The present study examines the structure and operation of social networks of information and advice and their role in making decisions as to whether to adopt new evidence-based practices (EBPs) among agency directors and other program professionals in 12 California counties participating in a large randomized controlled trial.Interviews were conducted with 38 directors, assistant directors, and program managers of county probation, mental health, and child welfare departments. Grounded-theory analytic methods were used to identify themes related to EBP adoption and network influences. A web-based survey collected additional quantitative information on members of information and advice networks of study participants. A mixed-methods approach to data analysis was used to create a sociometric data set (n = 176) for examination of associations between advice seeking and network structure.Systems leaders develop and maintain networks of information and advice based on roles, responsibility, geography, and friendship ties. Networks expose leaders to information about EBPs and opportunities to adopt EBPs; they also influence decisions to adopt EBPs. Individuals in counties at the same stage of implementation accounted for 83% of all network ties. Networks in counties that decided not to implement a specific EBP had no extra-county ties. Implementation of EBPs at the two-year follow-up was associated with the size of county, urban versus rural counties, and in-degree centrality. Collaboration was viewed as critical to implementing EBPs, especially in small, rural counties where agencies have limited resources on their own.Successful implementation of EBPs requires consideration and utilization of existing social networks of high-status systems leaders that often cut across service organizations and their geographic jurisdictions.NCT00880126 Each year, about 6% of U.S. children and adolescents receive some form of mental health care at an annual cost of more than $11 billion -5, 90% oe.g., data collection, evaluation, and feedback). Studies and meta-analyses have also shown that both the influence of trusted others in one's personal network and having access and exposure to external information are important influences on rates of adoption of innovative practices . In cas, . As autCharacteristics of study participants are described in Table e.g., directors, program managers), responsibility , geography , and friendship ties . These networks expose leaders to information about EBPs and opportunities to adopt EBPs and influence decisions to adopt EBPs. This information comes from others within the same county, including supervisors or employees within the same agency, counterparts in other agencies, community-based providers, and community advocates.Analysis of interview transcripts revealed that systems leaders develop and maintain networks of information and advice according to position in agency , outside agencies, community-based organizations, and community advocacy organizations. Network members located outside the county included professional organizations like the California Parole Officers Association, the Child Welfare Directors Association, and the California Mental Health Directors Association; intermediaries like the California Institute of Mental Health (CIMH); nonprofit foundations like the Annie E. Casey Foundation and Casey Family Programs; universities; and consultants. Peers from other counties were also an important source of information and advice; however, this occurred more in small rural counties than in large urban counties.Among the forums for the exchange of information and advice about EBPs are regularly scheduled meetings within the county, region, and state; initiatives that involve contact of systems leaders by CIMH; agency staff; and other county agencies and community-based organizations. One director specifically cited a monthly statewide gathering as a particularly useful venue for gathering information on EBPs:"I go monthly to the Children's System of Care meeting in Sacramento. And that's where other people in similar administrative positions to myself who are responsible for children's mental health services, we chew on these kinds of things. We discuss these kinds of things. And, you know, we have presentations, and so forth. So that is my peer group. And that, um, certainly provides a lot of information to me in making decisions."--Mental Health Department DirectorSystems leaders also obtain information and advice on EBPs from counterparts in counties widely regarded for serving as "models" for innovation and EBP implementation, as one agency director noted when asked who she looks to outside her own county:"There's a...always [our practice of] checking with Orange County, LA, [when considering adopting a new program]. Although quite big, they do some very progressive things as well. Um, and so you know which counties are kind of doing some leading edge, and, not just leading edge, but that also have uh, the evaluation component of it."--Chief Probation OfficerParticipants described a wide range of advice seeking in qualitative interviews, which included both whether to implement an EBP (MTFC in particular) or a new, innovative program in their county and how to best implement such a program. Social-network survey-based ties between respondents included both types of advice seeking. While some participants in the qualitative interviews simply provided a name of someone who they had contacted about an EBP (or other program), others provided a more elaborate description of the advice-seeking interaction. For example, several participants discussed advice seeking in relation to the cost and feasibility of implementing a particular program; this included instances of where they had decided not to implement a specific program because they had been informed by their counterparts in other counties or directors of community-based organizations within their own county that the cost of implementation would be prohibitive. Others discussed advice seeking related to approaching appropriate community partners for collaboration.Representations of the influence networks for exchanging information related to EBPs in general are found in Figure Table The principle of homophily was well supported for both county and implementation stage among members of the original sample. On average, 81% of network ties were among individuals who came from the same county, and 83% of network ties were among individuals who were classified in the same implementation stage as the respondent. Interestingly, only 38% of network ties were among individuals who came from the same county agency as the respondent. Taken together, these results indicate that individuals often rely on others from within their own county for advice on EBPs, although not necessarily individuals from within their agency, and from individuals outside their county. This latter observation was supported by the fact that seven counties had links to one individual who works for the CIMH and is known throughout the state as someone on whom agency directors can rely for information about EBPs.Implementation stage was also associated with position in the overall advice network. The multivariate regression model presented in Table In addition to identifying the potential predictors of implementation stage and supplementing the construction of the social networks, the qualitative analysis of the semistructured interviews identified features of these networks that were critical to the process of EBP implementation. Perhaps the most salient of these features was the role of collaboration within and between counties. Within counties, single agencies often lacked resources to implement EBPs independently and noted that implementation requires good systems partners. In small, rural counties where agencies have limited resources to implement EBPs on their own, agency directors cited a desire to participate in the Cal-40 Study in clusters with neighboring counties.Poor history of collaboration was often cited as a reason for failure to implement EBPs. The reasons for the lack of collaboration identified by study participants included the following: lack of funding to support a collaboration, different priorities and mandates of the collaborating agencies, different organizational cultures of the collaborating agencies and the lack of understanding of these cultures, and differences in personality and the strained relationships caused by these differences.Finally, criteria for effective collaborations among agencies in public youth-serving agencies included individuals who can play key roles in the collaborative process, especially agency directors and administrators with knowledge or experience working for another agency who can serve as a collaboration broker or facilitator. For example, one participant cited her varied experience working for multiple agencies as beneficial to understanding complex system interactions, stating, "I fortunately have had the experience of being a probation officer, a social service worker, and a mental health clinician" .These information and advice networks appear to have played an important role in the implementation of MTFC among the first cohort of counties participating in the Cal-40 Study. For those who had agreed to participate or were considering participation at the time they were interviewed, information about MTFC and the Cal-40 Study was obtained from presentations given by CIMH representatives at state or regional meetings, direct contact by CIMH with county agency directors, direct contact by other agency directors within the county, or staff within the agency:It came to my attention two different ways. I started hearing some discussion about it at the small county association meetings, which is a break off of the full body county Mental Health Directors Association. And I heard it from one or two of my peers... Then, the newest program manager brought it to my attention. And I think she found it on the CIMH website..."