident in the wealth of experience he brings at this important stage in our company's growth."
"I am grateful for the trust placed in me with the increased scope of responsibility, allowing me to continue to make a meaningful impact on Emergent's success," said Kramer. "I look forward to working closely with our seasoned leadership team, further strengthened by the addition of Rich. It is an exciting time to be part of Emergent as we accelerate our growth while meeting the needs of patients and customers in the global public health threats market."
"Emergent's compelling growth strategy, high quality leadership team, unique assets, and proven execution capabilities make this role a really exciting opportunity for me," said Lindahl. "I look forward to working closely with my new colleagues and adding value not only to achieve our business objectives, but also to advance the company mission – to
protect and enhance life."
About Emergent BioSolutions Inc.
Emergent BioSolutions Inc. is a global life sciences company seeking to protect and enhance life by focusing on providing specialty products for civilian and military populations that address accidental, intentional, and naturally occurring public health threats. Through their work, they envision protecting and enhancing 50 million lives with their products by 2025. Additional information about the company may be found at www.emergentbiosolutions.com. Follow them on Twitter @emergentbiosolu
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Vaginal Infections & STD's London
What is vaginitis?
The term vaginitis refers to the inflammation of the vagina. It is usually a result of the disruption of the normal balance of vaginal bacteria, but it may also be caused by an infection or due to a decrease in oestrogen production after menopause. Vaginitis is usually manifested by the presence of itching and increased fluids in the vagina, which sometimes have an unpleasant odour. Vaginal disorders are currently the most common health problem faced by women and they are the most common reason for a woman to visit her gynaecologist.
Disruption of the balance of the bacteria in the vagina
What are the most common types of vaginitis?
The most common types of vaginitis are:
Bacterial vaginitis, which is due to excessive growth of some bacteria that live and reproduce normally in the vagina.
Candidiasis: usually due to a fungus present in the vagina (Candida albicans).
Trichomoniasis which is caused by a parasite usually transmitted by sexual contact.
Vaginal atrophy or atrophic vaginitis, a result of reduced oestrogen production after menopause.
What are the symptoms of vaginitis?
The most common symptoms of vaginitis are:
Changes of colour, odour or amount of vaginal fluid.
Irritation or itching in the vagina.
Pain when urinating.
Slight vaginal bleeding or spotting.
How are vaginal infections treated?
Vaginitis, although at first glance seems to be a simple thing, can be one of the most difficult to address gynaecological problems. This is due to the distinctiveness of the physiology of the vagina and the complexity of the fine balances on which the proper functioning rests. Treatment entails taking a combination of oral antibiotics and vaginal suppositories or creams. However, even after the treatment, vaginitis can recur due to resilience being formed, or a reinfection happening.
What is Mycosis or Yeast Infection?
Within the vaginal fluids there are microbes that protect women from infections (Lactobacillus). Apart from these microbes there are others, but they are at a very small percentage. There are fungi in place whose percentage does not exceed 2%. In special cases (antibiotics, vaginal washes etc.) where Lactobacillus are being destroyed, fungi develop and the most common is Candida albicans. More than 80% of women have been pestered from a fungal infection. Mycosis is a very common vaginal infection and it is not considered a sexually transmitted disease.
What are the causes for mycosis?
Mycosis is an opportunistic infection and is related with factors that cause it, such as:
Broad spectrum antibiotics.
Diabetes.
Frequent intravaginal washes.
Immunosuppression.
Spiral.
Pregnancy.
Poor hygiene.
Use of cortisone.
What are the symptoms of mycosis?
Mycosis causes intense itching in the vaginal area. It also exhibits an increased amount of white vaginal fluids which have a cheesy texture. These liquids are odourless and thick. Finally, another symptom of mycosis is pain during urination and sexual intercourse.
How is mycosis cured?
There are treatments that last a day and treatments that last 3-7 days. Chronic mycosis usually needs treatment with pills, which lasts longer. We should never self-diagnose and treat because there is the risk of error or coexistence of the mycosis with another infection. Additionally, drugs exist that can mitigate the symptoms without curing the infection.
What is Chlamydia?
