Antibiotic resistance is a major public health problem affecting both current and future generations. The influence of environmental factors on antibiotic use and resistance development in bacteria is largely unknown. This study explored the perceptions of healthcare providers on antibiotic use and resistance development in relation to environmental factors i.e. physical, natural, social and behavioural factors.A qualitative interview study was conducted using face-to-face, semi-structured interviews among registered allopathic doctors, veterinarians and drug dispensers in Orissa, India. The interview transcripts were analyzed using latent content analysis.The main findings of this study relate to two themes: 'Interrelationship between antibiotic use, resistance development and environment' and 'Antibiotic management contributing to the development and spread of resistance'. The interviewees viewed the following as possible contributors to antibiotic use/misuse and resistance development: changes in the natural and physical environment i.e. climate variability, pollution, physiography and population growth; the socioeconomic environment affecting health-seeking behaviour and noncompliance with medication; a lack of healthcare facilities and poor professional attitudes; and ineffective law enforcement regarding medicine dispensing and disposal.Generally, the interviewees perceived that although behavioural and social environmental factors are major contributors to resistance development, changes in the physical and natural environment also influence development of antibiotic resistance. The respondents also perceived that there is a lack of information about, and poor awareness of, what constitutes prudent use of antibiotics. They suggested a need for information, education, dissemination and proper implementation and enforcement of legislation at all levels of the drug delivery and disposal system in order to improve antibiotic use and prevent pharmaceutical contamination of the environment. The environment is an omnipresent factor governing all human and animal activities and behaviours and also the micro-organisms that cause diseases in them. According to Smith et al. the environment consists of four major components-physical, natural, social and behavioural . The phyAll over the world, development of resistance to antibiotics is on the increase amongst pathogenic bacteria ,4. HowevIn general in India, and also in Orissa, there is a high incidence of infectious diseases, increasing use of antibiotics by a wide range of health care providers and increasing resistance, associated with commonly occurring indiscriminate use of antibiotics in humans as well as in animals ,6,7. In It is possible that environmental factors have a role to play in the way antibiotics are used in a population and the consequent development of resistance. To explore this issue, a qualitative study is needed to understand the way people perceive the issue and the meaning they attach to it, which can be further addressed quantitatively.We therefore, conducted a qualitative study among healthcare providers in the eastern Indian state of Orissa, taking it as an example, to explore their opinions about antibiotic use and antibiotic resistance development in relation to environmental factors.Out of the 30 districts of Orissa, four were purposely selected for the study. These districts were selected based on the geography, population density, urbanization, ethnicity, literacy rate and availability of healthcare facilities. The intention was to incorporate a variety of behavioural, social, natural and physical environmental factors. The districts of Cuttack and Khurda, were selected as representing an urban environment, proximity to sea, high population density (about 640 people per square kilometre), and high literacy rate (about 80%) . The disOnly allopathic providers were selected as they were most likely to handle antibiotics. To maintain a balanced distribution among the various types of healthcare providers i.e. registered allopathic doctors, veterinarians and drug dispensers included in the study, two participants from each district and from each healthcare provider category  were selected. Thirty-six potential participants had to be contacted to reach the desired distribution among the participants, as 12  did not agree to participate due to their busy schedule. All the participants were contacted in person or by telephone by the first author (KCS) before the interviews. All the participants participated voluntarily; no payment was offered nor given. Detailed information about the interviewees is presented in Table Data was collected by face-to-face interviews using open-ended questions (Appendix 1). All interviews were conducted in a mix of local language (Oriya) and English and lasted for an average of 29 (range 20-40) minutes for registered allopathic doctors, 24 (range 15-40) minutes for veterinarians and 17 (range 13-20) minutes for drug dispensers. All the interviews were conducted by the first author who is a native of the study area and has an educational background in biological and environmental sciences as well as experience in social services. The co-investigators have different backgrounds: agriculture, environmental medicine, pharmacy, nursing and qualitative research, all with a public health perspective.The tape-recorded interviews were transcribed verbatim and the transcripts were translated into English and analyzed using latent content analysis .Latent content analysis deals with the identification of the underlying meaning of the text. The selection of the unit of analysis is the first step in the content analysis. Meaning units i.e. parts of the original transcript text that are related to the aim of the study are selected from the interview transcript. The meaning units are condensed and coded. Similar codes are clustered together and collapsed into subcategories and categories. A category is a group of related codes. The theme is then identified and illustrates the underlying meaning of the text.Such a procedure was followed to analyse the