--Mental Health Program Director"Only one of the seven systems leaders interviewed from the three counties that had either decided not to participate in the Cal-40 Study or had not advanced beyond stage 1 had received any information about MTFC or the Cal-40 Study.The results of this study suggest that the structure and operation of social networks--specifically, higher in-degree centrality of network members, as well as network context, reflected in the size of county and whether it was predominately urban or rural--are central to implementation of EBPs. Further, social networks influence the implementation process through two mechanisms, development and operation of successful collaborations and acquisition of information and support related to EBPs. Although many factors influence the diffusion of EBPs, researchers have consistently found that interpersonal contacts within and between organizations and communities are important influences on the adoption of new behaviors ,8,33-36.In this study, the majority of network ties occurred within the same county and same implementation stage. This is understandable given that both randomization and use of the SIC measurement in the Cal-40 Study occurred at the county level . HoweverThe results of this study also help us to understand the context in which these networks influence the implementation of EBPs and how differences in context, like the size of a county or the structure of personal networks, can influence whether or not EBPs are adopted by public youth-serving agencies. Our results suggest that characteristics of the county and in-degree centrality are associated with EBP implementation stage. Characteristics of the county include its size and urban/rural status. In our sample, larger, urban counties were classified in a higher implementation stage than their smaller, rural counterparts. A similar association between county size and days to consent to participate in the Cal-40 Study in all three California cohorts was reported by Wang and colleagues . AnalysiHowever, we also found that MTFC implementation stage at the two-year follow-up was associated with position in the overall advice networks at baseline. Higher-status individuals, measured by in-degree centrality, were more likely to work in counties that achieved a higher stage of implementation two years later. These individuals were nominated by others as a source of information and advice about EBPs and innovative programs in general. The central position of these individuals in influence networks makes sense since systems leaders would be inclined to seek information and advice from someone who had experience and was successful in implementing such practices. These findings are also consistent with Valente and colleagues' findings of the association between the presence of opinion leaders in one's social networks and rates of adoption of innovative practices -16.Not all opinion leaders need have a high degree of centrality; in some cases, opinion leaders are persons who bridge different social networks, and their position as a bridging tie facilitates their success in bringing new practices from one network to another . There aOur study results also provide an indication of how influence networks operate to implement EBPs. The semistructured interviews provided numerous instances of exchange of information within agencies, within counties, and across counties. This exchange usually occurred through regularly scheduled meetings or conferences, through a search for information concerning the EBP by the systems leader, or through dissemination efforts of intermediary organizations like CIMH. Influence networks also operate to implement EBPs by sharing resources, which include funding, staffing, or consumers. This sharing is easier in large counties because agencies in these counties possess more resources than similar agencies in small counties. However, the existence of subgroups or cliques may preclude sharing due to competition for the same resources. In smaller, rural counties, on the other hand, resources are often shared between agencies in the same counties or with agencies in neighboring counties because the individual agency frequently lacks the capital, staffing, or consumer demand necessary to initiate or sustain implementation efforts.Implementation was also associated with greater connectivity across counties. Counties who declined to participate or did not advance beyond stage 1 had no ties or links outside the county. In contrast, counties that had achieved stage 6 or higher were all linked to CIMH, a primary source of information on EBPs in the state. Most of the network links to CIMH were with county mental health agency leaders, which is understandable given the involvement of CIMH in regularly scheduled meetings of the California Mental Health Directors Association and with county Chief Probation Officers, which can also be explained by the fact that the key CIMH "node" was a former county chief probation officer.One of the conclusions to be drawn from this research is that implementation strategies should be designed to either build influence networks or capitalize on existing networks. The CDT approach being tested in the parent study is designed to build social networks that offer support to network members in implementing EBPs. Other strategies with a similar aim include the Institute for Healthcare Innovation's Breakthrough Series collaborative . DissemiThere are several limitations to our study that deserve mention. First, this investigation was conducted during the initial or first steps of EBP implementation with a small number of counties. Although our findings suggest that there will be changes in patterns and processes of implementation over time, we were primarily interested in examining networks at the initial stages of the implementation process and then determining whether these "baseline" networks could predict the implementation trajectory over a two-year period. Second, systems leaders who participated in interviews at this stage of the Cal-40 Study represent almost all of the first cohort but may not represent the broader population of systems leaders participating in other cohorts, much less the broader population of systems leaders engaged in child and adolescent mental health services. Thus, the results obtained thus far may not generalize to either population, although cohort 1 counties were selected through a process of randomization and thus should be representative of all 40 counties participating in the parent study. Third, the 176-member network was constructed based on information from 38 interviewees who were not asked to provide information on sociodemographic and occupational characteristics on those they nominated. Consequently, we lacked individual-level measures on some of the nodes who were not directly interviewed, thereby limiting our statistical power to examine the influence of such characteristics as predictors of network structure or implementation stage. Finally, both collection and interpretation of qualitative data is susceptible to subjective bias and preconceived ideas of the investigators. However, the use of multiple observers as well as multiple sources of data to achieve "triangulation"  should mDespite these limitations, the results of this study suggest that social networking is central to implementation of EBPs through two mechanisms: development and operation of successful collaborations and acquisition of information and support related to EBPs. The most influential networks appear to be those that extend beyond service-system jurisdictions. This study helps us to understand the context in which these networks influence EBP implementation and how differences in context of personal networks can influence whether or not EBPs are adopted by public youth-serving agencies. It also helps to inform the design of implementation strategies that either build influence networks or capitalize on existing networks.PC is a partner in Treatment Foster Care Consultants, Inc., a company that provides consultation to systems and agencies wishing to implement MTFC. All other authors declare no competing interests.LAP is the principal investigator of the Social Network Study. He collected the qualitative data, supervised the analysis of the qualitative data and collection and analysis of the survey data, and contributed substantially to the writing of the manuscript. IWH, ER, DF, and QW contributed substantially to data analysis and the writing of the manuscript. PC is the principal investigator of the parent study randomized trial that forms the basis for this study and contributed to the conceptualization, design, and writing of the manuscript. All authors read and approved the final manuscript.


