Due to the fact that adolescents are more likely to participate in high-risk behaviors, this sector of the population is particularly vulnerable to contracting sexually transmitted infections (STIs) and resultant health problems.A survey was carried out among adolescents from poor homes in 204 small-urban areas of Mexico. Information was collected in relation to risk behaviors and socio-economic environment. A sub-group of the participants also provided blood and urine samples which were analyzed to detect sexually transmitted infections.The presence of Chlamydia was detected in nearly 8% of participants who had stated that they were sexually active (18%) and approximately 12% were positive for herpes type 2-specific antibodies. For both, a greater proportion of girls resulted positive compared to boys. The presence of these biological outcomes of sexual risk behavior was associated with other risk behaviors (smoking), but not with self-reported indicators of protected sex .The results presented in this study show a startlingly high prevalence of HSV-2 among sexually active Mexican adolescents in poor urban areas, suggesting that this group has participated to a great extent in risky sexual practices. The relationships between socioeconomic environment and adolescent risk behavior need to be better understood if we are to design preventive interventions that modify the determinants of risk behaviors. Adolescence is a critical period of development, as important behavior patterns are set in place during this period, and these patterns can have serious and long-term consequences for lifetime health and welfare. In particular, adoption of unhealthy risk behaviors such as smoking and drinking, and participation in others such as unprotected sex, can lead to health problems that will reduce both life expectancy and quality of life.Globally, adolescents face many problems related to sexually transmitted diseases including HIV/AIDS, unwanted pregnancy and drug, alcohol, and tobacco use. As countries develop and poverty rates fall, either because of economic growth or explicit poverty alleviation programs, adolescents living in poor households will obtain the knowledge and resources to be able to reduce their risks; however, they will also have more opportunities and resources to engage in these risky behaviors.The World Health Organization (WHO) estimates that 1 in 20 adolescents throughout the world will contract a curable sexually transmitted infection (STI)  [One of the most common viral STIs is herpes simplex type 2 (HSV-2) ,4. The lIn Mexico, problems associated with sexual activity leading to unwanted pregnancies and sexually transmitted infections, as well as alcohol and tobacco use, are a major concern, particularly among adolescents living in poor households. In 2003, 17% of all births in Mexico were to women under the age of 20 . As far There are very few figures relating to STIs among adolescents in Mexico and, in general, they are limited to one region or federal state. Therefore, very little is known about the prevalence of this type of infection in this age group ,16. Of pFurthermore, it has been suggested that risk behaviors occur in groups, i.e. the probability of risk behavior occurring is higher if another risk behavior has already occurred .The aim of this paper is to present evidence from a national survey among adolescents living in poor small urban areas, describing both prevalence of risky behaviors and their relationship with poverty.As part of the evaluation of an antipoverty program in Mexico, a survey was carried out in a sample of 23,000 homes located within poor census tracts  in 204 towns with between 2,500 and 75,000 inhabitants . The sample was selected to represent households eligible to receive the program's benefits, with an additional sampling of non-eligible households, selected to test targeting. To identify eligible households, the program identified census tracts with the highest prevalence of poverty from the 2000 national census within towns that had access to basic health and education services. The program conducted a preliminary survey of all households within the selected census tracts, collecting information about household members, household assets and housing characteristics which was used to generate a poverty score that determined. The towns to be included in the program defined the universe for the sample. Sampling was multi-staged. Towns were selected randomly with probability proportional to size. Then, within towns, eligible and non-eligible households were randomly selected.As a part of the survey, a specific questionnaire was administered to 15 to 21 years old and blood and urine samples were collected from the same. The questionnaire was based on others used in Mexico for national surveys, in particular the National Health Survey and the National Fertility Survey, as well as questionnaires developed by FHI/UNAIDS and by the authors to evaluate the impact of HIV prevention programs. The instrument is available as an additional file see .For the analyses presented here we took advantage of the entire sample (including non-eligible households). We used data from the general household survey on household socioeconomic status as well as data from the adolescent survey on characteristics of the individual adolescent and his/her participation in risk behaviors. The adolescent questionnaire was administered by a trained interviewer (low literacy levels in this very poor population limit the utility of self-administered questionnaires and computer-assisted self interviewing).We used a broader definition for adolescents, i.e. individuals from 15 to 21 years old. We acknowledge that 21 is old with respect to usual definitions, but the behaviors that we are collecting information about are largely behaviors that began in the past, so participants are reporting on behaviors over prior (adolescent) years.The design of the study was approved by the IRB at the National Institute of Public Health (INSP). Informed consent was obtained from parents or guardians for all underage participants, and directly for 18 to 21 years old participants.The adolescent component of the survey was designed for the 15- to 21-year-olds in the population. It consisted of a questionnaire and the collection of urine and blood samples, to measure the prevalence of sexually transmitted infections (STIs). STI data were collected because they are important health outcomes in their own right, as well as markers of risky sexual behavior.As the main purpose of the survey was to collect household-level data, up to three visits were made to each household and only adolescents present at one of the visits were interviewed. While some data were collected for the non-present adolescents from a proxy informant, none of the data on risk behavior could be collected using these informants and therefore these adolescents were excluded from the analysis.Information collected from adolescents included basic demographics, schooling and labor data, as well as health related behavior such as smoking, drinking, sexual activity, condom use, and participation in compensated sex .The household questionnaire included information on family members and socioeconomic characteristics. In order to estimate household socioeconomic level, data on monthly monetary consumption was estimated by adult equivalent using data on food and non-food consumption from the household survey.We compared these estimates with nationally representative consumption surveys to classify households into socioeconomic quintiles.After consent was obtained from parents of adolescents under the age of 18 and from the adolescents themselves, blood samples were drawn by trained phlebotomists and the adolescents were asked to provide a sample of urine. All samples were sent to the National Public Health Institute facilities, where the sera and the urine were frozen at -20 degrees centigrade until they were analyzed.The urine samples were analyzed for the presence of Chlamydia and gonorrhea using ligase chain reaction amplification  according to the manufacturer's protocol.The blood samples were analyzed using an Elisa test (Focus Technologies) to detect the presence of anti-herpes simplex type 2 virus antibodies, following the procedures indicated by the manufacturer of the tests.All samples were analyzed in the National Institute of Public Health by trained technicians.Biomarker data were merged with the individual data using a unique, pre-assigned identification code. All biomarker data could be matched with the socioeconomic and behavioral information.All variables included in the analysis reported here were revised to check for inconsistent, impossible, or missing values. To the extent possible these were recoded to the mean or more appropriate value when available information permitted, so as not to have to exclude the entire observation. These data-cleaning procedures affected less than 5% of the observations.Descriptive statistics and all analysis were estimated using Stata 8.0 (Stata Corporation). We Standard errors and confidence intervals are adjusted for design effect, considering both strata and primary sampling units (PSU). Sample weights were also employed.HSV-2 serostatus and Chlamydia infection were included as dichotomous variables and prevalences were estimated by age group (as defined below) and sex.To estimate the ability of socioeconomic variables to predict risk behaviors, we performed a set of multivariate logistic regressions, using each of the dichotomous indicators of risk behaviors  as dependent variables. All dependent variables corresponded to a specific yes/no question included in the survey or the result of a laboratory test.In addition to the household socioeconomic status defined above, we included as explanatory variables: age, sex, educational attainment, perceived social support, labor force participation, and whether the adolescent was living with a partner. In predicting condom use at last sex and compensated sex among the sexually active, we included, in addition to the above, years since first sexual intercourse, smoking, drinking, and history of reported STI symptoms. In predicting infection with HSV-2 and Chlamydia, we additionally included condom use at last sex and participation in compensated sex.Age was categorized into two groups , and years since first sexual intercourse into three categories . Labor force participation and marital status were categorized as yes/no variables. Marital status was coded as 1 if the adolescent was cohabitating with a partner, whether married or not.For schooling, we included three different variables: whether the adolescent was attending school at the time of the survey, whether they were older than predicted by their last completed grade in school (coded as 1 if not older), and, if they were older, the difference in years between actual and predicted age. In this way, we differentiated the effect of educational achievement from the peer group effect associated with attending school.Having social support was defined as having a friend in whom they could confide their personal problems.A total of 13,897 