Chlamydia infection, often simply known as chlamydia, is a sexual transmit-ted disease caused by the bacterium Chlamydia Trachomatis. It is one of the most common infections and is affecting worldwide 4,2% of the women and 2,7% of men.
What are the symptoms of Chlamydia infection?
Most people who are infected have no symptoms. When symptoms do develop this can take a few weeks following infection to occur.
Symptoms in women are:
Vaginal discharged
Burning sensation during urination
Pelvic inflammatory disease, if the infection spreads to the upper genital track
Symptoms in men are:
Discharge from the penis
Pain or swelling of one or both testicles
How does Chlamydia get Transmitted?
Can be spread during vaginal, anal & oral intercourse
Can be passed from an infected mother to her baby during child-birth
The eye infections may also be spread by personal contact, flies, and contam-inated towels
How do we diagnose Chlamydia?
By screening test which is recommended:
Yearly in sexually active women under the age of twenty-five
At higher risk patients
At the first prenatal visit
Testing can be done on the urine or a swab of the cervix, vagina or urethra Rectal or mouth swabs are required to diagnose infections in those areas.
Prevention of Chlamydia?
Use of condoms
Having intercourse with only one other person, who is not infected
Treatment of Chlamydia?
Chlamydia can be cured by antibiotics and you need to visit your doctor for diag-nosis & treatment. Both the partners must be treated.
Book an appointment at our;
London Clinic | +44 (0) 2081440336
Dubai Clinic | +971 (0) 507599137


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Markku Juntti
D.Sc (Tech)
443 peer reviewed publications in international journals. The author has a h-index of 33.00. (Scopus)
Communication and information theory in wireless networks
Statistical signal processing and signal processing algorithms and architectures
Wireless system and transceiver design and optimization
Biography (Long)
Markku Juntti received his M.Sc. (EE) and Dr.Sc. (EE) degrees from University of Oulu, Oulu, Finland in 1993 and 1997, respectively. He was with University of Oulu in 1992-98. In academic year 1994-95 he was a Visiting Scholar at Rice University, Houston, Texas. In 1999-2000 he was a Senior Specialist with Nokia Networks. Dr. Juntti has been a a professor of communications engineering at University of Oulu, Department of Communication Engineering (DCE) and Centre for Wireless Communications (CWC) since 2000. His research interests include signal processing for wireless networks as well as communication and information theory. He is an Editor of IEEE Transactions on Communications.
Thesis supervisions
1. S. Qian (co-supervised by T. Matsumoto),, "Statistical Performance Characterization of Lossy-Forward based Cooperative Wireless Networks over Fading Channels", October 2017.
2. E. Suikkanen, "Detection algorithms and ASIC designs for MIMO–OFDM downlink receivers", March 2017. (Now with Keysight, Oulu, Finland).
Link to Dissertation
3. J. Kokkoniemi (Principal Supervisor: J. Lehtomäki), "Nanoscale Sensor Networks: the THz Band as a Communication Channel", March 2017. (Now with University of Oulu and University of Buffalo, USA)
4. X. He (co-supervised by T. Matsumoto),, "Binary information sensing and multiterminal source coding: rate-distortion analysis and transmission design", June 2016. (Now with Anhui Normal University, Anhui, China).