The purpose of this study was to estimate the annual and per-patient budget impact of the treatment of moderate to severe psoriasis in Greece before and after the introduction of ustekinumab.A budget impact model was constructed from a national health system perspective to depict the clinical and economic aspects of psoriasis treatment over 5 years. The model included drug acquisition, monitoring, and administration costs for both the induction and maintenance years for patients in a treatment mix with etanercept, adalimumab, infliximab, with or without ustekinumab. It also considered the resource utilization for non-responders. Greek treatment patterns and resource utilization data were derived from 110 interviews with dermatologists conducted in February 2009 and evaluated by an expert panel of 18 key opinion leaders. Officially published sources were used to derive the unit costs. Costs of adverse events and indirect costs were excluded from the analysis. Treatment response was defined as the probability of achieving a PASI 50, PASI 75, or PASI 90 response, based on published clinical trial data.The inclusion of ustekinumab in the biological treatment mix for moderate to severe psoriasis is predicted to lead to total per-patient savings of €443 and €900 in years 1 and 5 of its introduction, respectively. The cost savings were attributed to reduced administration costs, reduced hospitalizations for non-responders, and improved efficacy. These results were mainly driven by the low number of administrations required with ustekinumab over a 5 year treatment period .The inclusion of ustekinumab in the treatment of moderate to severe psoriasis in Greece is anticipated to have short- and long-term health and economic benefits, both on an annual and per-patient basis. Psoriasis is a chronic, currently incurable, inflammatory skin disease. It is characterized by relapses and remissions, and is affected by several genetic and environmental factors . EstimatThe most common type of psoriasis, occurring in more than 80% of cases, is plaque psoriasis or psoriasis vulgaris, characterized by well-demarcated erythematous scaly plaques . Thirty-P < 0.001). More than 16% of those with high depression scores were treated with antidepressant medication. Both dissatisfaction with psoriasis treatment and illness-related stress were highly associated with depression [The chronic and incurable nature of plaque psoriasis indicates that it has a major social and economic impact on the community . The psypression . Many pepression . Increaspression ,13.The annual, per-patient direct cost of psoriasis has been reported to be more than $14,600 in the US , and morOne of the goals of psoriasis therapy is to reduce or clear plaques and induce remission . The ideCurrently available systemic treatments for moderate to severe psoriasis include conventional drug therapies  and biologics. The former have demonstrated varying degrees of efficacy, and long-term use can lead to serious side-effects . In addiOn the other hand, the available biologic agents  provide specific, targeted regulation of the cells in the immune system and pathophysiologically designed intervention in the immunological disease cascade of psoriasis. They thus offer a treatment choice for patients who have moderate to severe disease where “conventional” systemic treatments have failed, are contraindicated, or not tolerated .The primary safety concern with biologic agents is immunosuppression. Biologic agents are associated with increased risk of infection, serious infection and possibly malignancies . The safUstekinumab is the most recent biologic agent to come to market. It was approved in Europe in January 2009 and has been shown to be well tolerated, to improve moderate to severe psoriasis, and to have a favorable administration and monitoring schedule (one subcutaneous injection every 12 weeks during the maintenance period) ,24. MoreThe objective of this study was to estimate the annual and per-patient budget impact of the introduction of ustekinumab as a treatment alternative for patients with moderate to severe psoriasis in Greece, and to test the hypothesis that a treatment with improved risk–benefit and administration profiles compared with existing treatments can lead to cost savings.An economic model that estimated the annual and per-patient budget impact of ustekinumab was built in Excel 2007. The budget impact model estimated the impact of introducing ustekinumab into the treatment mix of biologic agents available for the treatment of moderate to severe plaque psoriasis in Greece, by comparing the costs incurred by the national health system before and after the introduction of ustekinumab.All available biologic agents for the treatment of moderate to severe psoriasis in Greece, namely ustekinumab, etanercept, infliximab, and adalimumab, were included in the model as treatment options. Efalizumab was excluded from the analysis as its European marketing authorization was suspended in February 2009.The economic analysis was performed from a national health system perspective. The model time frame was 5 years (base year 2009), during which the prevalence of psoriasis was assumed to be constant. The treatment response to biologic therapies was measured in terms of the probability of achieving a PASI 75 response, and the annual costs and resource utilization of both responders and non-responders to biologic treatment were considered in the model.Data on the clinical efficacy of biologic agents were taken from the meta-analysis conducted by Reich and colleagues . This syData on medical resource use were collected through face-to-face interviews with dermatologists, the results of which were validated by an expert panel of 18 dermatologists.http://www.edae.gr/). Randomization was based on market research techniques and resulted in a total of 200 dermatologists, who were both office and hospital based, and were from Athens, Thessaloniki , and other urban centers.The interviews were undertaken during January–March 2009 and included two stages. The first stage involved 5 minutes of computer-assisted telephone interviews (CATI), which aimed to identify dermatologists who were eligible for the second stage of the survey. CATI participants were randomly selected through a database including contact details for all registered members of the Hellenic Society of Dermatology and Venereology, which is publicly available on the official website of the society  was developed with the aim of exploring: a) epidemiologic data ; b) treatment pathways ; and c) resource utilization of both responders and non-responders   far outweighs the magnitude of other costs, such as productivity loss (an indirect cost). Thus, in this model, only direct costs expressed in euros (2009) were considered.Costs incurred during the maintenance years of therapy were not discounted. The costs associated with the management of adverse events were not incorporated in the model, as they were assumed to be the same across the biologics compared.Drug acquisition costs were calculated on an annual basis for both the induction and maintenance years for each drug. The doses and number of administrations for each product were taken from the respective European Medicines Agency summaries of product characteristics Table . Accordihttp://www.ypan.gr). Tariffs from the largest social health insurance fund (http://www.ika.gr) were used to assess monitoring (outpatient visits to dermatologist), administration , and inpatient costs.Prices of the biologics were taken from officially published price bulletins from the Ministry of Development  ,30. ThisIn order to assess the impact of uncertainty of various model inputs on the results of the study, univariate sensitivity analyses were conducted on three variables that contributed to the cost of treatment and that were derived from the expert panel: hospitalization for non-responders; supportive care costs for non-responders; and market share of ustekinumab. Non-responders’ health care costs were varied, with the variation attributed to differences in resource use . These costs were allowed to vary by ±10% in one-way sensitivity analyses, whereas the market share of ustekinumab for years 1–5 was allowed to vary by ±3% and ±6% .Interviews with dermatologists and the expert panel validation that followed showed that 8% of patients with skin disease visiting a dermatologist are diagnosed with psoriasis. Of patients with psoriasis visiting a dermatologist, 63% have moderate to severe disease; of these, 28% are eligible for biologic therapies.This primary research also showed that there is some variability in where patients receive their medicine, depending on the agent in question Table .The number of visits of patients with psoriasis to health care professionals for monitoring the progress of their psoriasis, outside the visits for treatment administration purposes, is presented in Table The annual number of visits to dermatologists increases with disease severity Table . Non-resFinally, the expert panel provided estimates of the market share of ustekinumab and the other biologic agents, after the introduction of the