Global warming and the established responsibility of the anthropogenic emissions of greenhouse gases represent a strong push towards the construction of new nuclear power plants (NPPs) to cope with the growing energy needs. The toxicity of nuclear waste associated with the extreme difficulty of their disposal and increase in cancer mortality and incidence following occupational radiation exposure are considered the only health problems.A search of scientific articles and government documents published since January 1, 1980 to July 1, 2010 was performed to evaluate cancer rate and mortality in residents, particularly children, in the vicinity of NPPs.A recent well conducted state-of-the-art case-control study of childhood cancers in the areas around German NPPs (KiKK study) showed a statistically significant cancers (2.2-fold increase in leukemia and a 1.6-fold increase in solid tumor) among children under five years of age living in the inner 5 km circle around NPPs when compared to residence outside this area. These findings have been confirmed by two meta-analyses. Nevertheless, other UK, France, Spain and Finland studies did not find cancer incidence and/or death increase near NPPs.Increased cancer risk near NPPs remains in fact an open question. The stronger evidence from the KiKK study suggests there may well be such increases at least in children regardless of the country in which nuclear reactors are located. In fact, few months ago the U.S. Nuclear Regulatory Commission has asked the National Academy of Sciences (NAS) to perform a state-of-the-art study on cancer risk for populations surrounding NPPs. Global warming and the established responsibility of the anthropogenic emissions of greenhouse gases represent a strong push towards the construction of new nuclear power plants (NPPs) to cope with the growing energy needs. Such a view however is based on the premise that nuclear power represents a safe, clean, sustainable and economic alternative and only nuclear waste could be a "solvable" problem.Nevertheless, scientific data show a different view. Along with an increase in cancer mortality and incidence following occupational radiation exposure, health consequences from populations residing near NPPs are a controversial issue.A search of scientific articles (PubMed/EMBASE) and government documents published since January 1, 1980 to July 1, 2010 was performed to evaluate cancer rate and mortality in residents, particularly children, in the vicinity of nuclear power plants (NPPs).In the late 1980 s and early 1990 s, increased incidence of childhood leukemia were reported near United Kingdom nuclear facilities but the cause or causes remained unknown because it was estimated that the radiation doses from these facilities were too low to explain the increased leukemia .In Germany, since a childhood leukemia cluster was first reported in 1980 in the vicinity of the nuclear plant Krümmel near Hamburg public anxieties have remained high ,6.In 2002 the German government contracted with the Childhood Cancer Registry at the University of Mainz (GCCR) to conduct a state-of-the-art case-control study of childhood cancers, particularly leukemia, in the areas around the country's 16 commercial nuclear power plants (NPPs). This Epidemiological Study on Childhood Cancer in the Vicinity of Nuclear Power Plants (Epidemiologische Studie zu Kinderkrebs in der Umgebung von Kernkraftwerken) is known by the acronym KiKK ,8. In coIn order to lend maximum credibility to this investigation, the German Federal Office for Radiation Protection  appointed an independent external review committee of 12 scientists  to assist in the study's design and evaluation.The KiKK study examined all cancers at all 16 nuclear reactor locations in Germany between 1980 and 2003, including 1,592 patients under five years of age with cancer (excluding leukemia) and 4,735 controls, with 593 under five years of age with leukemia and 1,766 controls. This means that the study is statistically strong and its findings statistically significant. Small numbers and weak statistical significance often limit the usefulness of many smaller epidemiological researches.This study showed a statistically significant cancers , among children under five years of age living in the inner 5 km circle around nuclear power plants when compared to residence outside this area. Risks for leukemia were also elevated in the 10 km zone. Regression models investigating the distance of residence at time of diagnosis to the nearest nuclear power plant showed a significant distance trend.Subsequent to the publication of the KIKK study, the Federal Minister for the Environment, Nature Conservation and Nuclear Safety charged the Commission on Radiological Protection with the Evaluation of the Study. In September 2008, the Commission on Radiological Protection submitted its Statement: "This study confirms a government-sponsored study of childhood cancer in the proximity of German nuclear power plants (KiKK) found that children < 5 years living < 5 km from plant exhaust stacks had twice the risk for contracting leukemia as those residing > 5 km" .In 2009, the Commission on Radiological Protection Presented a Substantiation of Its Statement to the Scientific Community .The KiKK's findings have been confirmed by two meta-analyses. Baker and Hoel analyzed data from 17 research papers world-wide covering 136 nuclear sites in the UK, Canada, France, the United States, Germany, Japan and Spain . In chilPrevious UK ,14 and FThe words "no evidence of an excess risk of leukemia" in the conclusions of the papers by Evrard et al.  and BithA report carried out at the request of Spain's Congress has shown no evidence of increased risks of death for cancer due to proximity to Spanish nuclear facilities (which include both NPPs and nuclear fuel storage facilities) . NeverthA study in Finland investigated leukemia incidence in children living near the two Finnish NPPs using both cohort and case-control analysis. The results were consistent and neither of them indicated an increased risk of leukemia, even though the small sample size and lack of population residing within the 5-km radius limit the strength of the conclusions .the question remains open. The stronger evidence from the KiKK study suggests there may well be such increases at least in children regardless of the country in which nuclear reactors are located.The French, English, Spain and Finland studies may mislead members of the public into thinking that there are no increased cancer risk near NPPs when in fact The U.S. Nuclear Regulatory Commission has asked the National Academy of Sciences (NAS) to perform a state-of-the-art study on cancer risk for populations surrounding nuclear power facilities. The study can begin this year .Because it was estimated that the radiation doses from nuclear facilities were too low to explain the increased leukemia, most researcher did not investigate the possibility of radioactive contamination of the environment by the NPPs. The latter are large plants with contact to the soil via water; they have high chimneys, and many people go in and out all the time. There are multiple opportunities for radioactive contamination of the ground water, the air, and the people who work there or live in their proximity. The possible cause of the increased number of cases of leukemia may not be ionizing radiation only, but also the environment of the power station. Through water and precipitation, radioactivity reaches the food chain and even small traces could be sufficient to trigger leukemia in a toddler .Among various hypotheses to explain cancer increases near nuclear installations the evidence that sensitivity to radiation is much higher during early embryonic and fetal stages -33 appea-2 to 10-4 mSv per year). Each model derives a range of results log-normally distributed from which only the median value is normally used. This means that, although the real value could be larger or smaller than the median value, in practice some high values could result [Estimated radiation doses to adults near nuclear power stations are invariably very low  occur at nuclear power reactors when their pressure vessels are opened (approximately once a year) to replace nuclear fuel . These sIt has been shown that in both human and murine hematopoeitic stem cells, heritable radiation-induced changes can be seen in the first progeny. However, a significant proportion of cells that survive radiation exposure may appear normal but have mutational changes in their progeny due to genomic instability. This chromosomal instability has been causally linked to leukemia .Epigenetics, a field at the epicenter of Modern Medicine , is modiEpigenetics may play an important role in genomic instability caused by radiation exposure . In 2008Until new data will be available on cancer risk near NPPs, the precautionary principle should be applied and radiation exposition of embryos, fetuses, infants and toddlers should be avoided even at very low doses. The precautionary principle covers cases where scientific evidence is insufficient, inconclusive or uncertain and preliminary scientific evaluation indicates that there are reasonable grounds for concern that the potentially dangerous effects on the environment, human, animal or plant health may be inconsistent with the high level of protection chosen by the E.U. .In view of the Italian Government will to built new NPPs, Italian pediatricians should be informed that a possible increase of cancer risk in children residing near the future sites of NPPs cannot be excluded. They should propose to the Ministry of Health to start monitoring cancer incidence for exposed population.For in deep commentary on NPPs and cancer in children residing nearby refer to the following articles authored by Ian Fairlie -44.The author declares that they have no competing interests.