5. J. Huusko, "Communication performance prediction and link adaptation based on a statistical radio channel model", April 2016. (Now with Nokia, Oulu, Finland)
6. Y. Takano (co-supervised by T. Matsumoto), "Spectrally efficient turbo reception technologies for single-carrier broadband wireless communications", February 2016. (Now with Kobe University, Kobe, Japan)
7. P.-S. Lu (co-supervised by T. Matsumoto), "Decoding and lossy forwarding based multiple access relaying", March 2015. (Now with Sony China Research Lab, Beijing, China)
8. V. Tervo (co-supervised by T. Matsumoto and A. Tölli), "Joint multiuser power allocation and iterative multi-antenna receiver design", January 2015. (Now with Nokia, Espoo, Finland)
9. X. Lu (co-supervised by A. Tölli), "Resource allocation in uplink coordinated multicell MIMO-OFDM systems with 3D channel models", December 2013. (Now with Huawei, Stockholm, Sweden)
10. P. Komulainen (co-supervised by A. Tölli), "Coordinated Multi-Antenna Techniques for Cellular Networks -- Effective CSI Signaling and Decentralized Optimization in TDD Mode", November 2013. (Now with MediaTek, Oulu, Finland)
11. A. Yadav, "Space-Time Constellation and Precoder Design under Channel Estimation Errors", October 2013. (Now with Université du Québec à Montréal as postdoctoral researcher)
12. J. Ketonen (co-supervised by J. Cavallaro), "Equalization and Channel Estimation Algorithms and Implementations for Cellular MIMO-OFDM Downlink", June 2012. (Now with Nokia, Oulu, Finland)
13. J. Janhunen (co-supervised by O. Silven), "Software based reconfigurable MIMO detectors", December 2011. (Now with University of Oulu)
14. J. Karjalainen (co-supervised by T. Matsumoto), "Broadband single carrier multi-antenna communications with frequency domain turbo equalization", September 2011. (Now with Nokia Bell Labs, Oulu, Finland)
15. M. Myllylä (co-supervised by J. Cavallaro), "Detection algorithms and architectures for wireless spatial multiplexing communications", May 2011. (Now with Nokia Networks, Oulu)
16. J. Vartiainen (co-supervised by H. Saarnisaari), "Concentrated signal extraction using consecutive mean excision algorithms", November 2010. (Now with University of Oulu, Academy of Finland Postdoctoral Researcher)
17. J. Ylioinas, "Reducing complexity through activation optimization and algorithm design in iterative receiver for MIMO-OFDM", June 2010. (Now with Nokia Bell Labs, Oulu, Finland)
18. J.-P. Haapola ((co-supervised by C. Pomalaza Raez and I. Oppermann), "Evaluating Medium Access Control Protocols for Wireless Sensor Networks", February 2010. (Now with University of Oulu)
19. J. Leinonen, "Analysis of OFDMA Resource Allocation with Limited Feedback", October 2009. (Now with Nokia, Oulu, Finland)
20. A. Tölli, "Radio Resource Management in Future Wireless Broadband Systems", April 2008. (Now with University of Oulu, Academy of Finland Research Fellow)
21. H. Miao, "Channel estimation and positioning for multiple antenna systems", May 2007. (Now with Intel, Munich, Germany)
22. J. Lehtomäki, "Performance analysis of energy detectors for communication signal intelligence", December 2005. (Now with University of Oulu)
23. N. Veselinovic (co-supervised by T. Matsumoto), "Iterative receivers for interference cancellation and suppression in wireless communications", December 2004. (Now with Varian Medical Systems)
24. Dj. Tujkovic, "Space-time turbo coded modulation for wireless communication systems", April 2003. (Now with Facebook, Silicon Valley)
25. Co-supervisor: M. Codreanu (supervised by M. Latva-aho), "Multidimensional adaptive radio links for broadband communications", December 2007 (with distinction). (Now with University of Oulu, Academy of Finland Research Fellow)
26. Co-supervisor: K. Hooli (supervised by M. Latva-aho), "Equalization in WCDMA terminals", University of Oulu, Department of Electrical and Information Engineering, December 2003 (with distinction). (Now with Nokia Solutions and Networks)
CWC-Radio Technologies
Faculty of Information Technology and Electrical Engineering
Erkki Koiso-Kanttilan katu 3, Oulu
P.O. Box 4500, FI-90014 University of Oulu, Finland
markku.juntti (at) oulu.fi
+358 (0)294 482834


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15 West 63rd Street #29/30FLOOR Upper West Side, NY 10023 - New York
Condominium Apartment for sale 15 West 63rd Street #29/30FLOOR, Upper West Side - New York