former for the treatment of moderate to severe psoriasis Table . UstekinBased on the model results, the inclusion of ustekinumab in the biologic treatment setting for moderate to severe psoriasis is predicted to lead to total per-patient savings of €443 and €900 in years 1 and 5 of its introduction, respectively , the introduction of ustekinumab as a treatment option for moderate to severe psoriasis is predicted to deliver substantial annual cost savings per patient, ranging from €254 in year 1 to €665 in year 5.Moderate to severe psoriasis is a chronic, incurable disease, with substantial economic consequences for the health care budget. This is the first study to investigate the treatment patterns and resource utilization of psoriasis in Greece and the economic impact of the introduction of a new biologic treatment option.The current study consisted of two parts: field work with questionnaires to dermatologists to identify resource use data; and a budget impact model to estimate the costs associated with adding ustekinumab to the current treatment options for psoriasis. The collection of resource use data through face-to-face interviews with physicians, rather than being derived from clinical trials or observational studies, could be criticized on the grounds of subjectivity and be considered a limitation of this study. However, in order to strengthen the validity of the data collected, an expert panel consisting of key opinion leaders was set up to assess the primary results.The selection of dermatologists to participate in the primary research was mainly based on the level of experience they had with psoriatic patients, the rationale being that physicians with more experience on psoriasis would be able to provide more robust estimates for the parameters investigated in the study. As a result, the estimated eligible patient population entering the model in year 1 is potentially shifted upwards compared to actual numbers, leading to a subsequent overestimate in the budget impact of the related biologic treatments. However, the results of the present study in terms of cost differences across treatments, are not affected, as the eligible population is the same for all treatments and therefore has a proportionate impact on respective budgets.The results reveal that etanercept is currently the preferred treatment option for moderate to severe psoriasis, followed by adalimumab and infliximab. An interesting finding is that although etanercept and adalimumab are administered at home for the majority of patients, patients more commonly visit hospital-based physicians than the private offices of dermatologists to monitor their treatment progress. This may be attributed to the fact that specialized psoriasis centers are located in some hospitals.The results also show that resource utilization and related costs increase with disease severity, a finding confirmed by the literature . MoreoveThe therapeutic benefits of ustekinumab have been confirmed in three large Phase 3 trials in patients with moderate to severe psoriasis ,26,28. TA possible shortcoming of the present study is that hospitalization and outpatient costs may have been underestimated. Social health insurance fund tariffs, which have been used in this model, do not reflect actual costs; actual costs are higher than the amount reimbursed by insurance funds.Another limitation is that indirect costs were not considered. Indirect costs related to psoriasis include lost work time  and reduced productivity. Indirect costs increase with disease severity and can be significant . In a UKAn important finding of this study is that, based on expert opinion, 67.5% of ustekinumab-treated patients will initially be administered the product in hospital rather than at home or in their dermatologist’s private office. This is probably due to physicians’ reservations regarding a new biologic agent. According to the expert panel, reinforcement of ustekinumab’s efficacy and safety data with local dermatologists’ own experience is likely to lead to patients receiving the drug outside of the hospital setting. The expert panel’s opinion was that similar treatment patterns as with etanercept and adalimumab  are expected for ustekinumab users in the future.Two Phase 3 studies of ustekinumab have shown that the drug has a comparable safety profile with self-administration versus administration by a health care professional ,26. A moOverall, the present study investigated, for the first time in Greece, the treatment patterns and resource utilization of patients with moderate to severe psoriasis. These findings may be used to inform the development of national treatment guidelines in psoriasis and health policy resource allocation decisions.Ustekinumab offers a promising alternative to currently approved biologic agents for psoriasis, with both short- and long-term economic benefits. Based on the present model calculation, the introduction of ustekinumab as an alternative treatment option for moderate to severe psoriasis in Greece is anticipated to bring substantial cost savings to the national health care budget.HK has provided consultancy services to Janssen-Cilag Greece Pharmaceutical SACI. LX was a paid employee of Janssen-Cilag Greece Pharmaceutical SACI until December 2009. BS is a paid employee of Janssen Scientific Affairs, LLC, Horsham, PA, USA. IB, GC, AK, MK, AP, DS, TS, PS, and ET received honoraria from Janssen-Cilag Greece Pharmaceutical SACI for their participation in the expert panel.HK and LX participated in the design and coordination of the study and the analysis and interpretation of the data, and drafted the manuscript. BS revised the manuscript critically for important intellectual content. GA, IB, GC, AK, MK, AP, DS, TS, PS and ET participated in the expert panel for the validation of the data on medical resource utilization and contributed to the manuscript preparation. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-5945/12/10/prepubPrimary research questionnaire. This is the full 40-item questionnaire which was used both during the face-to-face interviews with the dermatologists and during the expert panel. This is a pdf document and can be viewed with Adobe Acrobat. (PDF 78 kb)Click here for file


The technology for concentrating virions from 100-L volumes was developed previously at Oak Ridge National Laboratory, and the means for purifying and concentrating virions from volumes in microliters have been developed recently. At the same time, marine virologists have developed efficient methods for concentrating, amplifying, and sequencing complex viral mixtures obtained from the ocean. Given this existing technology base, we believe an integrated, automated, and contained system for surveillance of the human “virome” can be implemented within 1 to 2 years. Such a system could monitor the levels of known viruses in human populations, rapidly detect outbreaks, and systematically discover novel or variant human viruses.We propose a system for continuing surveillance of viral pathogens circulating in large human populations. We base this system on the physical isolation of viruses from large pooled samples of human serum and plasma  The traditional process of discovering previously unknown human viruses, or variants of known viruses, is neither rapid nor thoroughly systematic. The time between back-calculated initial infection and final identification is often many weeks, months, or even years. For a totally new agent, the estimated interval between initial infection and detailed characterization is variable and depends on the presence of unusual symptoms, the failure to identify a virus after using all available specific tests, the recognition of a unique problem, and, in the past, the ability to grow the agent in culture.The idiosyncratic nature of virus discovery contrasts with the broad survey approaches characteristic of genomics and proteomics. Only in the relatively small field of ocean viruses has a more inclusive, cataloging approach been tested. Facilitated by the relative ease with which viruses can be isolated from seawater , investigators in this area have examined a broad and essentially unbiased population of viral agents at the genome sequence level (including phage) and estimated the number of different genomes present   offers the best chance of detection. Analysis of pooled samples from a large number of persons should raise minimal privacy concerns.Methods are required for the routine isolation of all classes of viruses from a pooled sample and for concentrating them by factors of over a million while ensuring that all nonviral nucleic acids have been removed. The concentrates may be dangerously infectious, and sophisticated containment systems will be needed.The preferred technology for virus concentration from large volumes was developed by the Joint NIH-AEC Zonal Centrifuge Development Project at the Oak Ridge National Laboratory, Oak Ridge, Tennessee, USA, and the Oak Ridge Gaseous Diffusion Plant in the 1960s  in one dimension and banding density (rho) in the other, usually carried out in the order: S-ρ. For large-scale isolation and purification, the challenge was to perform