Cavo-tricuspid isthmus (CTI) block is currently assessed by coronary sinus (CS) pacing or low lateral and septal atrial pacing. Occasionally, CS catheterization through the femoral route can be difficult to perform or right atrial pacing can be problematic because of catheter instability or saturation of the atrial electrograms recorded near the catheter.Our aim was to evaluate the feasibility of assessing cavo-tricuspid isthmus block by means of right ventricular (RV) pacing in patients with ventriculo-atrial conduction, comparing it with CS pacing.Circumannular activation was analyzed during CS and RV pacing in consecutive patients in sinus rhythm undergoing CTI ablation for typical atrial flutter. Patients without ventriculo-atrial conduction were excluded from the study. The linear lesion was created during RV pacing and split atrial signals on the ablation line were analyzed. CTI block was confirmed by analyzing local electrograms on the line of block and circumannular activation during CS and RV pacing.Out of 31 patients, 20 displayed ventriculo-atrial conduction (64%) and were included in the study. Before ablation, during RV stimulation, the collision front of circumannular activation shifted counterclockwise in contrast with the pattern observed during CS pacing. After ablation, circumannular activation was similar during CS and RV pacing, showing fully descending lateral right atrium activation, even if double potentials registered on the ablation line were less widely split during RV pacing than CS pacing .In patients with ventriculo-atrial conduction, tricuspid annulus activation during CS and RV pacing is similar, before and after CTI ablation. The occurrence of split atrial electrograms separated by an isoelectric interval registered on the line of block can be detected during CS or RV pacing. In patients with difficult  CS catheterization via the femoral vein, before trying the subclavian or internal jugular  route,  if retrograde ventriculo-atrial conduction is present, RV  pacing can be an easy trick to assess isthmus block. The end-point of radiofrequency (RF) ablation of typical atrial flutter (AFl) is the creation of a bidirectional conduction block between the inferior vena cava (IVC) and the tricuspid annulus (TA), the so-called cavo-tricuspid isthmus (CTI) -4. ValidConsecutive patients undergoing CTI RF ablation of typical AFl were proposed for inclusion in the study. All patients gave written informed consent. Electrophysiological study was performed by using 3 catheters inserted via the right and left femoral or left subclavian veins: a quadripolar diagnostic catheter in the RV apex , a decapolar in the CS  and a duo-decapolar around the TA . An 8 mm tip ablation catheter  was inserted into the right atrium (RA) from the right femoral vein. In those patients who were in AFl, isthmus dependence was assessed by the entrainment technique before beginning the ablation procedure. In patients in sinus rhythm at the beginning of the study and in those in AFl whose sinus rhythm was restored during RF delivery, circumannular activation was registered during proximal CS and RV pacing. Efforts were made to pace the left atrium as nearer as possible to the CS ostium, consistently with pacing threshold and catheter stability and avoiding left ventricular pacing.   When the line of block had not yet been created, the 'difference of circumannular activation time' was defined as the time from proximal pole to collision point  minus the time from distal pole to collision point, recorded on the duo-decapolar catheter  during RV and CS pacing at the same cycle length . PatientBipolar digitized endocardial atrial and ventricular electrograms and surface ECG leads were simultaneously recorded , displayed on a multi-channel recorder and stored on magneto-optical disks . RF ablation was performed with an EPT-1000 XP generator   that  delivered  continuous  unmodulated  current  at  500  KHz  in  a monopolar fashion  programmed at a maximum  power output of 100 W. RF pulses were delivered through the 8 mm tip electrode catheter  in a temperature-guided mode (preset temperature of 70ºC). The preset duration of the pulse was 60 s.When patients were in sinus rhythm, the procedure was performed while pacing from the RV apex at a cycle length adapted to the individual retrograde conduction properties, 600 ms if possible, at twice the diastolic threshold. The ablation catheter was initially positioned, during sinus rhythm, close to the TA where a large ventricular potential and a small atrial electrogram were recorded (A/V ratio approximately 0.1). RV pacing was then started and the catheter was progressively drawn back in a posteroseptal direction under fluoroscopic guidance, with sequential stops between each RF delivery up to the edge of the IVC. At each step, the modifications of atrial potentials related to VA conduction  were observed in order to control the progression of the ablation line. The endpoint of the procedure was the achievement of a complete clockwise isthmus block. In the first instance, this endpoint was evaluated on the basis of evidence of a sudden increase in the distance between split, reduced-amplitude atrial potentials separated by an isoelectric interval registered after the ventricular electrogram during RV pacing in the corridor between the TA and the IVC edge. The presence of sites of recording of  single atrial potentials after the ventricular electrograms, or fragmented atrial potentials without an isoelectric interval between them, suggested the presence of conduction gaps. Complete block was then validated by analyzing local electrograms registered on the line of block and circumannular activation on the duo-decapolar catheter during low lateral RA and CS pacing. This activation model was then compared with the circumannular activation registered when pacing was performed from the RV . The timOut of 31 consecutive patients who underwent CTI RF ablation, 20  displayed VA conduction (64%) and were included in the study. No patients evidenced accessory pathways, nor had a permanent pacemaker. At the beginning of the procedure, 11 patients were in sinus rhythm, whereas 9 had typical AFl, with a mean cycle length of 222 ± 22 ms (range 181-250). In all  patients with AFl at the beginning of the procedure, atrial potentials recorded on the CTI coincided  with the plateau between F waves on the surface electrocardiogram, and the entrainment technique showed that the CTI was the critical zone of the re-entry circuit. In all of these patients, the arrhythmia was interrupted by RF delivery, but only in one of them complete CTI block was present when sinus rhythm was restored; in all the others, further RF pulses were necessary to eliminate conduction gaps. In all patients in sinus rhythm, including those in AFl whose sinus rhythm had been restored during the ablation procedure without achieving a complete CTI block, RF pulses were delivered during RV pacing, and electrograms were monitored to detect splitting of double potentials recorded  on  the  ablation   line   after   the ventricular signals. In all patients, the achievement of a complete CTI block (subsequently verified by CS pacing) correlated with a sudden increase in the distance between the two atrial components induced by retrograde VA conduction and recorded on the ablation catheter during RF delivery . Thus, oCircumannular activation was analyzed before and after the achievement of CTI block in all patients but one; in this case, AFl was interrupted during RF ablation, with immediate creation of a complete CTI block and pre-block circumannular activation could not be analyzed. Before ablation,  the collision front of the circumannular activation during RV stimulation shifted counterclockwise in comparison with CS pacing, with a significant increase  in the difference  of activation time registered on the duo-decapolar catheter . After ablation, the circumannular activation was very similar during CS and RV pacing, showing fully descending lateral RA activation. Following the creation of bidirectional block, according to previous findings [CS pacing, low lateral and septal atrial pacing are validated techniques to assess  true complete isthmus block -14. In tAnalysis of circumannular activation on the basis of the potentials recorded by the duo-decapolar catheter revealed a similar configuration during RV and CS pacing in patients without CTI block before the ablation procedure. There are, however, some important differences: during CS pacing, the atrial electrograms precede the ventricular potentials, while during RV pacing they follow; when RV pacing is used to assess CTI permeability, a counterclockwise shift occurs in the collision front of the two vectors of the circumannular activation because the impulse goes back to the atria through the His Bundle and the AV node that is situated in a more superior position than the CS ostium; this means that careful mapping of the lateral side of the ablation line is essential in order to avoid missing the point of the collision front, which is shifted downwards, and therefore to