contents of the interviews. During the conduct of this procedure, the tape-recorded versions and the Oriya and English transcripts were consulted repeatedly during the coding procedure to understand the full meaning of the text.The study was approved by the ethical committee of the Kalinga Institute of Medical Sciences, Orissa, India. Before the interview, information was given about the purpose of the study to the interviewees and they were told that they could withdraw from the study at any time. Written consent was obtained from each interviewee. All the interviews were carried out in complete privacy at the place chosen by the interviewee  and the names of the interviewees were kept confidential.Two major themes 'Interrelationship between antibiotic use, resistance development and environment' Table  and 'AntThis theme evolved from two categories (i) Influence of ecological factors on antibiotic prescription and (ii) Influence of presence of antibiotics in the natural environment leading to resistance development.Under this category two main subcategories were identified (i) Abiotic factors (ii) Biotic factorsThe abiotic factors are the non-living factors of the environment e.g. chemical-minerals, water; physical-temperature, sunlight. Two main abiotic factors, climate and physiography, were identified in this subcategory. Interviewees perceived that climatic factors such as precipitation, temperature and humidity had significant impact on antibiotic prescription. Interviewees felt that seasons influenced the occurrence of infectious diseases and hence changed the antibiotic prescription patterns. According to them, each season had its own types of diseases. In high temperature conditions in the summer, stress-related diseases in animals were more common. Diarrhoea was more common in humans in the rainy season. Both complaints led to high antibiotic prescription. High temperatures in the summer and high humidity in the rainy season resulted in more skin infections in humans and in the winter, although people were normally healthier, respiratory tract infections, including the common cold, led to misuse of antibiotics."When the monsoons start, at that time bacterial disease is more common and it is common in animals. There is less infection in winter. In summer, protozoan diseases are more common, due to summer stress; all Indian animals carry most of the diseases. Protozoan diseases are particularly common in forest areas. In coastal areas, a higher antibiotics prescription rate is more common. The environment is slowly changing, the temperature is rising." "In most of the cases, high doses of antibiotics are prescribed from the beginning, probably due to the change in climate." The interviewees' perception was that antibiotic use varied in different geographical areas, for example - in coastal and non-coastal areas. According to prescribers, higher antibiotics were used in coastal areas to control infectious diseases whereas in hilly areas most of the patients took traditional herbal treatment and lower antibiotics. They viewed that geographical variation in antibiotic consumption and resistance may be associated with factors such as regional climate, socioeconomic conditions, local population density and behaviours of a particular community towards antibiotic prescribing or consuming."In my view rampant use of antibiotics for minor infections is one cause of resistance in coastal areas; they are prescribing higher antibiotics unnecessarily." The interviewees also felt that pollution had a significant impact on antibiotic prescription. They perceived that in polluted areas, both infections and resistant bacteria spread more quickly."In polluted areas resistance is high, where pollution  is more, infections spread quickly. Now higher antibiotics are used due to pollution. In polluted areas, antibiotics are used for many days. We have to change two or three antibiotics." According to the interviewees, the health of humans is influenced by their habitat i.e. the area where they live and its components like plants, animals, micro-organisms and other human beings. The interviewees further perceived that large numbers of people making use of fewer health care facilities, leading to a high patient load in hospitals, caused improper diagnosis and inappropriate use of antibiotic treatment. The participants reported that overcrowding created unhygienic conditions which also caused infectious diseases to spread more rapidly, leading to increased irrational antibiotic prescription."In crowded areas, due to the unhygienic environment; infectious diseases are more common, if population density is high, then there are more diseases and more antibiotic prescriptions." Two main subcategories were identified under this category (i) Antibiotics in the natural environment and (ii) Effect of presence of antibiotics in the natural environment.Interviewees put forward a viewpoint that, due to the widespread improper disposal of pharmaceuticals, antibiotics are contaminating the aquatic as well as the terrestrial environment. According to them, hospital waste, out-of-date medicines from shops and unwanted household pharmaceuticals were not disposed properly and this was polluting water, grasslands and air. They believed that properly implemented and enforced environmental law or policy was essential for the safe disposal of pharmaceutical waste."Out-of-date medicine, if thrown outside, will impact the environment. What we throw away, it will mix with water, again when we drink that water, that water again enter into the blood and obviously it will have an impact. Environmental law is essential." According to the interviewees, the improper disposal of antibiotics was affecting aquatic organisms, grazing animals and also human beings, who were using river or pond water for drinking and cooking."If pharmaceutical wastes are disposed improperly, it will affect. Expired medicine loose its efficacy, but not toxicity.... If we throw these wastes outsides that will mix up with pond or river water; if that water is taken by human or animal it may create problem; what