these separations continuously and simultaneously in large continuous-flow centrifuge rotors spinning at high speed in a vacuum.In this scheme, a flowing stream passes inboard of a thin, nonflowing density gradient, held in place against the rotor wall by centrifugal force. The recovered virus forms a narrow band in the gradient, which is recovered after reorienting the gradient to rest at the end of the run. If the flow through two centrifuges is cascaded, the first operating at lower speed than the second, particles having a higher S rate than viruses could be removed from the flowing stream, and the viruses then concentrated and banded in the second higher speed centrifuge, thus providing a large-volume S-ρ separation.The end result of this work included the design and construction of the K-II large-scale ultracentrifuge , and to concentrate them down to tens of microliters .During the Oak Ridge centrifuge development project, large volumes of test material were required, and seawater, among other sources, was examined as a possible source of virus. The ocean was found to contain examples of almost every known viral form at high titers  appears technically feasible. Consequently, the titers of many known human viral pathogens may be estimated routinely, and new viruses (both pathogenic and nonpathogenic) may be discovered systematically.The initial choice is between filtration and centrifugation. Seawater contains little contaminating material of the size and density of the virus particles, filtration is simple and efficient, and no free nucleic acids have been reported. Plasma and serum present different problems, complicated by the presence of large amounts of protein, some nonviral particles in the virus window, and variable amounts of soluble nonviral nucleic acids  Can this process be carried out rapidly enough to support a timely therapeutic or prophylactic response to a new agent ? 2) Will the novel virions that originated from one or a very few infected persons be recovered and detected? 3) Can the affected persons be located?Samples can be collected weekly, and materials rapidly transported to one or more processing sites. Virus isolation, library construction, and preparation of clones for sequencing require <7 days but the time may be compressed into <4 days with a 24-hour per day operation. Sequencing time will be determined by available capacity, but since capacity is abundant, with large increases in sight, extensive library sequencing  could be carried out in 2 to 3 days. Less than 1 day would be required to assemble viral genomes as contigs in silico. By the conduction of each step in sequence, turnaround (serum pool to raw sequence data) could be completed in approximately 10 operating days. Additional time would be required for bioinformatics analysis of the data and annotation, but prevalence and novelty conclusions should be available almost immediately. These estimates assume an integrated and fully developed system in continuous operation, analogous in some respects to those monitoring computer viruses.-15 g; if the average titer of an infected person is 106 virions/mL, and if 0.1% of the samples are from viremic patients, then ~0.5 μg of virus would be recovered from each 500-L pool, substantially more than the few nanograms required to make a large library with current technology , thereby detecting parts-per-million sequences. Second, one could apply antibody-based affinity methods to deplete known viral particles from the initial concentrated viral sample. Third, one could use subtractive hybridization to remove known viral genomic sequences to further enrich libraries in novel genomes. The last two approaches can be progressively extended as viruses are characterized to provide a continuous increase in sensitivity to new agents .Two approaches can be used, if necessary, to link viruses to patients. In the first approach, viruses would be tracked geographically, first in terms of large regions, and then, sequentially, in terms of smaller areas. Detecting a new agent in large pooled samples would thus be repeated in smaller, localized pools that had been combined hierarchically to generate the larger pool  in the subpools and the affected persons identified in one step. To achieve this result, each sample is added to a series of different pools, the identity of these subpools providing an “address” of the sample , and the number of different clones sequenced.The number of intentional false positives (duping) is another matter and one that has two aspects. First, intentional introduction of unexpected pathogens or their genes into a global analytical system is itself a terrorist act and one that should be detected and known. To insert a substantial amount of recoverable viral particles into the sample collection system, a person trying to deceive the system would have to engineer and grow these viruses—an act sufficiently close to actual bioterrorist use that it requires detection, whether the agent is a serious human pathogen or not. The second aspect concerns the best response to the suspicion that such duping has occurred. Complete sequencing of the agent(s) involved would be important since one cannot initially distinguish a genuine sample from one used in duping. Only after extensive further studies and the demonstration that an outbreak has not occurred may the sample be determined not to be of patient origin.Forewarned is forearmed. Given advance notice, even by weeks, of an impending viral outbreak, the hope exists that the tools and imaginations of molecular biology will find the means to prepare some effective biological defense.The problem of developing new antiviral agents, especially those specific for one or only a few viral diseases, is circular. Without such treatments rapid agent identification is not necessary, but without such identification no pressing commercial justification for developing specific antiviral agents exists (except for HIV) because they will not be widely used. To be successful, diagnosis and therapy must be linked. This project would assist in forging that link.Isolating and sequencing the genomes of a wide variety of viruses from pools of the excess human serum and plasma currently collected and discarded by large diagnostic laboratories is now technically feasible. This collection and analysis process could allow new or unknown pathogens to be identified in the first, or at most second, round of infection. Not all human viral pathogens will be present in such mixtures, but they will include a large fraction of all known highly infectious viral agents. Since the core technologies, though varied, are highly developed, we believe that the initial feasibility studies could be completed in 1 year.Former Senator Sam Nunn and William H. Wulf, president of the National Academy of Engineering, have both proposed setting up a project concerned with bioterrorism, modeled after the Manhattan Project. We believe that the project described could form the nucleus of such an effort and suggest that lessons learned in the Oak Ridge centrifuge project may apply. As noted by Alvin Weinberg, that project was the first (and hopefully not the last) large-scale project in the biological sciences in which facile access to a wide range of technologies was provided, on the model of the original Manhattan Project (In separate articles, we will discuss the possibility of linking rapid detection to rapid responses, including vaccine and therapeutic antibody development, in an attempt to abort epidemics caused by new viruses while they are in progress.


The burial of coffins may pose an environmental and health hazard since the metals that are used in coffin-making may corrode or degrade into harmful toxins. These may leach into the surrounding soils and groundwater. Very little research has been conducted world-wide on the mineral contamination potential of cemeteries, and virtually none in South Africa. The aim of the study is to determine whether burial practices affect the mineral content of soils in cemeteries. This was done by comparing the mineral concentrations of soils within the Zandfontein Cemetery in Tshwane  to those off-site as well as those in zones with high burial loads with those zones with fewer burials. Twenty three soil samples were collected from various sites on- and off-site and analyzed for 31 minerals using ICP-AES. It was found that mineral concentrations of soils within the Zandfontein Cemetery were considerably higher than those off-site. Soil samples in multiple burials blocks also have elevated metal concentrations. These excess metals are probably of anthropogenic origin associated with burial practices and could pose an environmental and human health hazard. Strict monitoring of water quality in boreholes in the vicinity of the cemetery is recommended. Agriculture, industry and landfills are commonly believed to be major anthropogenic sources of environmental contamination. Little attention has been given to cemeteries as possible pollution sources. Research conducted on the latter has been limited to examining pollutants emanating from the bodies. However, cemeteries are not