avoid the mistake of regarding as blocked an isthmus that actually is not . Once thAnalysis of double potentials on the line of block can be simplified by the use of RV pacing because retrograde atrial potentials are usually detached from the ventricular potentials and clearly visible, especially the second component. During CS pacing, the second component of the split double potentials is usually very  near  or inside the ventricular electrograms, and in some cases an extrastimulus is needed to block or prolong AV conduction and to better visualize the atrial potentials without the ventricular ones. The mean intervals separating the two components of double potentials were shorter during RV pacing than during CS pacing: as the CS ostium is nearer to the CTI than to the AV node, the first component of the double potentials is rapidly recorded by the distal pole of the ablator when positioned on the line of block, while the second component can be recorded only after activation of the entire TA has been completed. When pacing is carried out from the RV, the impulse goes back to the RA through the AV node, which is located in the septal wall above the CS ostium. Therefore, unlike the case of CS pacing, the first component of the double potentials recorded on the line of block arrives later because it has to descend the interatrial septum, while the second component arrives sooner, because it starts from the higher septum. The delay of the first component and the advance of the second one shorten the interval, as a sort of differential pacing -18 betweThe shortening of the intervals between the double potentials does not interfere with their analysis. On the contrary, the delay of the first component makes it more detached from the ventricular electrograms and more visible; the advance of the second component does not interfere with the analysis of the first one, since the interval is still approximately 100 ms, which is enough to distinguish two potentials separated by an isoelectric line. The detachment from the ventricular electrogram of the second component of the double potentials during RV pacing, lets a more detailed observation of eventual changes in polarity of its initial deflection that were described as a reliable sign of conduction block  during pacing from the opposite side of the line of block ,19 if noDouble electrograms are by themselves not always easy to interpret. According to previous reports, 15% of patients with fractionated electrograms can still have intact CTI conduction on activation mapping, due to Some technical applications are suggested by these observations. If retrograde VA conduction is present, pacing from the proximal CS is not strictly necessary, in that it can be substituted by RV pacing. Catheterization of the CS is often easy, quick and feasible even via the femoral route that is mostly preferred, but when anatomical variants or the presence of a redundant Tebesio valve causes precious time to be wasted, RV catheterization can be a possible rapid alternative procedure, using the same femoral vein approach. A catheter in the CS can also be avoided by properly positioning the distal poles of special catheters in the mid septal RA, but occasionally the stability of this easy set is not acceptable, because of high pacing thresholds or saturation of the atrial electrograms recorded near the pacing catheter  and repoThe first limitation of this technique is obviously the presence of VA conduction; in the normal population, this is estimated to be about 70 % , while iIn patients with intact VA conduction, TA activation during CS and RV pacing is similar before and after the linear RF ablation of CTI. The occurrence of split atrial electrograms separated by an isoelectric interval registered on the line of block can be detected during CS or RV pacing. In patients with retrograde VA conduction, RV pacing is a little trick that may be helpful when CS catheterization via a femoral approach has failed or low septal atrial pacing is unsatisfactory.


Most epidemiological and clinical reports on snake envenoming focus on a single country and describe rural communities as being at greatest risk. Reports linking snakebite vulnerability to socioeconomic status are usually limited to anecdotal statements. The few reports with a global perspective have identified the tropical regions of Asia and Africa as suffering the highest levels of snakebite-induced mortality. Our analysis examined the association between globally available data on snakebite-induced mortality and socioeconomic indicators of poverty.We acquired data on (i) the Human Development Index, (ii) the Per Capita Government Expenditure on Health, (iii) the Percentage Labour Force in Agriculture and (iv) Gross Domestic Product Per Capita from publicly available databases on the 138 countries for which snakebite-induced mortality rates have recently been estimated. The socioeconomic datasets were then plotted against the snakebite-induced mortality estimates (where both datasets were available) and the relationship determined. Each analysis illustrated a strong association between snakebite-induced mortality and poverty.This study, the first of its kind, unequivocally demonstrates that snake envenoming is a disease of the poor. The negative association between snakebite deaths and government expenditure on health confirms that the burden of mortality is highest in those countries least able to deal with the considerable financial cost of snakebite. Every year snake envenoming kills more people in the tropics than some of the world's recognised neglected tropical diseases (NTDs), including schistosomiasis and leishmaniasis. While lacking the epidemic potential of an infectious/vector-borne disease, snake envenoming in rural tropical communities has as great a medical mortality, if not morbidity, as the NTDs. The recent categorisation of snake envenoming as an NTD is an important advance that hopefully will result in the wider recognition and allocation of resources, particularly since death from snake envenoming is preventable; antivenom is very effective when the appropriate antivenom is correctly administered. Snake envenoming urgently requires international support to instigate the epidemiological, health education, and effective treatment initiatives that proved so potent in addressing the medical burden of NTDs such as leprosy and dracunculosis. All the global estimates of snake envenoming and deaths from snakebite indicate that mortality is highest in the world's tropical countries. Here we examined associations between the globally available data on (i) snakebite-induced mortality and (ii) socioeconomic markers of poverty. Our data unequivocally establishes that snake envenoming is globally associated with poverty, a distinctive characteristic of the neglected tropical diseases. Our knowledge of the global medical burden of snakebite is limited to just a few reports based primarily on either hospital records http://www.cdc.gov/epiinfo] to populate the global map of snakebite mortality by country  database [http://apps.who.int/whosis/data/Search.jsp]. These three datasets were selected because of the potential link between snakebite mortality and an individual's high-risk agricultural occupation, income and access to healthcare. The Human Development Index  was also examined and countries categorised into Low (0.1 to 0.499), Medium (0.500 to 0.799) or High (above 0.800) HDI status.To gain a global perspective of the relationship between poverty and lethal snake envenoming, we entered the now readily available country-specific snakebite mortality data [Supplement 2,  country ; this diStatistically linear relationships were found between the logarithm of snakebite mortality and the HDI , the logThe World Bank defined the absolute poverty line as the percentage of a country's population living on an income of less than US$2 per day As with some other NTDs, effective therapy for snake envenoming is available. Antivenom is immunoglobulin purified from the blood of venom-immunised horses and sheep . While conceptually simple, the manufacturing process requires GMP-standard production plants and is reliant upon the husbandry and handling of both horses and venomous snakes. Antivenom is therefore relatively expensive  compared to many other medications used in the tropics. Presumably for this reason, in much of Latin America antivenom manufacture is government-subsidised and antivenom is usually provided free to the patient. This provision and delivery of effective therapy to the at-risk communities may be an important factor in explaining why although snakebite incidence in Latin America is high , the mortality rates are low . Much of Latin America has a high Human Development Index . In contThere are clearly limitations to this kind of analysis: much of the mortality data is estimated and the indicators, although standard, are still only relatively crude indicators. The limitations are indicated by the anomaly of India, with the highest global snakebite mortality rate but medium Human Development Click here for additional data file.