adolescents were living in the selected households at the time of the survey. Of these, socioeconomic and behavioral data were collected from 13,444 (97%), with the great majority of the remainder absent at the time of the visits. Blood and/or urine samples were collected from the 4,024 adolescents who agreed to provide them. Response was partially limited by the adolescents' refusal to provide a sample, but was more a function of the fact that the biological field teams were understaffed in comparison to the socioeconomic teams and thus requested samples from a subset of the adolescents. While samples were obtained from only 29% of the adolescents, all observable variables  are similar in the group that agreed to give just urine, just blood or both, compared with the total sample. Out of all of the complete samples collected, only those from adolescents who reported having been sexually active were analyzed, as well as small proportion of urine samples of those reported been non-sexually active. A total of 753 blood samples and 1,620 urine samples were analyzed . The main characteristics of the participants in the survey can be found in Table The average age of all sexually active adolescents (18.7) was similar to the average age of adolescents who provided blood samples (18.8) and urine samples (18.4).More girls than boys reported that they were sexually active, which is possibly due to the fact that the likelihood of finding girls during the survey was greater (they spend more time at home).Table As far as the consumption of addictive substances is concerned, a direct association was also observed between the prevalence of this behavior and sexual activity: the percentage of those surveyed who reported having smoked at some time is between 50% and 100% higher among those who are sexually active than among those who did not report sexual activity. The same was also true, although to a lesser extent, for the consumption of alcohol and marihuana.The percentage participating in any violent event or receiving social support was similar whether or not the subjects were sexually active. As far as sexual risk behaviors are concerned, participation in compensated sex was similar across age groups and sexes, with an average of 2% for both sexes and age groups. For participation in compensated sex, the survey was not able to distinguish between buyers and sellers and it is likely that the pattern of participation is different between boys and girls. As was expected, length of time since beginning sexual activity was greater for 19- to 21-year-olds compared with 15- to 18-year-olds, the average being greater for girls in the older age group, and for boys in the younger age group.The proportion of boys using condoms during the most recent sexual act was far greater than that of girls in both age groups, and the proportion was lower in the 19- to 21-year age group than in the 15- to 19-year age group. A very low percentage of adolescents reported having experienced symptoms of an STI during the previous 12 months.Sixty of the 1,241 urine samples from sexually active adolescents tested positive for Chlamydia and only one for gonococcus. Using sample weights and adjustment according to type of sample, the estimated prevalence of Chlamydia was 8% among sexually active adolescents. However, as presented in Table Furthermore, 102 of 753 blood samples resulted positive for herpes simplex type 2 virus specific antibodies, which, after adjustment, represents a prevalence of 12%. In this case, significant diversity was also found, with a prevalence of 4% in 15- to 18-year-old girls, and a maximum of 19% in 19- to 21-year-old girls.Tables As presented in Table Participating in the labor force was positively associated with drinking but not with smoking. Some geographical differences were also observed, as presented in the table.In regard to initiation of sexual activity, attending school, age-appropriate education level, and participating in the labor force were all associated with delayed initiation. As expected, older adolescents and adolescents living with a partner are more sexually active. The proportion that was sexually active also increased with household socioeconomic level.For sexually active adolescents, two additional behavioral models were estimated to predict condom use in the last sexual intercourse and participation in compensated sex. Men were more likely to use condoms and adolescents living with partners less likely, as expected given Mexican cultural norms. Of the remaining independent variables only socioeconomic status was significantly predictive of condom use: the higher the socioeconomic level, the greater the probability of using a condom.Having a close friend was strongly protective against participation in compensated sex.Finally, two models were estimated to predict HSV-2 and Chlamydia infection. The probability of infection with both STIs was dramatically greater for girls than boys and in the case of HSV-2, increased with age. The latter difference is not surprising, because the HSV-2 test measures antibodies which reflect cumulative life-time incidence, while in the case of Chlamydia, the test measures current active infection. Participation in compensated sex was associated with increased likelihood of being positive for both STIs, as was smoking, though the association was statistically significant only for Chlamydia.The panorama presented here of Mexican adolescents in poor areas is not an encouraging one. Unhealthy behaviors are broadly prevalent and there is at least a significant risk that economic development may worsen the situation. Poverty alleviation programs, if not well designed, can make it easier for adolescents to engage in unhealthy behaviors, thus highlighting the importance of both understanding how poverty and development affect risk behaviors, and of assessing the impact of poverty alleviation programs on those same behaviors. We observed a positive relationship between socio-economic level and sexual activity in these cross-sectional data. While this does not mean that socioeconomic development will lead to increased risk, it does heighten the concern.The results presented in this study show a startlingly high prevalence of HSV-2 among sexually active Mexican adolescents in poor urban areas. Although previous small-scale studies have been carried out that suggest that HSV-2 is highly prevalent among Mexican adolescents, this study, which sampled adolescents from 28 of the 32 Mexican states, offers a far more comprehensive overview of the problem, at least among adolescents in poor homes. The prevalence of HSV-2 found in this study is greater than that observed among young university students in the State of Morelos, a group with an average age greater than those interviewed here, which would suggest that infections are occurring at an ever earlier age.The high prevalence of viral STIs suggests that this group has participated to a great extent in risky sexual practices, which may have implications not just for sexually transmitted infections, but also for unwanted pregnancies and their consequences. Although the current prevalence of HIV among adolescents in Mexico is very low, this also suggests that there is serious potential for spread of HIV in this population.The other important result is the lack of correlation between self-reported risk behavior and HSV-2 serostatus. This calls calls into serious question studies that rely exclusively on self-reported behavior, as well as the assumption that there is necessarily a strong correlation between self-reported individual risk behavior and that individual's infection status. There are several possibilities that may help to explain the lack of association. One obvious possibility is that adolescents may not respond truthfully regarding condom use. While always a possibility, it seems unlikely that this explanation is sufficient because it suggests that they are untruthful in both directions. More likely, it is a combination of two other factors. First, if there is a lot of variability among adolescents in condom use from one sex act to another, then reported condom use at last sex would be a poor predictor of an individual's history of condom use. To the extent that the quantity/frequency of sexual experience is highly variable, it could further mask the association.  Second, The study also highlights the link between sexual behavior and other risk practices. Although a causal relationship between smoking and the presence of an STI is not suggested, reported links suggest that adolescents who participate in one risk behavior are more likely to participate in others. Similarly, the clear link between HSV-2 and participation in compensated sex suggests that this practice may make male and female adolescents in Mexico highly vulnerable to infections, although the limited size sample needs to be taken into consideration.The present analysis is not able to disentangle the mechanisms through which poverty, schooling, and other aspects of development affect individual risk behaviors. For example, we observed a strong positive correlation between smoking and sexual risk behavior and a strong inverse association between school achievement and smoking. Schooling, whether because of the education or the environment it provides, may have a broad impact on a large class of risk behaviors, which in our model is captured by the association with smoking. It may also be indirectly affecting sexual risk behavior, but the effect is masked in the model.Finally, one point to consider is the differences between boys and girls: although boys participate more in non-sexual risk behaviors, the probability of girls using condoms is less than for boys, which translates into a higher probability of becoming infected with an STI. It is highly probable that this is an indication of increased vulnerability on two levels: on the one hand, physiological, in terms of susceptibility to infections and on the other, social, in terms of the ability to negotiate the use of a condom.It is important to recognize the limitations of the results presented here. First, as the sample was selected to represent beneficiaries of an antipoverty program it is not representative of all adolescents in Mexico living in poor localities. Also, the response rate for biomarkers was far lower than ideal. Nevertheless, there is not an obvious bias that would suggest overestimation of the prevalence of risk behaviors. On the contrary, we might expect that adolescents with higher levels of risk behaviors would be less likely to be encountered by the survey teams in their parent's households. They might also be less willing to cooperate with government surveyors, with both effects resulting in underestimation of the true prevalences of risk behaviors and STIs.These data in some ways cause us to ask more questions than they answer. The relationships between absolute poverty, relative poverty, education, and adolescent risk behavior need to be better understood if we are to design preventive interventions that modify the determinants of risk behaviors. As a global community we have been strikingly unsuccessful at changing infection rates in this population, in part because of simplistic assumptions regarding the link between knowledge and behavior. We need to further disaggregate the adolescent population in order to identify sub-populations at higher risk and the factors that explain the large differences between the sexes and between geographic areas. We need to understand why self-reported behavior is such a poor predictor of infection.The author(s) declare that they have no competing interests.JPG conceived the idea of this report, contributed to the design of the study, designed and led the analysis and interpretation for this report, and drafted the manuscript. SMB contributed to the idea of this report and the design of the study, and to the design, interpretation and drafting of this manuscript. CJC and MAS coordinated the analysis of the samples and to the analysis and interpretation for this report. All named authors read, commented on and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:Survey questionnaire. The English translation of the questionnaire is presented in a PDF file.Click here for file