only the final resting place to bodies but also to coffins and caskets used for the interment of remains. Indeed, recent studies conducted found the highest contamination arising from cemeteries originated from minerals that are released by burial loads . The minToxic chemicals that may be released into groundwater include substances that were used in embalming and burial practices in the past as well as varnishes, sealers and preservatives and metal handles and ornaments used on wooden coffins. Wood preservatives and paints used in coffin construction contain minerals such as copper naphthalene and ammoniac or chromated copper arsenate (CCA) ,10. BesiMetals are also used for the handles and other ornaments that are attached to the outside of a coffin. The fasteners and coffin ornaments also contain minerals such as zinc and zinc- or copper-alloys, silver or bronze. Often these items are spray painted, vacmetalized, electroplated or a combination of these processes to enhance their aesthetic value .Although wood has traditionally been used in South Africa for the construction of coffins, the price of wood is becoming prohibitive and cheaper materials such as cardboard, plywood, MDF boards, supa-wood, chipboard or pressboard are being used as substitutes . These pThe current state of knowledge regarding the contamination loads from cemeteries is limited, with only sparse published information available . One of This article aims to investigate whether the mineral contents of soils in a cemetery are affected by burial practices, and thus by anthropogenic activities. In order to achieve this, the mineral contents of soils within a cemetery were compared with those off-site; and the soil mineral contents of densely “populated” areas of a cemetery with those in areas with fewer burials. Since the burial load may impact directly on the mass of anthropogenically introduced minerals into cemetery soils, the spatial distribution of burials and the burial loads were also determined. The study was conducted in the city of Tshwane in the province of Gauteng, South Africa. The City of Tshwane Metropolitan area, Pretoria, has a total of 40 cemeteries and one crematorium within the municipal boundary. The Zandfontein Cemetery, the study area, is one of the oldest cemeteries in the City of Tshwane (Pretoria) that is still in operation. Zandfontein Cemetery is located ten kilometres north-west of the city centre on a portion of the farm Zandfontein 318 JR and centres on the following coordinates: S25°41′38.70′′; E28°06′50.86′′ . It is lThe cemetery covers an area of about 123.25 ha. It is divided into quadrangular blocks with each block allocated a pre-determined number of burials. The locations of the blocks are shown in All the data on the burials at Zandfontein Cemetery were obtained from the administrative centre on site. The records on all burials have been noted by hand since 1958 by administrative personnel of the CCTM. Each block or section area in the cemetery has its own record book where the date of burial, particulars of the deceased such as gender and age of the deceased, and grave plot numbers are noted. The number of burials in each of the cemetery zones was obtained from these worksheets. A few problems were encountered while attempting to calculate the burial load. Firstly, record-keeping was not always adequate regarding the number of people buried (and hence the number of coffins) in each grave. It is thus difficult to make an accurate estimate of the mass of minerals in any given cemetery, especially in an older, fuller cemetery such as Zandfontein, where grave plots are re-used or where a single grave is used for multiple burials. Moreover, burials take place in different parts of a cemetery at different times and thus exhibit a very large range of spatial and temporal decomposition processes . A further shortcoming is that the exact mineral content of each coffin is not known, hence the mass of the mineral content of the burial load could not be determined with any degree of accuracy. However, literature reveals that one coffin handle weighs 300 g . The estSoil samples were collected on- and off-site for chemical analysis. The City Council of Tshwane Municipality (CCTM) by-laws on cemeteries stipulate that no person may, unless permitted to do so by the Strategic Executive Officer, disturb the soil in a cemetery . Soil saTo establish the naturally occurring background soil levels for the Zandfontein area, two samples were collected from a nearby off-site area . SamplesOne kilogram samples were collected from all sample points and placed in plastic bags. Samples were labelled with date, time, sample I.D, block name and sample depth. Samples were taken to the Agriculture Research Council’s—Institute for Soil Climate and Water (ARC-ISCW) accredited laboratories at Belvedere Street, Pretoria, for analysis. Microwave digestion and Inductively Coupled Plasma-atomic Emission Spectroscopy (ICP-AES) (USEPA Method 6010) were used to analyse 31 micro element concentrations in the soils. Unfortunately, the laboratory did not test for the concentrations of lead and aluminium. t-test was used to determine whether there is a statistically significant difference between the total mineral content of the soils in different parts of the cemetery. Means were calculated for each of the minerals in on-site samples. Student’s The estimated mineral burial mass due to coffins alone is approximately 108,000 kg . This mineral mass only accounts for metals that are used in coffin handles and may thus be an underestimation of the total mineral load.The possibility that cemetery soils are contaminated with toxic minerals was assessed by calculating the ratio of on- to off-site soil mineral content. Further proof of the anthropogenic origin of soil contamination requires that the areas within the cemetery with high burial loads should have higher mineral concentrations, than those with lower burial loads. i.e., those in blocks E and EA as well as in the adjacent sub-blocks of KA, KB and KC, and those around T5 and T6 . The estimated number of burials in the various blocks is shown in The approximate number of coffins was obtained by summing the number of graves in the immediate vicinity of the two sets of sample sites Since the graves in blocks T and U are used for multiple burials, the total number of coffins is higher in these blocks than in the relatively more densely “used” blocks E and EA.If the mineral content in the soils is influenced by the burial loads, the mineral content of soil samples collected in the T and U should exceed those in blocks E and EA. This assumption was tested using data obtained for each of the blocks, as shown in t-test shows that there is a significantly higher concentration of minerals in blocks T and U , signifying that the cause of contamination could be due to burial practices. The concentration of especially titanium, vanadium, chrome, manganese, cobalt, nickel and zinc are considerably higher in blocks T and U than in E and EA. Contrary to the general trends, the lead content is higher in soils from E and EA than from T and U. Exceptionally high levels of boron, rubidium and strontium were found in soils in EA3, lead in EA2, chrome in EA1 and caesium in EA0. The latter cannot be explained.As expected, Student’s Approximately 60,000 coffins have been buried at the Zandfontein Cemetery in Tswane . These are estimated to produce a burial load of approximately 108,000 kg minerals. This study was aimed at determining whether this burial load affected the mineral composition of the cemetery soils, thereby causing a potential health risk. It was found that the mineral composition of soils within Zandfontein Cemetery was significantly higher than those off-site and that the soils in the zones with the highest burial loads were more contaminated than in the less used parts of the cemetery. This indicates that burial loads have a direct impact on soil-mineral content and thus cemeteries can be regarded as anthropogenic sources of contamination. It should be kept in mind that the research did not include the pathogenic or organic releases from gravesites due to burials. It relies on estimations of the amount of metals that are already introduced into the Zandfontein cemetery. Because burials are not carried out in a fixed pattern the results reflect metal contamination from metal deposits that have accumulated over time and not necessarily from metals that have recently been introduced into cemetery soils. Moreover, these results do not necessarily reflect the situation at other cemeteries in Tshwane. The fact that this cemetery is located on the slopes of a mountain may cause leaching of minerals into groundwater and aggravate potential health risks. It is recommended that the mineral concentration of groundwater be measured and monitored at boreholes in the surrounding suburbs. Similar studies should be conducted at other cemeteries—not only in Tshwane but countrywide. Such studies will also establish whether cemeteries should be considered to be potential anthropogenic contamination sources—similar to—or even more hazardous than landfill sites.