Evaluation of evidence for the effectiveness of implementation strategies aimed at reducing prescriptions for the use of acid suppressive drugs (ASD).A systematic review of intervention studies with a design according to research quality criteria and outcomes related to the effect of reduction of ASD medication retrieved from Medline, Embase and the Cochrane Library. Outcome measures were the strategy of intervention, quality of methodology and results of treatment to differences of ASD prescriptions and costs.The intervention varied from a single passive method to multiple active interactions with GPs. Reports of study quality had shortcomings on subjects of data-analysis. Not all outcomes were calculated but if so rction of prescriptions varied from 8% up to 40% and the cost effectiveness was in some cases negative and in others positive. Few studies demonstrated good effects from the interventions to reduce ASD.Poor quality of some studies is limiting the evidence for effective interventions. Also it is difficult to compare cost-effectiveness between studies. However, RCT studies demonstrate that active interventions are required to reduce ASD volume. Larger multi-intervention studies are necessary to evaluate the most successful intervention instruments. Analysis of the use of dyspeptic medication demonstrate that acid-suppressive drugs (ASD) are prescribed in 10% of the population each year . Three pHowever, many physicians repeat prescriptions without systematic evaluation of symptoms. Consequently Dutch national prevalence data of oesophagitis do not match with the rate of people using ASD, indicating that prescription recommendations are not adequately implemented -9.Many patients with recurrent dyspeptic or reflux complaints also believe they have to use ASD lifelong -13. ReboTraditional strategies of implementation of guidelines, like passive education or economic measurements to optimise particular prescribing management have proven to be ineffective -21. GrolWe performed a systematic literature search from 1995 to 2004 in Medline, Embase and the Cochrane Library which included search parameters of the following subject heading terms: 'dyspepsia', 'guideline', 'medication', 'implementation' and 'costs effectiveness'. Furthermore reference sections in original papers and reviews were screened to find studies otherwise published.Selection of studies was done in two stages. In the first stage studies were screened by titles and abstracts for the description of involvement in an intervention aimed at changing management of dyspepsia. In the second stage the full text of the selected articles was retrieved to proceed the final selection by two criteria. The first inclusion criterion was that studies met criteria for adequate methodology and design. RCT and cohort follow up studies demonstrating quality criteria of evidence  set by Jailwala et al, were considered eligible to be included in the review . The secThe criteria selection for design and outcome assessment in the second stage was performed independently by a second reviewer (NdeW) and disagreement was resolved by consensus. Non-systematic studies that did not evaluate the intervention or did not report outcome measurements were excluded. After a description of the type of intervention of the included studies, from each study the data pertaining to the effectiveness of the intervention were extracted. Outcome figures of prescriptions volume and costs, as well as the expenditures per patient were analysed to compare the differences in effects related to the intervention method.We found 37 articles that met the inclusion criteria, 26 in the search selection and 8 in the reference sections of studies. Of these articles, 16 were marked as review articles and 21 represented original research reports  the number of involved GPs was unknown and outcomes were not reported sequentially and in the multi-centre study (B) was the randomisation procedure unclear ,42,49. NThree of the 10 selected studies did not evaluate cost-effectiveness. One study focused merely on costs. Excluding the evaluation of governments' intervention on population level (unknown numbers of GPs and patients), the studies involved a total of 847 GPs and/or 3512 patients.Intervention methods used in these studies were classified according to three pre-defined strategies. The first category focused on passive intervention without further implementation activities on individual patient or doctors level and enclosed the two cohort studies(I). The first evaluated the follow up of governmental directives . The secThe RCTs were included in the two categories of active single (II) and active multiple (III) interventions. In the first category two studies reported effects of guidelines introduced to the physicians by education and consensus meetings and one study reported effects of a guideline addressed to patients to reduce themselves medication ,48,50. IThe selection process of practitioners and adherence to the intervention were not clearly reported in all RCT studies. The duration of the intervention period as well as the compliance in the groups was not always described systematically. In general RCTs, reported detailed about the intervention strategy.The study on the authorisation program of de government caused a decrease of 80% of all PPI prescriptions . The stuIn the guideline and feedback group GPs held consensus meetings or were given feedback about their prescription policies, but in three of these studies effects on ASD use were not reported ,43,45. IIn general reduction of ASD was not described systematically, but if so studies with multiple active interventions demonstrated better results.From the cohort studies (I) the authorisation program in Canada reported 62% sustained decrease of costs for PPI . The othIn the studies with single intervention method (II) the promotion of the dyspepsia protocol resulted in an increase of 22% ASD costs . The othCalculation of costs in all studies was not done systematically nor uniform. Sometimes percentages of ASD costs were given, sometimes the absolute costs and sometimes none of the two. Some studies reported overall medical costs, including ASD costs. The different costs calculations are therefore difficult to compare in this review.There is no doubt that radical changes can be reached from a governments' intervention, but when doctors receive a passive mailing or recommendations of key players to pay more attention to prescription protocols the effects on the number of prescriptions and costs are disappointing . StudiesIn studies as identified for this review many of the interventions were concerned with eradication of H. pylori, which resulted in small changes of the number of ASD users or prescriptions. Focussing on positive effects of ASD reduction and related costs two of the three single intervention studies (II) demonstrated positive results. Among the four multiple intervention studies (III) three reported a positive cost reducing effect. On average this implies only a modest effect, comparable to the small effects observed in the earlier Cochrane reviews on the effects of changes in professional behaviour -28.There was only one study that particularly intervened on the gradual termination of unnecessary use of ASD . The GPsThe overall conclusion is that the number of high-quality studies on effective interventions for ASD reduction is limited. In addition the incomparable methods applied to calculate prescription rates and costs preclude identification of the most effective intervention strategies. The latter can only be achieved after several studies, including similar outcome measurements evaluating distinct well-defined interventions, have become available.Only a few quantitative studies evaluated with varying success that ASD reduction requires active intervention strategies with practical instrument for the GP. Grol and Grimshaw already showed the performance phenomenon that actual changes in practice depend on helpful attributes and in particular on attributes that will overcome identified barriers against changing behaviour ,18. MoreDoctors need rational arguments to get cooperation from patients. As long as side-effects of long term use of ASD are unknown and rebound effects make patients afraid to stop, to negotiate with patients to reduce medication is not an attractive alternative ,24.From this point of view government's interventions like in Canada, which forces cooperation of patients and doctors by financial incentives, seems attractive, but sustainability is questionable . An alteStudies demonstrate that evidence for effective interventions is limited and cost-effectiveness is often difficult to compare. Larger multi-intervention studies with similar outcome measurements and distinct interventions are needed to evaluate the most successful instruments.The author(s) declare that they have no competing interests.HMS conceived of the study, conducted the analysis and drafted the manuscript. NJdeW participated in the design and analysis and helped to draft the manuscript. AWH helped to draft the manuscript and approved the final concept. They all approved the final manuscript.The pre-publication history for this paper can be accessed here:


The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland.The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data.Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care.The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted in the different cultural backgrounds of the served populations. Previous research on variations in the volume of physician services in geographic areas has emphasized that an additional use of services is not necessarily associated with improved health in the corresponding populations. After cSuch findings may have contributed to a governmental decision to freeze new accreditations for physicians in private practice in Switzerland. This leThe Swiss health system is based on principles of free demand and supply and most services are reimbursed on a fee-for-service system. The system provides comprehensive coverage of high quality services, however, the financial costs rank second (after the US) among OECD countries and are still rising. Swiss health care is characterized by federalist structures and is fragmented into 26 cantonal health systems,5. NatioDue to this highly decentralized governing of Swiss health care, the specific goals of the study include the estimation of spatial variability of availability and utilisation of primary care resources, taking into account demographic, socioeconomic, and cultural attributes of the population.One of the problems associated with an estimation of the regional availability of health care is that patients frequently travel outside their residential areas to seek care, especially those residing in remote and non-urban areas. The formation of meaningful health service areas as a unit of analysis is thus an important issue as it allows the control of demand-induced utilisation phenomena, including medical consumerism. We have defined health care service areas for Swiss primary care based on the complete claims data of compulsory health insurance obtained from the data pool of all Swiss health insurers (santesuisse) and used these areas as the units of analysis. We therefore applied a new and alternative spatial model to describe the utilisation and provision of primary health care in Switzerland. et al.[1018 ambulatory care service areas were created according to Goodman et al. based on et al..Complete frequency data of all consultations reimbursed by the compulsory basic health insurance were obtained from the data pool of all Swiss health insurers (santésuisse) for all Swiss ambulatory care physicians for the year 2004. These data consisted of two files. The first file included a list of all Swiss ambulatory care providers classified into 49 different medical specialties with board certifications according to the Swiss Medical Association (FMH), together with the area codes of the practice locations. For this study, we used only consultations provided by primary care physicians . The second file included consultation frequencies of each physician classified by gender, by 20 age groups, and by community of patient residence. Patients' communities were therefore the smallest observational unit of this study. We used only data from consultations provided for illness and maternity. Accident-related consultations were excluded due to different health insurance coverage.Descriptive analyses included the calculation of means and medians, depending on the distribution of the data. Univariate associations between variables were assessed with Spearman correlation coefficients (rho). Statistical models had to account for the two-level hierarchical structure of the data; i.e. level I data at the level of 2762 community levels and level II data at the level of 1018 service areas; consequently, multilevel models were used[The main outcome variable of these models was the annual per capita consultation rate with a primary care physician for each community in the year 2004. Preliminary analyses indicated a symmetrical and almost normal distribution of this outcome variable. The following explanatory variables were analysed:- Average age of the population- Female-to-male ratio- Language code of the community - Proportion of non-Swiss citizens among the residents in each community- A nine level classification of communities: Urban, suburban, high income, peri-urban, tourist, industrial-tertiary, rural-commuter, agricultural-mixed, agricultural rural. This typology was developed by the Swiss Federal Statistical Office in order to provide a meaningful representation of communal characteristics for demographic and socioeocomic investigations . The cla- Area code of the service area (clustering variable)- Number of primary care physicians per 10'000 inhabitants (GP density)- Number of other, non-primary care physicians per 10'000 inhabitants  in the same service area- Presence of a hospital providing ambulatory services in the same service area .γij, random effects with μij and the redidual error is denoted with rij):Additionally, random effects variables for the intercept, average age, and female-to-male ratio were included in the model. The decision to include these random effects variables was based on preliminary analyses of heterogeneity of intercepts and slopes. The structure of the variance-covariance matrix was specified as unstructured. Other level I variables such as the income distribution within communities and the ratio of > 65 vs. < 20 years of age also were analysed initially. However, based on the extent of the respective variance components and the criteria of model fit, the set of level I variables mentioned above appeared to account for most of the outcome variance and provided the best fit between observed and expected data. A further analysis indicated significant first-order interactions between GP density and language region, between non-Swiss population and language region, and finally between female-to-male ratio and non-Swiss among the resident population. The corresponding interaction terms were thus also included in the model. Consequently, the final model used in this study had the following structure  with 95% confidence intervals (CI95), and the Bonferroni procedure was used to adjust for multiple comparisons. Variance components of level II variables were additionally calculated. VariancThe data obtained from the pool of Swiss health insurers (santésuisse) included the complete records of the 21'413'299 consultations of all 6564 Swiss primary care physicians with patients throughout Switzerland that were reimbursed by compulsory health insurance in 2004. These primary care data accounted for 39.5% of all ambulatory care physicians  and 56.5% of all ambulatory consultations reimbursed by basic health insurance . The geographic distribution of physicians and patient consultations across different community types is given in Table Ambulatory care service areas were constructed from community codes of physicians and patients,11 withoThe statistical procedures yielded significant effects for all main explanatory variables except for the proportion of non-Swiss citizens Table . The modPair-wise comparisons of means indicated multiple significant differences between language regions. Only the consultation frequencies for German and Italian vs. Romansh were not significantly different. Least square means indicated furthermore that agricultural/rural and high-income communities had the lowest and industrial/tertiary communities had the highest frequencies Table . All othSignificant first-order interaction terms indicated that the effects of GP density and the proportion of non-Swiss citizens were not constant across language regions. Therefore, additional specific analyses stratified by language Tables  and 4 weThe proportion of non-Swiss citizens appeared, in terms of effect size, to be the most important factor among continuous variables at the community-level for the Swiss German population Table . This imVariance component analyses showed that service areas account for 39.4% of the total variance of GP-consultations and imply considerable clustering of consultation rates within areas Table . VariancThere are several theoretical models in health systems research that are used to explain the availability and utilisation of health related resources -14. MostSwiss health care is characterised by a high degree of decentralisation with strong regional and cantonal influence and highThe analysis of per capita consultation rates across language regions confirms well known cultural differences in Switzerland that extend beyond health care ; but theAdditional research aimed at these topics is thus needed to investigate the distribution of population-based consultation patterns across language regions, community types, medical specialties, and the corresponding implications on cost for ambulatory care. Presently, we also see strong political pressure to implement managed care, e.g., by establishing physician networks based on gate-keeping. Our results may therefore help guide future developments by setting population-based and regional priorities.The data provide estimates of the importance of socio-demographic factors relevant for the utilisation of primary care resources in Switzerland. Effects of age and gender confirm well known phenomena in this context. However, particularly in the Swiss German population, the effect of non-Swiss residents far exceeds corresponding effects of other socio-demographic and supply-related factors. These results thus confirm other research in this field, showing a heterogeneity of emigrants across Swiss language regions in terms of gender, ethnical background, migration history and legal status of residency ,20. PossOur data provide evidence that the number of physicians accredited in a specific region is an important determinant for the utilisation of Swiss primary care resources. However, the associated effects are not consistent across Swiss language regions and show an inverse relationship between primary care providers and specialist care. The findings not only imply considerable competition for patients between specialists and primary care physicians in the Swiss German regions, but also indicate that the utilisation of primary care resources in these regions is obviously more supplier-driven than in other regions. In contrast, effects of hospital-based supply of ambulatory services remain constant across language regions and indicate consistent patterns of competition: the presence of ambulatory hospitals reduces GP consultations by 0.18 per year and inhabitant.The question remains, therefore, what are the major driving forces for these findings? Is it supplier-induced demand, clinical uncertainty, or patient needs; and what are the roles of the 'zero risk society' or of medical consumerism?  