The impact of immigration on health services utilisation has been analysed by several studies performed in countries with lower levels of immigration than Spain. These studies indicate that health services utilisation is lower among the immigrant population than among the host population and that immigrants tend to use hospital emergency services at the expense of primary care. We aimed to quantify the relative over-utilisation of emergency services in the immigrant population.Emergency visits to Hospital del Mar in Barcelona in 2002 and 2003 were analysed. The country of origin, gender, age, discharge-related circumstances , medical specialty, and variable cost related to medical care were registered. Immigrants were grouped into those from high-income countries (IHIC) and those from low-income countries (ILIC) and the average direct cost was compared by country of origin. A multivariate linear mixed model of direct costs was adjusted by country of origin (classified in five groups) and by the individual variables of age, gender, hospital admission, and death as a cause of discharge. Medical specialty was considered as a random effect.With the exception of gynaecological emergency visits, costs resulting from emergency visits by both groups of immigrants were lower than those due to visits by the Spanish-born population. This effect was especially marked for emergency visits by adults.Immigrants tend to use the emergency department in preference to other health services. No differences were found between IHIC and ILIC, suggesting that this result was due to the ease of access to emergency services and to lack of knowledge about the country's health system rather than to poor health status resulting from immigrants' socioeconomic position. The use of costs as a variable of complexity represents an opportunistic use of a highly exhaustive registry, which is becoming ever more frequent in hospitals and which overcomes the lack of clinical information related to outpatient activity. Several studies support the idea that immigrants make greater use of emergency services than other healthcare modalities and that the reasons for this phenomenon are diverse. Firstly, emergency care in Spain is public, free and universal, independently of nationality and length of residence . In addiAll of the above refers to a context of lower healthcare utilisation by the immigrant population than by the Spanish-born population. This is attributable to the "survivor effect", also known as the "healthy immigrant effect", according to which recently arrived immigrants have better health status than native-born residents -12. ThisStatistical Office of the European Communities ..19].Our hypothesis was that immigrants preferentially use the emergency department to access healthcare. As a result, emergency care in this population involves a lower workload than that corresponding to the Spanish-born population due to the lower level of complexity. Consequently, much of this care could be provided in primary care. In Spain, the private health sectors is small, accounting for approximately 15%, and, especially in emergency care, the vast majority of the population uses the public health services.In Catalonia (Spain) information on patients' country of origin, case mix in emergency care and the costs attributable to these episodes is stored separately and is not easily related. Our hospital information sources allow case mix to be adjusted through specialty and variable costs (direct consumption) registered for each emergency visit. Currently, because the catchment areas fall within a metropolitan area, populational information is not available, since the various catchment areas overlap. Consequently, attendance rates cannot be analysed and the present study is based on analysis of utilisation.In 2001 the hospital case mix of Hospital del Mar in Barcelona was analysed [Since then, further evidence has indicated that hospital services utilisation by the immigrant population is centered on paediatric and obstetric services.We hypothesised that greater variable cost is related to higher complexity due to the greater workload involved in the diagnosis and follow-up of the patient.The aim of the present study was to determine the workload generated by emergency department visits by immigrants according to country of origin.A total of 165,267 emergency visits to Hospital del Mar between 2002 and 2003 were included in the analysis. From 2001–2004 information was gathered on the country of origin of immigrants attending the emergency department of Hospital del Mar. The cost per patient in 2002–2003 was also calculated, thus enabling the workload involved in each emergency visit to be evaluated.The patients' country of origin was identified and the patients were subsequently divided into three large groups: Spanish-born residents, IHIC , and ILIC, which included all remaining countries. In turn, ILIC were divided into groups of countries according to geographical criteria: Latin America, northern Africa and the Nile Valley, sub-Saharan Africa, the rest of Asia, and eastern Europe. Country of origin was identified through the hospital's admissions registry. Patients from the department of and neonatology were classified according to the parents' country of origin.Emergency care episodes were classified into five large clinical categories , which, for the purposes of this study, are termed "specialties". The type of specialist who will attend the user is determined by initial triage in the emergency department.All hospital activity is costed under Activity-Based Costing criteria. Thus all discharges (admissions and ambulatory surgery), day hospital sessions, minor surgery, outpatient consultations and emergency visits are evaluated once the unit cost of each activity involved is known. For the hospital as a whole, the sum of all the final products expressed will correspond exactly to the total cost for the period analysed. When costing an emergency visit, two main activities are evaluated: on the one hand, the costs imputed to the emergency medical and nursing services, which are used to generate the unit costs of the physicians' and nursing staff's workload according to the time the patient spends in the emergency department. On the other hand, variable costs, which are those directly related to the patient according to the medical records and the unit costs corresponding to prostheses and the activities of laboratory, pathology, pharmacy and complementary tests, which effectively function as external companies and bill for each product and patient. The cost of an emergency visit, as analysed in the present study, did not incorporate the cost incurred if the patient was admitted to the hospital, given that the aim was only to compare the workload associated with visits to the emergency department.Ethical approval was obtained from the Local Research Ethics Committee.The average variable cost stratified by specialty, gender and age group  and groups of country of origin (Spanish-born patients and IHIC versus ILIC) was calculated.For each, gender-group, age group and specialty, the average cost was compared between the two groups of countries and Student's t-test for two independent samples was applied. Subsequently, the strata of immigrants incurring lower costs than Spanish-born residents, those incurring higher costs and those showing no differences with Spanish born residents were grouped together.Lastly, a mixed linear model was adjusted with random effects in which direct cost variability was explained according to the patients' country of origin and was adjusted by gender, age, and death or hospital admission as causes of discharge from the emergency department. Specialty was considered as a random effect that was controlled for by adjusting the model. Both the dependent variable of variable cost and the explanatory variable of age were transformed logarithmically to normalise the variable of costs as far as possible and to be able to read the B parameter in terms of elasticity. Elasticity is the ratio of the incremental percentage change in cost with respect to an incremental percentage change in each dependent variable.Most of the analysis was performed with the statistical package SPSS V11.5 and the mixed linear model was adjusted through SAS.From 2002–2003 there were 165,257 emergency visits, of which 19.9% were made by immigrants. When visits made by ILIC only were included, this percentage was reduced to 15.5% , a stratified comparison was made Table . The groWhen the distinct gender and age groups were classified according to whether differences were significant or not and, if significant, in which sense, 42.4% of emergency visits showed the expected association (lower cost among emergency visits by ILIC), 27.5% showed higher cost among emergency visits by ILIC, and 30.1% of the visits involved age groups in which the deviation was not significant.2) of 9.1%. Notable in this model was the behaviour of all groups of countries of origin. Both IHIC and ILIC showed lower costs than did Spanish-born residents. Emergency variable cost was 9 to 17% lower for all immigrant groups. IHIC showed a negative deviation of 17.2%, quantitatively the most important.Lastly, the characteristics that could explain variations in variable cost were analysed as a whole through a mixed linear model with logarithmic transformation of continuous variables Table . The varThe values of the adjustment variables were normal for age, with a positive elasticity of 19%. Gender showed little variation although male gender implied lower variable cost in emergency care, death as a reason for discharge showed an increased cost that almost tripled basal cost, and hospital admission carried a small increase in workload. Specialty was incorporated into the model as a random effect to control for its impact on the care provided but did not form part of the estimation of the model's parameters. Medicine and traumatology showed a higher cost independently of country of origin. Gynaecology showed lower