happened recently at Cuttack, some cattle died by eating expired medicine including some antibiotics which were thrown improperly at the river beach. Some aquatic organisms also died. Every drug is in proper dose medicine and improper dose poison." Interviewees also assumed that antibiotics in the environment had a significant impact on micro-organisms. One interviewee pointed out that waterborne bacteria might develop resistance if they were exposed to low doses of antibiotics in water."If waterborne diseases causing bacteria are exposed to low doses of antibiotic every day, they gradually become tolerant to that particular drug and resistance will develop." Some of the interviewees were of the opinion that there was not much research on the environmental aspects of antibiotic resistance and they suggested further research in this area in order to find out the exact problems and their proper solutions."Antibiotic resistance in relation to the environment is a research question, further study is essential in this field." This theme emerged from the categories (i) Antibiotic use and factors influencing prescribing and (ii) Health systems and policy factors influencing resistanceUnder this category, two subcategories were identified (i) Humans and (ii) AnimalsThe interviewees used the term 'higher antibiotics' in varying meanings including new generation, broad spectrum, high dose or high-price antibiotics. Their view was that the prescribing of any type of 'higher antibiotics' in the first encounter was one of the reasons for bacterial non-response to 'old' antibiotics. Most of them viewed that the indiscriminate use of antibiotics has lead to the resistance problem. In their opinion, high patient load, prior prescription by unqualified prescribers and high prices of antibiotics are major reasons for inappropriate prescribing of antibiotics. The interviewed doctors said that a single doctor prescribes to approximately 50-90 patients per day in both rural and urban hospitals. This high patient load can cause improper diagnosis, leading to inappropriate treatment and improper use of antibiotics. All the interviewed doctors mentioned that before visiting an authorized medical practitioner, many patients take earlier treatment from 'quacks', i.e. untrained people, who act as physicians and give medical advice and treatment. Furthermore, patients may also have bought medicines directly from the drug store on the advice of drug dispensers or based on their own diminutive knowledge. The interviewees said that quacks are prescribing incomplete courses and doses of antibiotics and some of them suggested that the quacks should receive training."Doctors are not available, quacks are helping the patients...... in my view we have to give training to them and license them, something that has recently been done in Kolkota [a city in India], and we have to train them as paramedical practitioners." Drug dispensers said that sometimes prescribers are influenced by a particular company and prefer to prescribe that company's medical products. They thought that these factors influence antibiotic prescriptions. On probing, some of the drug dispensers admitted recommending antibiotics themselves even for the common cold."If the patients say that they have a sore throat, we prescribe five tablets of roxithromycin. We force them to take [buy] the full course, but they often just take for one day or one to two tablets. The common cold is very common here and people usually take anticold tablets with antibiotics. We prescribe lower antibiotics like cefadroxil for colds. If they aren't cured, we prescribe higher antibiotics like cefixime." According to the interviewed veterinary surgeons, penicillin, amoxicillin, cloxacillin, ciprofloxacin and tetracycline are the most commonly used antibiotics on dairy and poultry farms and for household pets for therapeutic purposes. These are also commonly prescribed antibiotics in humans. In their opinion, prior prescription by unqualified prescribers was influencing antibiotic prescriptions for animals although pharmaceutical companies do not exert the same influence in veterinary practice as in human medicine. Prescribers perceived that if antibiotics were used on dairy farms during lactation, it would get into the milk. In their perception, this might be one of the reasons behind the resistance development as people use a lot of milk in food preparation. All the veterinarians said that in the case of poultry, antibiotics were used both for prophylactic purposes and as growth promoters in feeds. They disliked the use of antibiotics as growth promoters and some of them suggested the use of probiotics for this purpose instead."In poultry, antibiotics are generally used as growth promoters in feeds, e.g. tetracycline and lincomycin. Nonhuman use of antibiotics definitely creates resistance problems in humans." Three major factors influencing resistance were recognized under this category: (i) Patients (ii) Health systems and professionals and (iii) Policy and regulatory issues.Interviewees felt that patients' noncompliance with prescribers' instructions, self-medication, poverty, ignorance about antibiotic use and lack of awareness about resistance were all possible contributors to resistance development. According to them, poverty in rural areas and self-medication in urban areas were the major reasons for patients taking incomplete courses of antibiotics. The interviewees felt that the cost of the drugs varied from company to company and believed that many patients were under the impression that more expensive drugs were more effective and were therefore purchasing high-priced antibiotics but not completing the entire course of treatment due to the high expense involved. Interviewees were of the opinion that a lack of public awareness about the consequences of improper use of antibiotics was a cause of irrational antibiotic use, which led to resistance development."If patients have taken incorrect medicine, it will develop resistance and due to resistance to previously prescribed antibiotics, the doctor will prescribe new, more