The lengThe results were derived from the claims database of all Swiss health insurers and provide complete coverage of all ambulatory or outpatient services reimbursed by compulsory Swiss social health insurance in 2004. The spatial model used in this study yielded service areas in which, on average, 57% of the population used local health resources, and/or physicians treated local patients in 61% of all consultations. We therefore consider this approach an appropriate spatial representation of utilisation and provision of primary care in Switzerland. It can be debated, however, whether a proportion of 36.4% of explained variance of the outcome is enough to draw relevant conclusions about the effect of physician density and socioeconomic determinants on per capita consultation rates. Our model was based on a set of only nine explanatory variables and on an outcome with known high random error. We consider it unlikely, given the type and extent of data available, that the results are biased due to measurement error. Furthermore, the explanatory variables were derived from aggregated data at the community and service area levels, and not from individuals – the interpretation of the results is thus limited to these two distinct levels of aggregation and cannot be extended for individual patients or physicians. Given these factors, we believe the achieved amount of explained variance merits publication of the data. Furthermore, the distinct multi-cultural population mix in Switzerland offers excellent conditions for studying health care use across different cultures. A potentially significant imitation in interpreting our data on resource use and volume in Swiss primary care is related to the fact that the referral data are still incomplete. A further limitation derives from the fact that the activity levels of the physicians were not accounted for in the analysis, i.e., full-time and part-time physicians were equally weighted. Other limitations attach to the cross-sectional nature of the study, since service areas are not stable constructs over time because the availability and utilisation of resources may change rapidly. The methods applied in this work are not perfect, but they may be helpful in describing, understanding, and managing the underlying processes.Our study confirms other reports documenting large small-area variations in the utilisation and provision of health care resources in the multicultural population of Switzerland ,23. In cThe author(s) declare that they have no competing interests.AB obtained the mandate to perform the study, he performed all statistical analyses and wrote the first draft of the manuscript, BK reviewed and completed the manuscript with reference to all aspects of primary care.The pre-publication history for this paper can be accessed here:


Blood pressure lowering drugs are usually evaluated in short term trials determining the absolute blood pressure reduction during trough and the duration of the antihypertensive effect after single or multiple dosing. A lack of persistence with treatment has however been shown to be linked to a worse cardiovascular prognosis. This review explores the blood pressure reduction and persistence with treatment of antihypertensive drugs and the cost consequences of poor persistence with pharmaceutical interventions in arterial hypertension.We have searched the literature for data on blood pressure lowering effects of different antihypertensive drug classes and agents, on persistence with treatment, and on related costs. Persistence was measured as patients' medication possession rate. Results are presented in the form of a systematic review.Angiotensin II receptor blocker (ARBs) have a competitive blood pressure lowering efficacy compared with ACE-inhibitors (ACEi) and calcium channel blockers (CCBs), beta-blockers (BBs) and diuretics. 8 studies describing the persistence with treatment were identified. Patients were more persistent on ARBs than on ACEi and CCBs, BBs and diuretics. Thus the product of blood pressure lowering and persistence was higher on ARBs than on any other drug class. Although the price per tablet of more recently developed drugs  is higher than that of older ones (diuretics and BBs), the newer drugs result in a more favourable cost to effect ratio when direct drug costs and indirect costs are also considered.To evaluate drugs for the treatment of hypertension several key variables including the blood pressure lowering effect, side effects, compliance/persistence with treatment, as well as drug costs and direct and indirect costs of medical care have to be considered. ARBs, while nominally more expensive when drug costs are considered only, provide substantial cost savings and may prevent cardiovascular morbidity and mortality based on the more complete antihypertensive coverage. This makes ARBs an attractive choice for long term treatment of hypertension. Blood pressure lowering drugs are approved based on short term trials determining the absolute blood pressure reduction during trough and the duration of the antihypertensive effect after single or multiple dosing. The absolute amount of blood pressure reduction in mmHg over the short term can however not be extrapolated to the degree of protection against hypertensive end organ damage because low patient's compliance and poor persistence with treatment may lead to early discontinuation of treatment in clinical practice -3.To be effective treatment must continue, sometimes for a patient's life, despite an absence of symptoms or any perceived benefit to the patient -6. UnforTherefore this review explores the cost consequences of poor persistence with pharmaceutical interventions in arterial hypertension. The aim is 1) evaluating the antihypertensive effects of drugs, 2) reviewing persistence with different pharmacotherapies and 3) exploring the related expenditure, such as drug costs, overall healthcare expenditure and productivity costs, and investigating the effect it has on the cost-effectiveness of pharmaceutical interventions for hypertension.In this review, the definitions of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) were used, which define compliance as taking medication as prescribed, on time and at the correct dose, and persistence as the continuing use in time of the prescribed therapy . DefinedWe have identified studies describing compliance/persistence with treatment using different antihypertensive classes and their related costs. The following search term was entered into pubmed: "hypertens* AND (complia* OR adhere* OR persiste*) AND (cost* OR econo*)" with the limits: "Publication Date from 1995/01/01, Humans, English." A manual search of the reference lists from retrieved publications was also performed to identify further relevant studies.Studies were regarded relevant if they were in English language, involved human studies published before November 2008, involved patients with hypertension, examined compliance (adherence) and/or persistence to pharmaceutical interventions (even if the primary objective was not to measure compliance/persistence), provided an economic evaluation or cost analysis and quantified the cost consequences of compliance/persistence. Studies published before 1995 were excluded as results from those earlier studies could not be compared with those from more recent studies because of changes in treatment patterns, study methodology and the price of healthcare resources, including drug prices. Studies were also excluded from analysis if the economic consequence of compliance/persistence was not quantified.Qualitative data extracted from the studies included the country where the study was performed, the number of patients, the database used, the type of study , the duration of follow-up, definitions used for persistence, compliance, switching and discontinuation as well as the type of patients with mean age, gender and drugs at the onset of the study  or ARBs  was analysed for example for the degree of blood pressure reduction -14. At o,651 pts Table Bloom et al. .,42.WithiThe majority of patients with hypertension receive combination antihypertensive therapy. Current guidelines of the ESH/ESC recommend combination treatment for patients uncontrolled on monotherapy or in patients with blood pressure values on presentation exceeding 20/10 above the respective patient target . Fixed-dTo evaluate drugs for the treatment of hypertension several key variables have to be considered. These variables include the blood pressure lowering effect, side effects, compliance and persistence with treatment, as well as drug costs and direct and indirect costs of medical healthcare. Given that the highest persistence with treatment results in the lowest non-drug costs, substantial cost savings and a reduction of morbidity might be expected making these drugs an attractive choice for long term treatment of hypertension.All authors have attended advisory boards and have held lectures for a number of pharmaceutical companies including sanofi-aventis and BMS.All authors have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. PB has drafted the manuscript. JH revised the manuscript for important intellectual content. All authors have given final approval of the version to be published.