cost. No significant differences were found in surgery or paediatrics with respect to the average for all emergency visits.Differences in variable cost reflect lower complexity of emergency care due to the lower workload involved. The variable costs of a substantial number of emergency visits were analysed, enabling a series of distinguishing features to be established according to the patients' countries of origin. The results can be discussed according to the type of analysis performed; those presenting few discrepancies, or none at all, will be discussed first.Emergency visits by adult immigrants (16–50 years) involving medicine, traumatology and surgery occasioned lower workload than those by Spanish-born residents and reductions in variable costs exceeded 10%. The remaining age groups were insignificant, as they included a small immigrant population. The results were fairly consistent for these three large specialties and can be generalised for all the age categories, given that the signs of the differences were homogeneous, although, due to the small number of cases, they did not reach statistical significance. Notably, the specialties of medicine and traumatology were those that most closely fitted the original hypothesis, since they showed higher variable costs and, therefore, their ability to act as a proxy of workload-complexity was greater.Emergency visits involving gynaecology and paediatrics showed no overall differences. When stratified by age, higher variable cost was found in gynaecological emergencies for ILIC. This difference in cost was very low (9% of an average cost of 3.8€) and, although this difference was clearly statistically significant (p < 0.008), its economic importance was lower than in other specialties, in which the reduction in cost was much higher in percentage and absolute values.The expected finding of greater emergency department use services utilisation among immigrants than among Spanish-born residents was consistent among the adult population, supporting the hypothesis that immigrants overcome certain barriers by using the emergency department as the route of access to health services in preference to other routes. The finding that IHIC also showed greater emergency services utilisation department use suggests that the cause lies in overcoming barriers to access rather than in immigrants' socioeconomic position. Furthermore, the average income in both the immigrant and the native populations within the hospital catchment area is low. Since both IHIC and ILIC showed the same behaviour, the most coherent explanation seems to be the short length of residence among immigrants and their consequent lack of knowledge of the normal routes of access to health services.The finding that gynaecological emergencies in adult immigrant women of reproductive age represented greater workload than those by their Spanish-born counterparts can be explained by the difficulties of pregnancy follow-up in ILIC in primary care. Participation in primary care pregnancy follow-up programs is substituted by sporadic contact with the emergency services that perform the pertinent procedures, with the variable cost that this represents. The same occurs at delivery, increasing the cost of hospital care of the neonate in the early postpartum period .Importantly, socioeconomic position and health status in the catchment area as a whole are lower than the averages for the city of Barcelona. This is an important difference and the differences detected may be smaller than those that would have been found if immigrants had been compared with a Spanish-born population with better health, social and economic indicators.This study presents several limitations. Firstly, variable cost is used as an approximation of workload and, in turn, this workload is what determines whether the emergency visit constitutes a real emergency or could have been treated in primary care. This is undoubtedly an indirect approximation. However, publications that provide direct evidence in our environment are lacking. The methodology used in this study is therefore conceived of as an alternative that may provide information useful for adapting hospital services to the non-Spanish-born population and for indicating the interventions required to achieve utilisation patterns similar to those of the Spanish-born population.A second limitation concerns a possible subregister of immigrant patients, basically of children born in Spain who, to all intents and purposes, count as Spaniards; what matters in our analysis is behaviour relating to the socioeconomic and cultural position of the family and, in this sense, these children are immigrants. The paediatric and neonatology database constitutes an important attempt to minimise this problem; since 2001 the parents' country of origin has been registered, representing a significant improvement. Even so, a certain subregister of these children who were not born in or admitted to the hospital, or who did so before 2001, may still exist in the emergency department.A third limitation concerns the profile of utilisation among the visits that took place, which cannot be used to infer populational behaviour. This problem could be resolved by determining the origin of all the patients attending the emergency department of the hospitals in a sufficiently large area to ensure that all the emergency visits by a specific population are included. This is a methodological alternative that implies the use of the variable of cost as an indicator of complexity and which, by itself, has demonstrated its viability.The fourth limitation is due to the scarcity of clinical information available on emergency visits. This is a consequence of the policy in the Spanish health system, which has prioritised codification of hospital admissions, as this was an essential step in constructing diagnosis-related groups (DRGs). An analogous system to DRGs has not been established for ambulatory activities, which has discouraged codification of ambulatory activity. This is a general defect, affecting the entire system, and should be resolved; however, until this happens, the available information must be used. In this sense, differentiation by specialty can be useful, as shown in the present study.Notable among the strengths of the study is determination of the variable costs registered for all the emergency visits and their association with country of origin. This information allows an analysis that provides a certain level of evidence that is useful for the planning of health services and interventions to improve the healthcare of the distinct emerging collectives in the Spanish health system.Leaving aside the behaviour of the profile of gynaecological and paediatric emergency visits from the remaining emergency visits among adults, some useful conclusions for health policy can be drawn. The immigrant population tends to access the health service through the emergency department even more than the Spanish-born population. Consequently, the substantial increase in both IHIC and ILIC in the health system has a multiplying effect on the lack of equilibrium that an increase in demand for emergency services represents for a hospital. The increase in pressure on the emergency services is probably related to lower levels of efficiency, since it involves the use of expensive high-intensity resources to respond to non-urgent conditions that could be managed in the primary care setting .Because of the relatively high volume of obstetric and gynaecological emergency visits, as well as their level of complexity, greater efforts should be made to reach immigrant women of reproductive age and include them in antenatal care programs.To take the next step in investigating the impact of the immigrant population on the Spanish health system, a direct relationship with the populational setting should be established, to characterize not only patterns of use but also attendance rates.The author(s) declare that they have no competing interests.All the authors have contributed to the achievement of this study. FC conceived of the study, participated in the design of the study, performed the main statistical analysis and drafted the manuscript. XC, OV and OG participated in the design of the study and helped to draft and review the manuscript. AF and MR performed data management and review the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Gorik Ooms sheds light on the controversial use of the concept of sustainability by development agencies . InternaOn the other hand, Médecins Sans Frontières (MSF) fosters the illusion of independent aid in a vast world full of necessities, makes irrelevant political views through the flag of neutrality, and digests the lecture of conflicts for the taste of the white man's tears. MSF knows that their projects, as most of the projects, are not sustainable and therefore rejects sustainability as an argument to act. But MSF is concerned about sustainability as the organization calls for stronger national commitment and more international aid for health through emergency development. Behind the oratory, MSF assumes that the governments have the power for an appropriate answer.Sustainability cannot be analyzed alone. Community development, grassroots democracy, social justice, human rights, humanitarianism, or empowerment are the conceptual ideas that back the illusion of aid in the Western civil society. They are rhetorical terms that could even sound radical but, paradoxically, due to their apolitical approaches, make international aid and cooperation harmless for governments and policies that generate injustice. Moreover, postmodernism appeals for individual attention and marginalizes collective political actions that could have greater impact.Solomon R. Benatar wrote in this journal that poor health reflects systemic dysfunction in a complex world and calls the attention to address the complex system forces that sustain poverty and poor health . We are