In academic medicine, women physicians lag behind their male counterparts in advancement and promotion to leadership positions. Lack of mentoring, among other factors, has been reported to contribute to this disparity. Peer mentoring has been reported as a successful alternative to the dyadic mentoring model for women interested in improving their academic productivity. We describe a facilitated peer mentoring program in our institution's department of medicine.Nineteen women enrolled in the program were divided into 5 groups. Each group had an assigned facilitator. Members of the respective groups met together with their facilitators at regular intervals during the 12 months of the project. A pre- and post-program evaluation consisting of a 25-item self-assessment of academic skills, self-efficacy, and academic career satisfaction was administered to each participant.P = 0.0001), improvement in skills necessary to effectively search the medical literature , an improvement in their ability to write a comprehensive review article , and an improvement in their ability to critically evaluate the medical literature .At the end of 12 months, a total of 9 manuscripts were submitted to peer-reviewed journals, 6 of which are in press or have been published, and another 2 of which have been invited to be revised and resubmitted. At the end of the program, participants reported an increase in their satisfaction with academic achievement (mean score increase, 2.32 to 3.63; This facilitated peer mentoring program demonstrated a positive impact on the academic skills and manuscript writing for junior women faculty. This 1-year program required minimal institutional resources, and suggests a need for further study of this and other mentoring programs for women faculty. Women physicians continue to lag behind their male counterparts in academic advancement and in promotion to leadership positions . Women hStatistics regarding women faculty in leadership positions are equally disconcerting. In 2010, only 13% of department chairs were female, with numerous medical schools reporting never having had a woman in a department chair or dean position -19. LackMentoring has long been an essential component of career advancement within academic medicine and other disciplines -10. UndeReports of women faculty's greater appreciation of the process of collaboration , and difThe Department of Medicine at Mayo Clinic, Rochester, Minnesota, has 153 women  faculty. Gender disparities in academic rank and leadership opportunities led the department's leadership team to evaluate strategies to close the gap. Focus group discussions and surveys suggested that a lack of mentoring and social isolation were common themes reported by women faculty. Peer mentoring was considered to be a critical ingredient to a multipronged approach to address these issues. By means of this paper, we aim to discuss the process and outcomes of an expanded 12-month facilitated peer mentoring project. Our primary objective was to study the impact of facilitated peer mentoring on scholarly output, specifically manuscripts submitted for publication. Secondary objectives were to study the impact of peer mentoring on self-efficacy of writing skills and networking.This project was declared exempt by the Mayo Clinic Institutional Review Board.n = 106) were invited to participate in the project and asked to submit names of peers of similar academic rank with whom they wished to potentially work in a group setting.All women faculty in the Department of Medicine at Mayo Clinic, Rochester, Minnesota, who hold the rank of instructor or assistant professor , the groups were not required to meet on a specific day. A tentative 12-month timeline of projects, primary authors for the manuscripts, and target journals for manuscript submission was also developed.During the year-long program, facilitators were encouraged to meet regularly with their groups at intervals of every 2 to 4 weeks, participate in brainstorming sessions, review the suitability of topics for development and manuscript submission, edit drafts, and provide additional individual and project mentoring on an ad hoc basis. Additionally, phone conferences were scheduled for each month among the 4 facilitators.t-test was used to compare serial survey results, and a P value of < 0.05 was considered statistically significant. The qualitative comments were reviewed and categorized into either positive/value added or constructive/suggested improvement comments.At the end of the program, the initial self-assessment survey was repeated, with the addition of several questions allowing free-text response options specifically aimed to assess the value and effectiveness of the program to participants. A paired Five peer mentoring groups, comprising a total of 19 as mentees and 4 as facilitators, formed the project group. Of the 19 mentees, 17 were on faculty in the Department of Medicine of Mayo Clinic, Rochester, Minnesota. The mean number of years on faculty was 6.20 . Six of the mentees held an academic rank of assistant professor, 11 had achieved the academic rank of instructor, and the clinical fellow and nurse practitioner had no academic rank. The participants were divided into 5 groups each with 3 to 5 mentees and 1 facilitator.Groups were encouraged to meet once weekly, and to meet at least monthly with their facilitator. The actual meeting frequency varied widely from every week to once every 4 to 6 weeks. In one group, the facilitator joined the mentees for most meetings. Others met with their mentees at least once a month. Regardless of meeting frequency, mentees had regular e-mail and phone connectivity with other mentees and facilitators between meeting times. The facilitators had a monthly in-person or phone meeting during which they updated the others, discussed successes, problems and roadblocks, and shared best practices.At the end of the 12-month project, 9 manuscripts were submitted  by the 5 groups. Of the 9 submitted, 6 papers are in press or have been published and another 2 have been invited to be revised and resubmitted. In addition, 1 peer mentoring subspecialty group designed and completed a clinical research project, and at the time of manuscript writing had presented their findings at a national meeting. They are working on completing the manuscript related to this project. The distribution of papers and academic work completed was not equal between the groups: 1 group completed 3 manuscripts, 3 groups completed2 manuscripts, and 1 group completed1 manuscript. Another group did not focus on manuscript writing, but on clinical protocol design and execution. In addition, 1 of the groups who completed 2 manuscripts also completed and submitted a grant.Although each mentor and participant signed an agreement to consistently participate in the group mentoring sessions, the individual groups were not asked to commit to a specific frequency of meetings and were not required to document number and length of interactions. Thus, data on the distribution of frequency or total number of hours the groups met are not available.Participation in the peer mentoring program was associated with the achievement of several additional academic and career goals. Among these participants were 2 individuals who pursued advanced degrees: a masters of public health and a masters in academic medicine, and the appointment of 1 individual as a divisional practice chair. Four individuals received 5 grants . These achievements were distributed throughout the groups without concentration in the groups with the higher manuscript completion.Self-efficacy and career goal data were obtained from the study participants at baseline and after the study period through the self-assessment survey and is represented in Table P = 0.0001) and improved skills necessary for academic success (P = 0.0083). As shown in Table P = 0.0009); use EndNote to manage references ; write a comprehensive review article ; and critically evaluate the medical literature . Skills related to developing clinical research projects from original clinical questions were not enhanced following participation in the program , whereas understanding the process for submitting research protocols for institutional funding was gained . Study participants also stated that the confidence in their ability to assist residents in designing, completing, and publishing academic projects improved over the course of the program . At the conclusion of the 12-month study period, there was also a significant improvement in perceived ability to effectively network with other physicians in the institution to find opportunities for collaboration  and an improved understanding of how to identify an effective mentor . Qualitative feedback from participants is noted in Table At the conclusion of the mentoring program, participants reported an increase in their satisfaction with academic achievement  and with the overall interaction of their individual peer mentoring groups . The facilitators' satisfaction with the quality of the papers was also high, with a mean satisfaction score of 4.25 . All facilitators and 89% of the peer participants reported that they were willing to both facilitate future peer mentoring groups and recommend the program to other faculty members.A recent call for cultural change acknowledged the disappointing progress in the advancement of women in academic medicine . This prPeer mentoring, as used in this project, has been described as an effective mentoring method for both male and female faculty ,16,19-21In our facilitated peer mentoring program, participants were, by design, required to work in a collaborative manner within their own peer group. Also, when queried, the mentees reported an improvement in their ability to effectively network with other physicians to find opportunities for collaboration. Our questions, as posed, did not delineate participants reporting an improvement in networking skills in isolation; rather, it was asked in the context of networking as a way to find opportunities for collaboration.Our program also explored the efficacy of a peer-to-peer mentoring group guided by a more senior faculty member who was gender-matched and acted as a facilitator. The peer mentoring groups in this study were loosely