According to the International Association for the Study of Pain criteria of 1994, pain is a diagnostic requirement for Complex Regional Pain Syndrome type I. However, other authors have suggested that patients can rarely present with the sensory and vascular symptoms of Complex Regional Pain Syndrome without pain. This entity has not been reported following hip surgery in the English medical literature.We present two cases of Complex Regional Pain Syndrome-like symptoms following hip surgery and with the total absence of pain. The first case was a 29-year-old Caucasian woman who had a reattachment of the greater trochanter following non-union of an intertrochanteric osteotomy of the hip. Five weeks later, the patient presented with features of Complex Regional Pain Syndrome but with the absence of pain. The second patient was a 20-year-old Caucasian woman who had undergone an open debridement and repair of a torn acetabular labrum. Ten days later, the patient presented with features suggestive of Complex Regional Pain Syndrome which was again painless. Both patients were non-weight bearing at presentation and the symptoms resolved following recommencement of weight bearing.The authors believe these symptoms are manifestations of vascular changes to the lower limb as a result of non-weight bearing status. Painless Complex Regional Pain Syndrome-like symptoms may occur in patients who are kept non-weight bearing following hip surgery. However, vascular insufficiency and deep venous thrombosis must be excluded before this diagnosis is made. If the clinical situation permits, early weight bearing may relieve symptoms. Orthopaedic and vascular surgeons should be aware of this entity when a postoperative patient presents to them with the above clinical picture. This is also relevant to general practitioners who are likely to see the patients in the postoperative period. Pain out of proportion to the injury is an essential criterion for the diagnosis of Complex Regional Pain Syndrome (CRPS) type I -3]. We . We 3]. A 29-year-old Caucasian woman had a varus intertrochanteric osteotomy with trochanteric advancement for an old malunited femoral neck fracture. The femoral neck fracture was sustained in a childhood injury and was treated conservatively. The patient underwent reattachment of the greater trochanter for a failed trochanteric fixation approximately 4 weeks after her initial operation. She was discharged 2 days after the second procedure. Approximately 5 weeks later, the general practitioner referred her to the vascular surgeons with painless discolouration of the right leg. Clinical examination revealed a discoloured right foot associated with mild swelling and several small blisters on her toes. The most prominent feature was that the right foot exhibited bluish discolouration which evidently subsided to near-normal colour on elevation Figure . The femHandheld Doppler examination demonstrated a relative decrease in the audible quality of the biphasic pulse when compared to the normal side. Duplex scan of the right lower limb excluded the possibility of any superficial or deep venous thrombosis. The patient was commenced on 50% weight bearing status and was discharged home. A recent follow-up demonstrated significant improvement in symptoms since commencement of weight bearing status.A 20-year-old Caucasian woman who presented with symptoms of right hip impingement underwent open debridement and repair of a torn acetabular labrum. The patient was discharged on the 5th postoperative day following an uneventful recovery period. She was to remain non-weight bearing for 6 weeks. Ten days following discharge, she presented to the clinic complaining of her right foot going blue and cold and with the complete absence of pain. The discolouration occurred when the limb was in a dependent position. Clinically, all peripheral pulses were present and normal. The patient was reviewed by a vascular surgeon who excluded the possibility of arterial insufficiency and deep venous thrombosis.The patient was discharged with the advice to commence on weight bearing of the operated hip. In the follow-up clinic 5 months later, she was found to have complete resolution of her vascular symptoms.According to the International Association for the Study of Pain (IASP) criteria of 1994, pain, evidence of change in blood flow or abnormal sudomotor activity and the absence of conditions that would otherwise account for symptoms are essential diagnostic entities of Complex Regional Pain Syndrome type I. Eisenberg and Melamed [et al. reported a series of 829 patients with reflex sympathetic dystrophy (RSD) and among them, 7% of the patients did not have pain as a symptom [Veldman  symptom . AlthougThe authors of this article postulate that in the hip, CRPS-like symptoms develop following a period of non-weight bearing. In both of our patients, the symptoms occurred during non-weight bearing and subsided after weight bearing was commenced. Unilateral lower limb suspension experiments in normal patients have shown an increase in flow mediated dilatation of arteries of the lower limb along with a decrease in venous capacitance . This mePainless Complex Regional Pain Syndrome-like symptoms may occur in patients who are kept non-weight bearing following hip surgery. However, vascular insufficiency and deep venous thrombosis must be excluded before this diagnosis is made. If the clinical situation permits, early weight bearing may relieve symptoms.Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors declare that they have no competing interests.JGA postulated the concept and designed the study, interpreted the data and revised the final manuscript. AJSK identified and re-examined the cases, acquired the data and analysed it, reviewed the literature and wrote the article. SKSW also re-examined the cases for the study, assisted in data acquisition, analysed the data and assisted in writing up the article.


Smoking Cessation by General Practitioners).We developed an instrument assessing the extent of smoking cessation activities by general practitioners (GPs) within the Cologne Smoking Study (CoSmoS). The objective of the present study was to examine further psychometric quality of the "SmoCess-GP" instrument (127 current smokers who had participated in the Cologne Smoking Study (CoSmoS) were included in our analyses. Confirmatory factor analysis (CFA) was conducted to examine the model fit and to retest the single-factor structure of the instrument using the Mplus software. Further construct validity was tested with bivariate analysis using an instrument which measures patients' trust in physicians.2df = 6 = 4.63 (p = 0.59). Analysis of discriminant validity resulted in a non-significiant correlation of r = 0.092 (p = 0.350).CFA supported the unidimensional structure of the instrument. The factor loadings exceed the threshold of ≥ 0.50. All indicator reliabilities were higher than 0.30. The composite reliability was 0.86 and the average variance extracted (AVE) resulted in a value of 0.50. The calculation of global fit indices identified a CFI value of 1.00 and for TLI a value of 1.02. The root mean square error of approximation (RMSEA) indicates that 0% of the information is not accounted for by the model. The chi-square value was χResults indicate preliminary evidence for the construct validity of the "SmoCess-GP" instrument which therefore appears to be a promising tool for analyzing the extent of smoking cessation advice offered by GPs from the patients' perspective. Future research should examine the psychometric properties in a population based sample, further improvements of the instrument and should apply other methods of validation. In developed countries, smoking remains one of the most significant and preventable risk factors for cardiovascular and lung diseases. In Germany, in particular, approximately 37% of men and 28% of women smoke every day or on occasion . SimilarGeneral practitioners (GPs) play a major role in the secondary prevention of smoking . Acting According to German law, an important task of health care professionals - especially of GPs - is preventive care . GPs shoAlthough special treatments for smoking cessation have increased in recent years  and the Cologne Smoking Study (CoSmoS). The present study evaluates the unidimensional structure of the "SmoCess-GP"  instrument which could be found in a previous study [In Germany in particular, however, there is a lack of data concerning the extent and effectiveness of GPs' smoking cessation activities. According to Pfaff et al. , such daus study  and to eThe "SmoCess-GP" instrument was carefully developed within the context of the CoSmoS study, a case-control study that examines which genetic and/or psychosocial factors lead to a higher risk for smokers to suffer from myocardial infarction, develop lung cancer and/or become addicted to nicotine.In order to ensure content validity, internal consistency and the assessment of practice-relevant dimensions, the "SmoCess-GP" instrument was developed based on recognized international and German guidelines for the professional treatment of smoking dependence ,21,22. BAn initial psychometric evaluation of the instrument was conducted using exploratory factor and reliability analysis as discussed in a previous study . In summWith regard to construct validity, especially in order to examine convergent validity, within the context of CoSmoS it was not possible to integrate another, similar instrument for assessing smoking cessation activities by physicians. Therefore, as an example, the Health Plan Employer Data and Information Set (HEDIS) measure "Medical Assistance with Smoking