Chronic disease, and particularly cardiovascular disease (CVD), is the major cause of death in most developed countries, despite the downward trend observed during the last three decades. Although CVD is emerging in developing countries, little is known there about comprehensive preventive measures for controlling its expansion.The health care system in Tunisia faces the challenge of increasing rates of CVD risk factors. Epidemiologic studies show high levels of CVD risk factors among Tunisian adults and children. Evidence shows that several risk factors and conditions are commonly associated with major chronic diseases. Integrated actions against selected risk factors , implemented within the social context, can lead to the reduction of major chronic diseases. These interventions should take place early in childhood.In Tunisia, a much-needed community-based intervention program to control CVD is being planned. This program will promote healthy living, smoke-free air, healthy nutrition, regular physical activity, and supportive living and working environments. Its ultimate goal is to reduce the burden of CVD and its related behaviors. A description of this program and how it will be implemented and assessed in the region of Sousse, Tunisia, is presented. Chronic disease, particularly cardiovascular disease (CVD), is the major cause of death in most developed countries ,2, despiTunisia is now facing the phenomenon of epidemiologic transition : total mThe major CVD risk factors — high blood cholesterol, high blood pressure, cigarette smoking, physical inactivity, and unhealthy diet — satisfy the public health criteria of causality . In factIn Tunisia, a much-needed community-based intervention program to control CVD is being planned. This program will promote healthy living, smoke-free air, healthy nutrition, regular physical activity, and supportive living and working environments. Its ultimate goal is to reduce the burden of CVD.In the context of epidemiologic transition and disease prevention, it is important to be able to assess the scope of existing CVD, but there is a lack of systematic monitoring of CVD morbidity and mortality in Tunisia and in most of the developing world. In Tunisia, the only available population-based epidemiologic data is a profile of CVD risk factors -24. In 1Based on this profile of CVD risk factors, Tunisia can be compared with Western societies and should consider a national strategy of primary prevention and heart-health promotion in addition to the efforts recently made in secondary prevention of some chronic diseases such as hypertension and diabetes.Urbanization is expected to raise the level of CVD risk factors in Tunisia as a result of the adoption of new dietary habits, the lack of physical activity, and the stresses of working conditions in urban areas. Changes in dietary habits have not yet reached a critical point, however; a study published in 1999 showed that the food regimen in Tunisia was still based mainly on carbohydrates, and the percentage of lipid calories did not reach 20% of total intake .The assessment of CVD risk factors during childhood is also important because the underlying process of developing CVD starts early in life. The assessment of CVD risk factors before adulthood could inform us about the etiology of CVD. The results would serve as basic information in a public health context, notably in the promotion of healthy lifestyles. In 1999, we conducted a study of students aged 13 to 19 years; the study was partially funded by the Tunisian Ministry of Higher Education, Scientific Research and Technology  and was Available evidence supports the feasibility and effectiveness of population-wide prevention directed toward increasing the proportion of people at low risk of developing CVD . CVD risFor developing countries, evidence supports the benefits of lowering risk distributions. For example, the Asia Pacific Cohort Studies Collaboration indicates that a 2% reduction of mean blood pressure has the potential to prevent 1.2 million stroke deaths annually  and 0.6 million coronary deaths  by the year 2020 . Much moOne could expect a long-term positive impact of a community-based intervention program to control CVD in developing countries, based on the accumulated experiences of developed countries. The CVD epidemic is not a matter of fate in developing countries; it can be controlled or at least postponed in a country with a transitional economy, such as Tunisia. Because communicable diseases have not yet been conquered, the health care system in Tunisia is ill prepared to provide the costly care required for managing chronic diseases, but some efforts have been made recently. A national program was launched in 1993 by the Ministry of Health; this program was designed to improve the quality of care for patients with diabetes and hypertension in primary care settings. Its main objective was to standardize the management of these two CVD risk factors with a focus on general physician training and health education. This program is insufficient, however, and needs to be completed with a primary prevention approach, which is the main objective of our current initiative.In Tunisia, we are in the initial stages of documenting the CVD burden and identifying its risk factors. This phase should be followed by a population-based preventive intervention to control the expansion of CVD. The potential for prevention generated by a community-based intervention program is important, and so is the idea of building collaboration among different categories of professionals toward a common goal of CVD prevention. In Tunisia, the launch of such an intervention would represent a cornerstone for a chronic disease control program. To launch the intervention, we should adopt a stepwise approach, described below.In this phase, we will focus on community mobilization and establish a task force of politicians, health professionals, and nongovernmental organizations committed to decreasing CVD in Sousse. This stage will also include a community assessment with the following parameters: levels of CVD risk factors; knowledge, attitudes, and behaviors related to CVD risk factors; patterns of use of primary health services; and barriers to and facilitators of healthy behavior.First, the task force will use the community assessment data for setting priorities. Second, educational and skill-building activities will be coordinated through existing social and organizational structures such as primary health care centers, work settings, secondary schools, health clubs, and community recreational facilities.This phase will focus on the sustainability and evaluation of the intervention based on its feasibility and impact on CVD in Sousse. Evaluation is a continuous, systematic process of determining what has been achieved in a program and comparing these achievements with the objectives set out in the plan. Evaluation should not take place only at the end of the program; it must be considered in the planning phase of the program, as soon as program activities begin, and should continue until after the activities have ended. Components of evaluation should include the following:Implementation. This component systematically examines what is delivered and how it is delivered. It does not focus on program results but provides documentation of program delivery.Impact. This component assesses the intervention's ability to produce positive changes in levels of risk factors and other determinants of CVD .Outcome. This component assesses the effectiveness of the intervention in producing long-term changes in CVD among the target population of Sousse.Sousse is the fourth largest city in Tunisia, with a total population of 547,000, according to the most recent census in 2004. There are 92 primary health care centers and two university hospitals. The total number of primary health care physicians is 168; 92 physicians are in the private sector and 76 are in the public sector. There are 57 secondary schools with a total of 1762 classes and 56,752 students. Sousse has 413 worksites that employ more than 50 employees each.The integrated program will target youths as well as adults through lifestyle-education activities within the general framework of community mobilization. Improving the preventive practices of health professionals at different levels of care will also be central to the program. The program will address the entire community  and propose interventions centered on promoting healthy habits  and preventing main risk factors  toward the ultimate goal of reducing or delaying CVD.The program focuses not only on interventions targeting internal factors that are controlled by each individual but also on the external environmental factors not individually controlled. The effectiveness of interventions on behavior modification  represents our primary challenge.The program objectives include a 10% relative improvement in healthy habits in 5 years in the target population of Sousse, including the following:10% reduction in the proportion of sedentary adults10% reduction in the prevalence of adult smokers 10% reduction in the prevalence of young smokers 10% reduction in the prevalence of obese adults 10% increase in the proportion of the adult population consuming 5 daily servings of fruits and vegetablesThe program will be implemented gradually with the following objectives:To implement the intervention annually among 30% of the physicians in the private sector and 30% of the physicians in the public sectorTo implement the intervention annually among 30% of worksites with more than 50 employeesTo implement the intervention annually among 30% of the secondary schools Other objectives may be added during implementation as we adapt to the process; for example, we may add other target groups such as pharmacists and nurses.The program will emphasize an integrated approach that combines two strategies: educational actions and environmental actions.Educational actionsThe educational actions will aim to encourage physicians and other primary health care professionals to introduce a brief counseling session to patients on the healthy habits related to CVD risk factors. For physicians, workshops of continuing medical education will focus on managing CVD risk factors in primary care.Environmental actionsThe environmental actions will aim to modify the environments of work settings, schools, and the general community. Three types of environments are targeted: physical, economic, and social. At worksites, we will actively engage the support of members of management and occupational health and medicine groups. We plan to approach a new group of schools each year during the program so that by the end, we reach all schools in the region. In the community, we will focus on leisure services and sports facilities to help them develop and implement public policy to modify environments to promote the adoption of healthy habits. The promotion of healthy lifestyles in these environments is intended to create smoke-free environments, encourage smoking cessation, promote the consumption of fruits and vegetables, and encourage regular physical activity. These dimensions are summarized in the Figure.Tunisia is a country with a transitional economy that faces the challenge of an increase in morbidity associated with chronic disease. With this epidemiologic transition, the health care system must be prepared to address the growing expansion of chronic disease, particularly CVD. Many epidemiologic studies have demonstrated high levels of CVD risk factors among Tunisian adults and children. The time for prevention is now. There is evidence that several risk factors and conditions are commonly associated with major chronic diseases. This means that integrated actions against selected risk factors  implemented within the social context can lead to the reduction of major chronic disease. Prevention of chronic disease should focus on decreasing risk factors early in childhood. The community-based program in Tunisia will target access to positive healthy living, smoke-free air, healthy nutrition, regular physical activity, and supportive living and working environments. Its ultimate goal is to reduce the burden of CVD. The implementation of this program is a public health priority and will serve as a useful example for other developing countries.