constructed around 3 models of collaboration described by Schneider ,29. Our There are a number of possible explanations for the variable outcomes among the mentoring groups. Facilitator and participant engagement, discrepancies in baseline academic skills, and frequency of group interactions all could have played a role in the degree of each group's success. As above, the facilitators and participants were not required to log meeting times or report on the degree of individual engagement, but all participants did sign a good-faith agreement to remain active participants. Of note, the group that completed only 1 manuscript was comprised of individuals from different specialty divisions, whereas the other groups included individuals from the same specialty or division. This diversity in background may have led to a slower ramp-up period for this group.In response to the survey item, "I have the skills necessary to take a clinical question and develop a clinical research project," peer participants' responses did not show a statistically significant improvement over time. This result was not unexpected, perhaps because the project was designed to enhance the writing skills of the peer groups by producing clinical review articles or resurrecting and publishing results from a previously acquired data set. The relatively limited 12-month time frame prompted a stronger emphasis on publishing, which constitutes a solid criterion for academic promotion at most academic medical centers, and less emphasis on idea generation and research project initiation.As in traditional mentoring relationships, although the gist of instruction regarding manuscript writing was likely similar across all groups, the timing and method of instruction would have varied based on immediacy of issues being discussed in the group, the content of the manuscript, the baseline knowledge of the group members, and the interaction between the facilitators and mentees. Item 14 on the assessment survey, "I have identified an effective mentor," showed a nonsignificant improvement at the end of the program; we are unsure if this means that the various groups were dissatisfied with the mentor assigned to them or if this reflects the participant's response to finding an effective traditional one-on-one mentor.This program was not designed to serve the facilitators in any way; there were, however, unexpected benefits from their perspective. These included the opportunity to interact with motivated early-career faculty, to participate in a novel and exciting department-wide program, and to serve as coauthor on papers with a variety of fresh topics. Thus, this new program itself was truly bidirectional in its benefits, providing positive effects among both participants and facilitators.This study is not without limitations. First, although this study spanned a full year, we do not have data on long-term outcomes beyond the project year. It remains to be seen whether the favorable effects observed here are in fact sustained and whether they ultimately lead to academic promotion and increased leadership roles among these women faculty. Secondly, in an effort to be evenhanded in allocating opportunities, this facilitated peer mentoring intervention was provided to all interested junior women faculty within the department of medicine. Traditional one-on-one mentoring continues to be the mainstay for mentoring models in the department, and this project was introduced to engage faculty without such mentors, which likely accounted for the lower number of women who signed up for the program. We did not compare the academic achievements of the faculty who did not sign up for the program with those who did, as this was beyond the scope of the study. Third, in the absence of a comparative arm that might have included either another intervention or no intervention, it is impossible to assess accurately the true positive impact of this facilitated peer mentoring approach. It remains possible that the program self-selected for highly motivated individuals who might have been productive independent of their participation in the program. We point out that this third criticism could be raised regardless of details on the participants or specifics related to the program, and that it remains a criticism of any mentoring program that does not include a control group. Nevertheless, we also point out that this program's heavy emphasis on introducing the mentees to the practical aspects of acquiring clinical research skills, writing papers, and getting these papers published likely had a direct effect on the favorable survey and productivity outcomes described here.Future efforts may include extending the duration of the intervention, assess long-term outcomes, and seek comparative data that might result from studying other approaches. Although the peer participants in our women-only program did not strongly advocate same-gender mentorship, future studies might also focus on whether different mentoring approaches might resonate better with some groups versus others based on gender distribution.Mentors are a valuable resource within academic medical centers, and the spirit of altruism that drives such mentoring also drives the academic accomplishment of faculty at most academic medical centers. The current project extended such mentoring opportunities to junior women faculty, demonstrated preliminary positive outcomes in terms of academic accomplishment, and suggests a need for further study of this and other mentoring programs for women faculty.The authors declare that they have no competing interests.All authors read and approved the final manuscript; all authors contributed to study design, results analysis and write up of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/12/14/prepub


Vietnam has made impressive progress toward improving the health status of the population, with progress that equals or surpasses that of many neighboring countries. Life expectancy in Vietnam is 72.8 years (70.2 for men and 75.6 for women), a level that is considerably higher than that in many countries with similar levels of GDP per capita. From 1990 to 2009, the infant mortality rate fell from 44.4% to 16.0%, the under-five mortality rate dropped from 58.0% to 24.5%, and the maternal mortality ratio declined from 233 to 69 maternal deaths per 100,000 live births. Estimated to be around 18% in 2010, the rate of under-five malnutrition has also fallen dramatically. These improvements are attributable to a widespread health care delivery network, increasing numbers of qualified health workers, and expanding national public health programs  and infectious diseases , an ageing population, inadequate capacity of the health system, and problems of inequities in access to health and health care . The finThe fact that infectious diseases remain a public health concern is illustrated by Toan et al. in a study demonstrating that Dengue fever remains pervasive and that the geographical scope of the disease has expanded in recent years . VietnamSmoking is common in Vietnam, partly due to the general population's poor knowledge of its health consequences. An et al. demonstrate that adult smokers, especially those belonging to ethnic minority groups, have low levels of knowledge regarding the harmful effects of smoking. Alcohol misuse is also a rising public health problem . In theiVietnam is also experiencing a rapidly ageing population. It is therefore critical to have an in-depth understanding about quality of life and associated factors among elderly groups. In their study on ageing populations, Huong et al. find that quality of life among the elderly is strongly correlated with issues related to finances and economics, as well as with social relationships and familial support .In the coming years, equity-oriented reform will be a major focus for the health system in Vietnam. Despite substantial achievements, there are still large health status disparities across regions and between demographic and socioeconomic groups. In this regard, Thuy et al. illustrate the extreme marginalization and distress among Vietnamese mothers whose children have disabilities. These authors identify modest levels of social capital among this population group, although relatively better mental health is also detected . OtherwiVietnam has over eight million people belonging to ethnic minorities, the majority of which live in remote and mountainous areas. These populations are relatively more disadvantaged in terms of socioeconomic and health status. The study by Xuan et al. finds poor hand washing with soap behaviors among schoolchildren in a multi-ethnic population of Vietnam, a potential cause of a number of health conditions . Human rBased on the empirical evidence, all contributing authors have developed recommendations for policy changes and interventions in Vietnam. These recommendations are comprehensive and include primary, secondary and tertiary approaches, as well as policy-level interventions –21. BothPolicy makers, managers, health staff and other health system stakeholders in Vietnam are committed to ensuring that all people attain a level of health that enables them to participate actively in the social and economic life of the communities in which they live. An important factor that can help the health system achieve this goal is the availability and quality of information on which decisions are based. As academics and scientists, we have conducted research to generate robust scientific evidence to support health planning and decision making in Vietnam. We hope that health system stakeholders will find this cluster of papers useful. We enthusiastically stress that scientific evidence on health is crucial for policy changes and interventions and, when the evidence is compelling, actions toward better health and health care should be taken.Nguyen Duc HinhPresident of the Hanoi Medical University, HanoiVietnamHead of the Department of Medical Ethics and Social MedicineInstitute for Preventive Medicine and Public HealthCenter for Health System ResearchHanoi Medical University, HanoiVietnamHoang Van MinhLecturerDepartment of Health EconomicsInstitute for Preventive Medicine and Public HealthCenter for Health System ResearchHanoi Medical University, HanoiVietnam