Cessation"  would haThe subjects of the present study were patients who had participated in the Cologne Smoking Study (CoSmoS) and who had been randomly recruited at the University Hospital Cologne.The study was approved by the Ethics Committee of the University Hospital of Cologne (UHC). Patients were included in the study after signing an informed consent form. The participating patients suffered from either myocardial infarction or lung cancer or from neither of these conditions (control group). All patients smoked daily or on occasion up until the time of data collection. In face-to-face interviews, the participants were asked, in particular, about their smoking habits and the smoking cessation counseling provided by their GPs.The sample was then reduced by excluding nine patients who stated that they had not consulted a general practitioner. This resulted in a total sample size of 127 currently smoking patients. The response "I don't know" was treated as a missing value.The socio-demographic and illness-specific characteristics of our sample are presented in Table The Statistical Package for Social Science (SPSS) Version 17.0 was used to compute the descriptive statistics and to obtain both the frequency and percentage distributions. The percentage of missing values for each item did not exceed 2.5%. In order to avoid biases, missing data were imputed using the NORM software, which uses the expectation-maximization (EM) algorithm to replace missing values .2 algorithm were applied using Mplus Version 4.2 [Confirmatory factor analysis (CFA) was conducted to determine whether the instrument measures a unidimensional construct as intended. Due to the non-normal distribution resulting from dichotomous items, the analysis was conducted using tetrachoric correlations . In addision 4.2 .CFA assumes that each manifest variable is a distinct indicator of an underlying latent construct. A CFA model is evaluated using measures of global and local fit. Such measures indicate whether the proposed model adequately reproduces the empirical correlations among the manifest variables .For several of the recommended global fit measures, certain criteria must be met in order to accept the model as being plausible and parsimonious. Measures of absolute fit, such as the root mean square error of approximation (RMSEA), can be interpreted as the amount of information within the empirical covariance matrix that cannot be explained by the proposed model. The model may be classified as acceptable if only 8% or less of the information is not accounted for by the model (RMSEA < 0.08). Other goodness-of-fit indicators, including the comparative fit index (CFI) and the Tucker-Lewis index (TLI), were also examined. Hair et al.  suggest The process of psychometric evaluation also involves testing the reliability of measurement and assessing the quality of the individual items, both of which are evaluated using component fit results  from the confirmatory factor analysis. Measures of local fit evaluate whether each construct can be reliably estimated from its indicators . The facIn addition to CFA, we tried to examine construct validity with further analysis. In the context of the present study it was possible to test the discriminant validity of the "SmoCess-GP" instrument as one form of construct validation . TherefoThe SPSS Version 17.0 for Windows software was used to conduct the analysis for construct validity.The descriptive statistics for each item of the "SmoCess-GP" instrument is shown in Table In addition, the descriptive findings of the "trust in physicians_short form" scale, which is used for examining the discriminant validity of the "SmoCess-GP" measure, are presented in Table 2df = 6 = 4.63 and a nonsignificant p-value of 0.59, a very good model fit was obtained [CFA of the "SmoCess-GP" measure found that the same unidimensional structure of the six items was replicated as in the exploratory factor analysis in our pilot study . To quanobtained . The modExamination of the factor loadings reveals that all six items have significant loadings on the construct in the model and exceed the threshold of ≥ 0.50 as recommended  for assessing the extent of smoking cessation interventions provided by GPs as seen from the patients' perspective. The present study evaluated the psychometric quality of the "SmoCess-GP" measure using confirmatory factor analysis (CFA) in order to analyze its unidimensional structure. The analysis indicated a very good model fit. Both the resulting chi-square value with a non-significant p-value as well as the CFI, TLI and RMSEA values provide evidence of an adequate global data fit. The local fit indices support the explicitness of the "SmoCess-GP" instrument, and the indicator reliabilities prove that the items reliably measure the construct. Acceptable factor loading values, composite reliability and the average variance extracted confirm the quality and reliability of the measure and its items. As confirmed by all of the goodness-of-fit indices, it was possible to replicate the unidimensionality of the instrument.In terms of discriminant validity, the results of the bivariate analysis confirmed the initial hypothesis that there is only a weak relationship between the patients' trust in their GPs and the provision of smoking cessation counseling by them.Our findings can therefore be seen as preliminary indicators of the construct validity of the "SmoCess-GP" instrument which has to be further evaluated using other forms and methods of validation.The descriptive findings - in specific, the mean sum score - of the "SmoCess-GP" instrument indicate a lack of preventive care in German general practices because not every smoking patient in our sample received anti-smoking advice from their GPs and because several different concrete intervention options were seldom offered. However, these results are not unique to Germany. Other international studies have reported similar findings ,15-18, aSeveral limitations of the present study have to be mentioned. First of all, given the retrospective design of the study and the hospital setting, there may be a bias caused by distortions in the patients' memory. Although participants were asked to think of their general practitioner when responding to statements, it is not known exactly which physician and which consultation experiences the patients were actually remembering when being surveyed. Furthermore, in view of the findings of Houston et al. , which iSecond, the face-to-face interview method may also have been a source of bias. An interviewer and other patients in the hospital room may have prompted participants to provide false or socially desirable responses. Third, the convergent validity of the "SmoCess-GP" instrument could not be tested against similar measures because a comparable instrument had not been integrated in the CoSmoS questionnaire.The generalizability of our findings is limited because the sample was inpatient and thus no conclusions for the population can be drawn.Future research should evaluate the instrument psychometrically in prospective studies with a population-based sample. In addition, the convergent validity should be tested with similar smoking cessation intervention measures like for example the Health Plan Employer Data and Information Set (HEDIS) measure "Medical Assistance with Smoking Cessation" . Also coFollowing the practice guideline of the U.S. Department of Health and Human Service, smoking cessation interventions should be adapted to the smoker's stage of readiness . TherefoIn the present study, we did not ask about how often the smoking cessation counseling was provided. This could be of interest in this context and should be considered in further development of the instrument.Our aim was to develop a measure, which describes and evaluates the smoking cessation interventions in general practice. Despite the study's limitations and requirements of valuable improvements of the instrument, the findings indicate reasonable results in terms of the preliminary validity and reliability of the new "SmoCess-GP" instrument. As a patient-reported measure, it provides researchers and GPs an instrument that makes it possible to analyze the extent of smoking cessation interventions in general practices.Although the GP plays a major role in preventive care, the change of unhealthy behavior is often considered to be a matter of personal choice . DespiteThe theoretical and empirical basis of the "SmoCess-GP" measure  provideGP: general practitioner; SmoCess: smoking cessation; CoSmoS: Cologne Smoking Study; CFA: confirmatory factor analysis; RMSEA: root mean square error of approximation; CFI: comparative fit index; TLI: Tucker-Lewis index; AVE: average variance extracted; M: mean; Mdn: median; SD: standard deviation; Min: minimum; Max: maximum; OR: odds ratio.The authors indicated no potential conflict of interest.We confirm all patient/personal identifiers have been removed or disguised so that the patient/person(s) described are not identifiable and cannot be identified through the details of the story.JJ conducted data collection and analysis, and wrote the first draft of the manuscript. MN contributed to study design, editorial review and data analysis. NE contributed to study design and editorial review. MW contributed to data analysis, technical, including statistical and editorial review. ASJ and JW contributed to study design and editorial review. HP contributed to study design and editorial review. All authors read and approved the final manuscript.The corresponding authors take full responsibility for the content of the paper.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/11/9/prepub