Utzinger and de Savigny discuss the implications of a new policy paper, which argues that the control of "the big three" diseases  should be integrated with control of the neglected tropical diseases. PLoS Medicine, throw down a compelling challenge to the global health community to intensify its response to the neglected tropical diseases. The authors discuss opportunities for integrating neglected disease control with interventions against the “big three,” namely, HIV/AIDS, tuberculosis, and malaria [Peter Hotez and colleagues, in a new analysis inmalaria . They hiIn the last decade, the world has witnessed the establishment of numerous global partnerships for health that address some of the grandest challenges, specifically the big three, child and maternal mortality, and micronutrient deficiencies. These new partnerships have succeeded in substantially raising the profiles of those health problems, generating unprecedented financial resources, and improving the technical means to tackle them. The global health partnerships and additional resources provide leverage to attain health- and poverty-related international development targets, such as the Millennium Development Goals.In sharp contrast, advocacy to increase public awareness of and response to the neglected tropical diseases has been far less evident. This lack of advocacy can be attributed to the diseases' primary impact on the poorest of the poor in rural and deprived urban settings, the underestimation of their public health and economic significance, and the lack of coordinated research and control efforts. How can this unacceptable situation be changed? Hotez and colleagues provide some bold thoughts for a way forward. Building on several recent publications , Hotez eFrom global health and development perspectives, two issues in Hotez and colleagues' analysis are worth highlighting. First, the authors have made a laudable attempt, using a diversity of recent data sources, to update the annual number of deaths and the disease burden—expressed in disability-adjusted life years (DALYs) lost—due to the neglected tropical diseases. Their new estimates are 534,000 deaths per year and 56.6 million DALYs lost. These estimates are more than 3-fold higher than those put forward in the annex tables of the World Health Report 2004  ,9.Polyparasitism is the norm rather than the exception in the developing worldSecond, the article stresses the important, albeit largely overlooked, issue of geographic overlap of the neglected tropical diseases, which emphasizes that coinfections are pervasive. Recent cross-sectional surveys confirmed that polyparasitism is the norm rather than the exception in the developing world . HoweverHotez and colleagues summarize an emerging body of literature that emphasizes the crosstalk between the neglected tropical diseases and the big three. For example, recent studies suggest that helminthic infections may be associated with an elevated incidence rate of malaria, and may worsen clinical outcomes of malaria. Although this topic is in its infancy, there is a pressing need to further our understanding of this kind of interaction. At a fundamental level, polyparasitisms represent a major opportunity for a deeper understanding of the physiology of homeostatic balance of a host organism harboring multiple bacterial and/or parasitic infections concurrently. At a more pragmatic level, it has been suggested that regular deworming might have ancillary benefits for malaria control and vaccine efficacies ,13.It makes sense to integrate interventions for multiple diseases when those interventions share a common technical approach, a common target population, and a collectively high disease burden. Integrating interventions against multiple diseases is the basis of the cost-effective success of the Expanded Program on Immunization, and, more recently, of the Integrated Management of Childhood Illness . Hotez aOf course, there are many tactical issues to be addressed concerning this strategy of integrated chemotherapy-based control. What are the most efficient and cost-effective means to rapidly identify or map areas at highest risk of coinfections? Will the approach be effective across a diversity of epidemiological and sociocultural settings? How do we tailor integrated chemotherapy for specific age groups? What are the most appropriate time intervals, delivery systems, and monitoring and evaluation systems, especially for drug interactions, compliance, and development and spread of resistance? How do we move from morbidity control to transmission containment?http://www.oecd.org/dataoecd/11/41/34428351.pdf) and the High-Level Forum on the Health Millennium Development Goals to work toward systemic approaches that are aligned and harmonized with locally owned national programs, and thereby point the way for truly integrated and more sustainable solutions in the years that lie ahead. 3Failure to address this collective burden of disease, now that an integrated approach seems feasible, will result in it moving steadily up the ranking into the top three once the impact of current global health partnerships starts to register. We will have to deal with the burden sooner or later, so why not now so this effort can take advantage of the economies of scale that occur during national scale up of responses to the big three? Hotez and colleagues have made a strong case to act, and have sketched a strategic approach. Now an agenda needs to be developed to map out the way forward. Such an agenda will need to wrestle not just with the challenge of integrating interventions into an appropriately designed package but also with integrating that package into appropriate delivery systems. A growing realization in the context of how the health-related Millennium Development Goals can be achieved, especially in sub-Saharan Africa, is the need for strengthening health systems . The Jan


Diseases of cartilage, such as arthritis and degenerative disc disease, affect the majority of the general population, particularly with ageing. Discovery and understanding of the genes and pathways involved in cartilage biology will greatly assist research on the development, degeneration and disorders of cartilage.We have established the Integrated Cartilage Gene Database (iCartiGD) of genes that are known, based on results from high throughput experiments, to be expressed in cartilage. Information about these genes is extracted automatically from public databases and presented as a single page report via a web-browser. A variety of flexible search options are provided and the chromosomal distribution of cartilage associated genes can be presented.iCartiGD provides a comprehensive source of information on genes known to be expressed in cartilage. It will remain current due to its automatic update capability and provide researchers with an easily accessible resource for studies involving cartilage. Genetic studies of the development and disorders of cartilage will benefit from this database. Diseases of cartilage, such as arthritis and degenerative disc disease, affect the majority of the general population, particularly with ageing. In recognition of the impact of musculo-skeletal disorders on society, 2000–2010 has been declared the bone and joint decade by the World Health Organization [When compared with databases of relatively well studied organ systems, such as the human prostate gene database  or the oin vitro and in vivo studies [However, large amounts of information about cartilage associated genes are available publicly. Numerous genes involved in skeletal development have been discovered through  studies ,7. Expre studies -10 as ha studies . Another studies ,13. ThesiCartiGD has been designed to facilitate access to the wealth of publicly available information on cartilage associated genes by providing a one-stop source for this information. Rather than search a variety of databases, scientists and clinicians studying cartilage can utilise the automatically updated iCartiGD, with its flexible search functions, to access the data and resources they require.Many databases of publicly available information have been mined or cross-linked and integrated to create iCartiGD. These databases include several of the National Center for Biotechnology Information (NCBI) databases such as Genbank, Entrez Gene, UniGene, MapViewer, dbEST, dbSNP, HomoloGene, SAGEmap, PubMed, Gene Expression Omnibus (GEO), RefSeq and OMIM. Other resources and databases used are Ensembl, UniProt, the UCSC genome browser, the Protein Data Bank (PDB), InterPro, Sage Genie, HapMap, Affymetrix, SymAtlas of the Genomics Institute of the Novartis Research Foundation, the Gene Ontology Annotation project (GOA), and the Kyoto Encyclopedia of Genes and Genomes (KEGG). See Table Only genes that are expressed in cartilage are included in the database. We determine genes that are expressed in cartilage based on reference to four lines of evidence. Currently, eight EST libraries from dbEST at the NCBI give approximately 5,000 genes that are expressed in normal and osteoarthritic cartilage, and chondrosarcomas. SAGE libraries derived from chondrosarcomas, and microarray studies and a cDNA library of normal cartilage complete the cartilage tissue data set. This gives a total of approximately 14,000 genes (based on EntrezGene identifiers) that are expressed in at least one cartilage tissue type. An evidence display, based on these sources, reports the justification for the inclusion of a gene in the database.EntrezGene records were primarily used to build the database. Where appropriate, UniGene or Affymetrix probe-ids were mapped to EntrezGene identifiers. Based on these, the relevant information from the databases mentioned above was downloaded and integrated into iCartiGD. The gene name, obtained via the EntrezGene identifier, forms the primary key for the tables in iCartiGD, with the Human Genome Nomenclature Commission (HGNC) gene name being used where available.Data parsing and extraction from the source databases are performed by PERL scripts, some of which utilise published parser modules . The extUpdate of the database is performed by automatically regenerating the database each week using a shell script to link the data extraction and database update scripts. The EST and other libraries are down loaded for each update run and the weekly updated mirrors of the source databases provided by the BIOSUPPORT project are accessed. This allows iCartiGD to take account of frequent modifications to databases such as UniGene and to provide the correct mappings from UniGene to the latest version of EntrezGene. Rebuilding the database from the current versions of the source databases ensures all modifications to the data are obtained.An ever expanding amount of information that would be of interest to biologists and clinicians who study cartilage is being gathered in a wide range of databases. If these data are to be utilised effectively, coordination of the resources should prove an invaluable help to the research community. iCartiGD has been developed to provide a single point of entry for cartilage biologists into this wealth of knowledge. A unified web-based, graphical user interface (GUI) was developed to allow users to search and access the data in iCartiGD Figure . CurrentFor cartilage researchers needing access to information on their genes of interest, a variety of query options have been provided through either a quick query box or a query form. The query form allows the combination of search results or further searches within the current results, and the history of the last 30 searches is retained. Queries of the database can be based on all genes in the database, or on the genes expressed in a particular tissue subtype. Advanced search options, such as field limits, Boolean operators, wild cards and phrase matching are available. It is possible for a user to construct queries in URL format so that scripts can be used to access the database instead of the web-based GUI if high throughput is needed. Users can also browse the genes stored in the database by chromosome number or alphabetically by the gene symbol or the gene name. Another form of query is provided by an interface to the BLAST search programs . Users mTo assist with genetic studies, the genomic location of the genes and transcripts in iCartiGD can be visualised on a transcriptome map. At any chromosomal position a user can retrieve the genes or transcripts in the database at that location. This will allow the identification of genes that are expressed in cartilage in the region of, for example, a candidate gene for cartilage disease, or the cartilage expressed genes in a region in significant linkage with disease markers. Comparisons of the differences in gene expression patterns among the cartilage tissue types can be made by examining the gene or transcript density  along eaAs iCartiGD is automatically updated on a weekly basis from major public data sources it will not suffer the lack of currency that befalls many databases. In the event of new EST libraries or large scale transcriptome studies on cartilage being made available, they can be added to the gene expression sources parsed by the update scripts which extract the list of gene identifiers to be supplied to update iCartiGD. Current data for the newly obtained and existing genes will then be automatically retrieved and included in iCartiGD.A knowledgebase is provided in the website to allow new visitors to become familiar with site. Questions received from different individuals can be posted in the knowledge base when appropriate to also allow fellow users to respond to queries or initiate discussions.Searches of expression databases and the literature will be used to identify new studies of gene expression in cartilage. Further developments in iCartiGD will include a differential display tool to assist with comparative studies of different conditions and tissue subtypes. Improved methods to search the database using finer subdivisions of the data than the tissue sub-type currently available will be added. Other methods to examine the genomic distribution of cartilage expressed genes  will be iCartiGD provides a comprehensive source of information about genes known to be expressed in cartilage. It will remain current due to its automatic update capability and will facilitate the research of basic scientists and clinicians studying cartilage related genes. Genetic studies of cartilage development and disorders will also benefit from this database.iCartiGD is available to the public at YQS initiated and supervised the project; MYY, MSYC, CML and DKS carried out the database construction and programming; DKS wrote the manuscript from an initial draft by MYY; DKS, BCW, KMCC, KSEC, PS, DC and YQS participated in its design and coordination and helped to revise the manuscript. All authors read and approved the final manuscript.