This extraordinary home encompassing 2 full floors at the Park Laurel has the best layout and design. Spread out over approximately 7800 square feet inside with an approximately 1250 square foot terrace with Central Park views, it is that rare residence that offers complete privacy with the best in class service. Designed by renowned architect Alan Wanzenberg, it features 7+ bedrooms, 5 full bathrooms, a staff bedroom and 2 half bathrooms. The living and entertaining space (including the terrace) is on the 29th floor, while bedrooms and private space are appropriately secluded on the 30th floor. All rooms have grand proportions - it is truly the perfect layout with Central Park views from all major rooms! From a private elevator landing, enter into the almost 30' long gallery off of which all rooms flow. The grand living room is over 40 feet long with 3 exposures, including direct Central Park views and open North City and Park views. The elegant paneled library has direct Central Park views, as does the large formal dining room. The fabulous chef's gourmet kitchen has both a large eating area and is open to a "great room". This wonderful expanse of space takes up the entire South end of this floor. Off the kitchen is the planted terrace which has mesmerizing Park views and enchanting South City and Central Park South views. The terrace has plenty of space for cooking, dining and entertaining! Completing this floor is a powder room for guests and a large windowed assistant's office with half bath, which also functions well as a mud room. There are two staircases that lead to the 30th floor, one dramatic and architectural, the other off the kitchen for staff. It is also possible to take the elevator to the 30th floor, where the apartment is accessed off another private landing. At the top of the main staircase is a wonderful screening room/library with stunning Park views. The sumptuous corner master suite has direct Central Park and North open City and Park views. There are 2 large walk-in closets, a gigantic bathroom which has separate sinks, a separate room for the commode, a large soaking tub with spectacular North city views and a separate dressing area. There are 6 additional bedrooms serviced by 4 full bathrooms on this floor, all of which have views. In addition there is a generous laundry room with 2 sets of full size vented washer/dryers. Behind the laundry room, facing West, is a well sized staff room with full bathroom. The entire apartment has gigantic picture windows, over 9 foot ceilings, wiring for sound/shades and central air conditioning. 15 West 63rd Street, The Park Laurel, is well loved as a distinguished white glove, full-service building in the best location. There is a new fitness room, playroom, storage room and bike storage (both upon availability) and is located moments from Lincoln Center, The Time Warner Shops, and many of the Upper West Side's finest restaurants. Please call for a private showing.
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In July 2018, Kalium Lakes and BCI Minerals Limited (BCI), the owners of the Carnegie Potash Project (CPP) via the Carnegie Joint Venture (CJV), announced the completion of the Scoping Study and a maiden Resource and Exploration Target for the CPP in Western Australia.
A summary of the Scoping Study is provided below and further information is contained within the JORC (2012) and NI 43-101 Technical Report, compiled by German Potash Experts and Competent Persons, K-UTEC AG Salt Technologies (K-UTEC) – link to ASX Announcement also appears below.
Scoping Study, Maiden Resource and Exploration Target confirm the CPP has potential to be a technically and economically viable project.
Scoping Study leveraged the significant technical knowledge, experience and intellectual property developed by Kalium Lakes in advancing their Beyondie Sulphate of Potash Project.
Inferred Resource of 0.88 Mt SOP @ 3,466 mg/l K1 (equivalent to 7,724 mg/l SOP) based only on the top 1.7 metres of the 27,874 hectare surficial aquifer on granted tenement E38/2995 plus an Exploration Target2 for material below the top 1.7 metres.
A further 82,000 hectares of lake surface on pending tenements is not included in the current Inferred Resource or Exploration Target, providing further resource upside potential.
BCI Minerals has now earned a 30% CJV interest and Kalium Lakes holds a 70% interest.
The JV Companies have endorsed proceeding to a staged Pre-Feasibility Study, with an initial focus on securing tenure and access to all required tenements.
In March 2017 BCI Minerals Limited (ASX:BCI) and Kalium Lakes Limited announced that the companies had entered into a joint venture agreement over Kalium's 100 per cent owned Carnegie Project.
The Carnegie Project is a potash exploration project located approximately 220 kilometress north-east of Wiluna that comprises one granted exploration licence and two exploration licence applications covering a total area of approximately 1,700 square kilometres (see map below). The Carnegie Project is highly prospective for hosting a large sub-surface brine deposit which could be developed into a solar evaporation and processing operation that produces sulphate of potash (SOP).