International health organizations and officials are bracing for a pandemic. Although the 2003 severe acute respiratory syndrome (SARS) outbreak in Toronto did not reach such a level, it created a unique opportunity to identify the optimal use of the Internet to promote communication with the public and to preserve health services during an epidemic. The aim of the study was to explore patients’ attitudes regarding the health services that might be provided through the Internet to supplement those traditionally available in the event of a future mass emergency situation. We conducted “mask-to-mask” surveys of patients at three major teaching hospitals in Toronto during the second outbreak of SARS. Patients were surveyed at the hospital entrances and selected clinics. Descriptive statistics and logistic regression models were used for the analysis. In total, 1019 of 1130 patients responded to the survey . With respect to Internet use, 70% (711/1019) used the Internet by themselves and 57% (578/1019) with the help of a friend or family member. Of the Internet users, 68% (485/711) had already searched the World Wide Web for health information, and 75% (533/711) were interested in communicating with health professionals using the Internet as part of their ongoing care. Internet users expressed interest in using the Web for the following reasons: to learn about their health condition through patient education materials (84%), to obtain information about the status of their clinic appointments (83%), to send feedback to the hospital about how to improve its services (77%), to access screening tools to help determine if they were potentially affected by the infectious agent responsible for the outbreak (77%), to renew prescriptions (75%), to consult with their health professional about nonurgent matters (75%), and to access laboratory test results (75%). Regression results showed that younger age, higher education, and English as a first language were predictors of patients’ interest in using Internet services in the event of an epidemic. Most patients are willing and able to use the Internet as a means to maintain communication with the hospital during an outbreak of an infectious disease such as SARS. Hospitals should explore new ways to interact with the public, to provide relevant health information, and to ensure continuity of care when they are forced to restrict their services. International public health organizations and officials around the world are bracing for a pandemic -6. ReporThe 2003 severe acute respiratory syndrome (SARS) outbreak caused major disruption of hospital services in affected countries -15 and pAlthough effective, telephone-based communication proved to be a resource-intensive solution that may not be sustainable in the event of a more widespread epidemic or external disaster. Considering that most Canadians have access to the Internet , it coulCommunication with staff and outpatients: Shortly after the beginning of the SARS outbreak, the hospital enhanced its communication capability to ensure the flow of real-time information for public and staff. This process included mass voice mails from the Chief Executive Officer informing staff of the current status and expanding videoconferencing and Web mail services. Web mail traffic increased by 300% in the first days of the outbreak. Meanwhile, hits to the UHN website almost doubled from January to July 2003, from 273269 to 548108, respectively. Interestingly, website hits continued to increase throughout the year and never returned to pre-SARS figures. The corporate intranet was also made accessible over the Internet, enabling UHN to communicate with staff and ensure work continuity despite the environmental restrictions.                            Communication support for inpatients: UHN contracted the services of TLContact CarePages, enabling patients to send updates to family and friends over the Internet [                            Internet .Remote access to UHN’s electronic health record: The electronic health record was made accessible to physicians over the Internet. Since then, physicians can consult patients’ charts remotely. Through an application known as Patient Results Online (PRO), the hospital is providing its clinicians with real-time access to patient results. PRO also allows access to lab results stored in partner hospitals.                            Electronic scheduling: UHN developed an electronic scheduling application to reduce unnecessary patient travel, improve patient satisfaction, and reduce waiting lists. Implemented across all three UHN sites, this system allows electronic access to scheduling and contact information. In the event of a hospital closure, staff working offsite will be able to access schedules and contact patients, removing the need for intense telephone booking, rescheduling, and cancellations.                            Infection control screening and surveillance: UHN developed a SARS screening tool that is currently built into its registration screens. In the event of an outbreak, the surveillance software can be activated and the hospital can track where patients have been in the hospital and where they are headed.                            Insight-alerting system software: This software monitors patient information and alerts health care professionals about critical situations in real time. The software checks information as it is entered into the system and is supported by “rules” to detect potentially dangerous clinical situations. This will be beneficial during an outbreak as the system can detect a positive diagnosis of an infectious disease and alert health care providers by pager, email/Blackberry, the Web, or fax.                            After obtaining permission from the UHN’s Command Centre and approval from the institutional Research Ethics Board, we conducted a cross-sectional survey at the single access points of each of the hospitals comprising UHN  and six of the ambulatory clinics that remained open during July 2003.The survey was based on the core questions of the UHN e1000 study, a cross-sectional survey exploring the patterns of Internet use among patients and providers associated with the UHN. The e1000 survey  is a lon                    To alleviate possible anxiety during the crisis, only 9 questions with categorical responses were asked, in addition to those capturing demographic information .The initial plan to survey all patients entering the hospital after being screened for SARS  proved to be unrealistic due to the cumbersome process of registration and screening that created additional challenges for those people approaching patients. For three days, we surveyed patients after they passed the entrance screening points, and we concluded that the clinics’ waiting rooms would be a more appropriate venue for recruiting. Only adult ambulatory patients were approached. Ten trained multilingual interviewers conducted the surveys in English after obtaining verbal consent. The interviewers and patients were required to wear full protective gear, which meant “mask-to-mask” rather than face-to-face communication .With no face recognition and to avoid re-approaching the same patients, interviewers used colored stickers on the masks of patients to identify those already invited to participate in the survey.Contact information provided voluntarily by patients was stored in a secure database on the Centre for Global eHealth Innovation servers. Hard copies of the surveys were stored in locked cabinets and were accessible to researchers for analysis only at the Centre.P value of .2 was chosen for variable elimination. Then, we applied the enter method on those variables to force all variables into the equation. Results reported in the tables are based on the remaining variables only and include odd ratios (OR) and 95% confidence intervals. A P value less than .05 was considered statistically significant. The variables that did not stay in the model at first step are marked with "NS." All statistical analyses were conducted using the SAS System for Windows, release 8.02 .Descriptive statistics were gathered for each of the answers. Multiple logistic regression analysis was used to assess the effect of the sociodemographic variables on patients’ views of Internet usage for specific services in the event of a mass emergency. We used stepwise, forward, and backward methods with all variables to specify which ones stayed in the model. A cutoff To ensure better reporting, we used the relevant items of the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) . Althoug                    A total of 1130 patients were approached, and 1019 chose to complete the survey, giving an overall participation rate of 90%. Refusal rate was initially higher at the entrances of the hospitals during the first three days of the survey  than later at the clinics that remained open . The most frequent reasons for declining were being late for a clinic appointment (50%), frustration and exhaustion due the long lineup to enter the hospital (20%), lack of interest (20%), and inability to speak English (10%).We found that 91% of patients were aware of the Internet (926/1019) and that 70% used the Internet (711/1019) by themselves and 57% (578/1019) with the help of a friend or family member. Of the Internet users, 68% (485/711) had already searched the World Wide Web for health information, and 75% (533/711) were interested in using the Internet to communicate with health professionals as part of their ongoing care.Table 1 shows the demographic characteristics of all respondents, those with Internet access, and by survey location (entry point or clinic). Overall, there was a balanced gender representation of Internet users in our sample, with 44% (313/711) women and 45% (320/711) men. The majority of Internet users were in the 21 to 40  and 41 to 60  age categories. Almost half  of the Internet users had college or undergraduate education, 3 out of every 4 Internet users (558/711) spoke English as their first language, and 64% of them (453/711) were born in Canada. These demographic proportions are comparable for all users and for users at the entry doors or clinics.P = .14), English as a first language (P = .90), or country of birth (P = .54). However, there were significant differences with respect to education (P < .001) and gender (P = .005). Regardless of the survey location, when all users were combined there was no significant gender difference.There were no statistically significant differences between Internet users surveyed at entry doors and clinics with respect to age , to obtain information about the status of their clinic appointment , to send feedback to the hospital about how to improve its services , to access screening tools to help determine if they were affected by the infectious agent responsible for the outbreak , to renew prescriptions , to consult with their health professional about nonurgent matters , and to obtain laboratory results . Respondents had the opportunity to suggest other uses for the Internet, and 10% (70/711) chose to do so. Their most frequent suggestion was the ability to communicate with family members, as visits were restricted. Others wanted to use the Internet to access their electronic health record, participate in virtual support groups, replace certain follow-up visits with online consultations, and find information on drug compatibility or clinical trials.Statistically significant demographic predictors for interest in specific Internet services among Internet users are shown in Internet users  younger The detailed results for the populations at the entry doors and at the clinics are provided in At the clinics  were used in order to overcome new obstacles, such as high volume of air travel, increased media attention, and generalized panic, alternative methods of communication and collaboration to overcome them were required.Similar to what happened during the anthrax scare , the IntOur results suggest that most patients are willing and able to use the Internet as a means to preserve and complement hospital information and communication services during an outbreak of an infectious disease such as SARS.The results of this study are consistent with previously conducted surveys at UHN during non-SARS times. These results are related only to the proportion of patients using the Internet for general and health purposes. Earlier iterations indicate that 60% of respondents have used the Internet for general purposes and 69% for retrieving health information . During We conducted a systematic review of the literature looking for surveys of patients in relation to the type of services desired but did not find similar enough studies to justify a comparison with our SARS survey (data not shown).There are many other potential uses for the Internet as a means of communication if hospitals and clinics were disabled by a new outbreak. Members of the public with Internet access who are quarantined may use it to get answers to nonurgent questions related to the infectious disease or to receive reassurance that they are managing their health properly . PatientHarnessing the power of the Internet in the event of a new outbreak, and particularly during a pandemic, will require changes at the hospital level that need to be gradually introduced during “new normal” times. At the very least, as part of the patients’ registration process, hospitals should collect data regarding patients’ choice for communication method  in the event of an outbreak.The SARS crisis underscored many opportunities for the use of Internet-mediated communication to extend the continuum of care outside of hospital walls, even under normal circumstances. Embracing the Internet as an integral part of clinical care, however, will require changes in legislation, funding structures, and flexible work patterns to enable health professionals to use it .The findings of our survey highlight the need for timely, relevant, valid, feasible, and substantiated options to maintain communication lines with the public during crises that disable hospitals. We are aware that Internet access is not yet universal, but it certainly could be very valuable for the large subset of the population that uses it , while eWith the current increased risk of pandemics and bioterrorist attacks, it is essential to put in place the mechanisms necessary to use the Internet effectively and efficiently in order to reduce the impact of these crises on the health system and the public at large.The special circumstances under which these surveys were conducted presented several design, execution, and data analysis limitations.The sample chosen was one of convenience. Due to constraints inherent to the emergency, it was difficult to ensure that all individuals attending the hospital at any given date had the same probability of being selected. The difficulty of obtaining an up-to-date list of patients visiting the hospital limited our ability to establish an accurate denominator. Therefore, the likelihood of the sample being representative of the population attending the hospital during the second outbreak of SARS is unknown. To reduce the evident sampling bias, a number of random sampling techniques could have been used. Assuming that the population at selected clinics was captive and had patients with similar health conditions, cluster sampling may have been indicated.At the hospital entry points, some interviewers noted that respondents were rushing and may have fallen into a rut (a “response set”), continuing to give the same response unthinkingly. This was particularly evident for question 6, which may have elicited repeated identical responses . In addition, the number of refusals at the single point entrances was higher than previously obtained at UHN . To mitiComparisons of participants from the three participating hospitals and an assessment of users versus non-Internet users were outside the scope of this study. Furthermore, the patient’s health condition was not collected. For future studies, these elements will be considered.


The objective of the current study was to examine performance and correlates of performance on a decision-making card task involving risky choices (Iowa Gambling Task) in adolescents with ADHD and comparison controls. Forty-four participants with ADHD and 34 controls were administered measures of estimated intellectual ability, working memory, and the card task. Also, behavioural ratings were obtained from parents and teachers.Adolescents with ADHD scored lower on the measures of intellectual ability, working memory, and made less advantageous selections on the card task compared to controls. Performance on measures of intellectual ability and working memory were unrelated to card task performance in both the ADHD and control samples. Parent ratings of hyperactivity/impulsivity were significantly associated with card task performance in the adolescents with ADHD, but not in controls.These findings demonstrate impaired decision-making in adolescents with ADHD, and the separability of motivational and executive function processes, supporting current dual pathway models of ADHD. Individuals with Attention-Deficit-Hyperactivity Disorder (ADHD) are more likely than their peers to make poor real-life decisions, as these individuals are described as impulsive , engage The most recent development in the field has been an emphasis on multiple pathways for explaining impairment in ADHD -16,12. SIn addition to separability at a neuropsychological level, it has been hypothesized that the executive and motivational pathways are rooted in conceptually similar, but functionally segregated brain circuits . It has or low gains and low losses (advantageous decks)] and in frequency of penalties . Expected outcome and frequency of penalties are crossed, creating four different conditions with these four decks. What has been particularly striking and important about these studies on Iowa Gambling Task performance with patients who have ventromedial cortex lesions is not simply the link between brain function and higher cognitive processes, but also the possibility that this form of reasoning may be fairly modular and localized, and separable from other cognitive abilities, such as intelligence  comprisAuditory and Visual-Spatial Working Memory. We used two different tasks to measure memory performance, one auditory-verbal and one visual-spatial. Our measure of auditory memory was the Digit Span subtest (Forwards and Backwards components) from the Wechsler Intelligence Scale for Children – Third Edition  and theor a reward and penalty indicated. Each deck varied on expected outcome [two decks are composed of quick high gains and high losses (disadvantageous decks) or low gains and low losses (advantageous decks)] and in frequency of penalties . Expected outcome and frequency of penalties are crossed, creating four different conditions with these four decks. Therefore, deck A was a disadvantageous deck with frequent, lower penalties, deck B was a disadvantageous deck with infrequent, high penalties, deck C was an advantageous deck with frequent, lower penalties, and deck D was an advantageous deck with infrequent, high penalties. The cards were organized in the exact same order for each and every participant. There were 50 cards in each deck. The reward-penalty schedules that were used for this task are displayed in Table Card Task. This task was designed after the Iowa gambling task by Bechara et al. . The matParticipants were told that they would play a card game in which they had to select 100 cards, and that the purpose of the game was to maximize the amount of money they could win. They were told that on the back of each card in each deck, there was a reward or a reward and a penalty. They were to select cards one by one, and the examiner would give them the reward and collect the penalty after each card pull. Participants were loaned $20.00 at the beginning of the game. Participants were not given any cues or signals during the game about the content of each deck. Participant selections were recorded on a score sheet following the task. As play money was used, participants were told that they could win a $10 gift certificate to a popular local bookstore if they made a net gain in the game as an added incentive, as participants did not receive the actual amount of play money in the game.The dependent measures were the total number of cards participants selected from each deck and the net amount of money participants had at the end of the game. At the end of the game, participants were asked about how the four decks differed to determine whether the participants realized the reward and penalty structure of the advantageous and disadvantageous decks. Specifically, they were asked: "Did you notice anything about the content of each of the decks?"MT was involved in the theoretical conceptualization, data collection and analysis, and writing of the present manuscript. UJ was involved in the clinical assessment of the participants and feedback on the manuscript. RT was involved in the theoretical conceptualization, and provided ongoing input and feedback on the analysis and writing of this manuscript.