Under the terms of the Agreement, BCI Minerals can earn up to a 50 per cent interest in the Carnegie Project, by predominantly sole-funding exploration and development expenditure across several stages. Kalium will be the manager of the joint venture.
Under the terms of the Agreement, the parties will form an unincorporated joint venture over the Carnegie Project with BC Iron having the right to earn up to a 50 per cent interest in a sequential staged manner.
During an initial Scoping Study Phase (Stage 1), BCI Minerals (formerly BC Iron) can earn a 30 per cent interest in the Carnegie Project by contributing its mobile camp facilities to the joint venture and sole-funding the first $1.5M of expenditure. During a Pre-Feasibility Study Phase (Stage 2), BC Iron can elect to earn a further 10 per cent interest in the Carnegie Project (for a total interest of 40 per cent) by sole-funding a further $3.5M of expenditure through Stage 2. During a Feasibility Study Phase (Stage 3), BC Minerals can elect to earn a further 10 per cent interest in the Carnegie Project (for a total interest of 50 per cent) by sole-funding a further $5.5M of expenditure through Stage 3.
Kalium will be appointed the manager of the joint venture, allowing the parties to leverage Kalium's experience and expertise in developing their primary potash project, Beyondie, which is at an advanced pre-feasibility study stage. Kalium will also contribute relevant intellectual property from the Beyondie Project, which is expected to materially reduce the time and cost of progressing the Carnegie Project towards development. The Manager will report regularly to a Joint Venture Management Committee.
Further strengthening the parties' co-operation on solar evaporation projects, BC Minerals has provided Kalium with the right to acquire a 50 per cent interest in the Mardie Project at certain development stages. The Mardie Project, which is located on the coast approximately 100km south-west of Karratha, has a large area of natural salt lakes, making it highly prospective for solar salt production with many similarities to other successful solar salt operations in the region. BC Iron is currently completing a high level scoping study on a potential 3 Mtpa solar evaporation salt operation at Mardie, with an aspirational goal to potentially strengthen Australia's position as the largest exporter of solar salt globally in the future.
BCI Minerals is an ASX-listed development and mining company with a portfolio of assets primarily located in the Pilbara region of Western Australia. The Company's key assets include Iron Valley and Buckland.
Iron Valley is an iron ore mine located in the Central Pilbara. The mine is operated by Mineral Resources Limited (MIN) under an ore purchase agreement with BC Minerals and is generating low risk royalty earnings for the Company.
Buckland is a strategic iron ore development project located in the West Pilbara region, comprising a proposed mine at Bungaroo South and a proposed infrastructure solution incorporating a haul road and transhipment port at Cape Preston East. It has a completed feasibility study and all primary tenure and approvals secured.
BCI Minerals holds a number of other exploration stage projects in a range of commodities and potential iron ore royalties over the Nullagine, Koodaideri South, Extension and Breakaway tenements.
The Company is also targeting new opportunities with a strong value proposition and near-term earnings potential, including commodities other than iron ore.


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Q: Fabry-Pérot-Interferometer: What Reflectivity Apologizing for that narrow question, but considering such interferometer with mirrors characterized by Reflectivity $R$ and reflection coefficients $r = \sqrt{R}$, where $R$ describes the amount of Intensity that the mirrors are reflecting and $r$ the amplitude ratio of reflected wave and incident wave. Now dealing with a Fabry-Pérot-Interferometer, it's of interest to calculate the ratio between the electric field vector $E_{out}$ coming out and the field vector $E_{in}$ that was coming in: $E_{out}/E_{in}$. Further this can be converted to intensity: $I_{out}/ I_{in} = (E_{out}/E_{in})^2$.
But isn't that the same as $R = r^2$? I'm just wondering what's the difference between those 2 relations. The one ($R, r$) is qualifying the ratio of a single ray going in and and being reflected and the other one ($I_{out}/I_{in}, E_{out}/E_{in}$) does account for multiple reflections?

A: The electric field out will consist of a reflected field plus that transmitted from within the interferometer. So no, $(E_{\rm out}/E_{\rm in})^2$ will not in general be $r^2$, where $r$ is a property of one of the mirrors.

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