expensive antibiotics. Because of the high price involved, the patient is unable to buy the full course, which will once again create resistance to the new antibiotics, so public awareness is essential." A majority of the prescribers interviewed considered that a lack of infrastructure, improper diagnosis of diseases, inadequate prescription by some prescribers and irrational use of antibiotics by some patients were the major health system and professional factors responsible for improper use of antibiotics. For them, inadequate prescription meant insufficient dose or too short a course of antibiotics and irrational use involved indiscriminate and improper treatment of diseases. They said that sometimes antibiotics were used for a disease condition that might not need antibiotic treatment and this was the result of improper diagnosis."The common cold is a viral disease but we are prescribing antibiotics for this, possibly to prevent a suspect secondary infection, not for the original viral infection." According to the interviewees, there was a lack of good laboratories for culturing and sensitivity testing, which caused improper diagnosis and hence irrational antibiotic prescribing in humans. Veterinarians reported that the lack of good laboratories and staff was the major factor responsible for improper use of antibiotics in veterinary practice. All interviewees considered that this erroneous way of antibiotic treatment was one of the causes of resistance development.Many interviewees said that weak implementation of prevailing legislation governing the health care system was one of the possible contributors to resistance development. Due to weak drug policy, fake and low-quality antibiotics are available in the market and prescription-only drugs are also available without a doctor's prescription. Some interviewed doctors suggested that the selling of antibiotics without a prescription from an authorized medical prescriber should be banned and that a strong drug policy was needed to promote rational use of drugs. The participants informed that antibiotics are also commonly prescribed by some of the homeopathic and ayurivedic healthcare providers although they are not supposed to do so. Most of the doctors suggested that antibiotics used in humans should not be used in animals."Now fake medicines are available in India, I do not know how it is possible." "Unauthorized medical practice should be banned, either they are quacks or homeopathic or ayurivedic doctors, they should prescribe their own medicine, the majority of them are prescribing antibiotics, they don't have enough knowledge about dosage, course......half of the drugs which are banned in developed country end up and are prescribed here." To the best of our knowledge, this is the first qualitative study exploring perceptions about the interrelationships between antibiotic use, resistance development and environmental factors, i.e. physical, natural, social and behavioural factors. The views put forward here suggest that the possible contributors to antibiotics use/misuse and resistance development are - changes in the natural and physical environment, i.e. climate variability, pollution, physiography and population growth; socioeconomic environmental factors affecting health-seeking behaviour and noncompliance with medication; a lack of healthcare facilities and poor professional attitudes; and ineffective law enforcement in relation to drug dispensing, manufacture and disposal.According to Brown , there iThere is a general lack of studies on whether changes in weather conditions modify levels of antibiotic resistance. However, some studies from Europe and the United States have reported on geographical variation in antibiotic consumption and resistance, taking into account the influence of social and climatological factors -17, whicPrevious studies have shown that outdoor environmental air pollution from various sources, such as motor vehicles, industry, and neighbourhood-level solid waste burning, is associated with increased morbidity and mortality from respiratory infections in children and adults ,19. IncrThe impact of antibiotic use on the environment was also perceived by healthcare providers. One participant suggested that antibiotic contamination of the aquatic environment may be one of the reasons for the resistance found in waterborne bacteria, due to exposure to below-threshold concentrations in water. Studies have shown that antibiotics and antibiotic resistant bacteria are found in the aquatic environment ,21, howeParticipants in this study perceived that socioeconomic and behavioural factors, i.e. poverty; self-medication and non-compliance result in inappropriate use of antibiotics. This finding is consistent with the results of other studies from low- and middle-income countries ,24. The According to previous studies from India by Basu et. al.  and PateThe participants also offered a view that monitoring resistance patterns at the local level and making available this data to local prescribers may help appropriate empirical therapy. They also felt that information about and awareness of what constitutes prudent use of antibiotics given to practitioners routinely, might help reduce unnecessary antibiotic use and hence prevent resistance development. Our participants, especially the drug dispensers perceived that supplier incentives to the prescribers, is one of the factors responsible for higher antibiotic prescription rate. A study in China , in addiStudies have documented the presence of antibiotics in milk from dairy animals ,34. The In India, state governments have adopted central government guidelines on policies and programmes for healthcare development, and the state of Orissa adopted a policy on rational drug use in 1997 . PreviouAfter the United Nations Conference on the Human Environment in Stockholm in 1972, India passed the Environmental (Protection) Act in 1986. It provides for "the protection and improvement of environment and the prevention of hazards to human beings, other living creatures, plants and property". There is need for effective enforcement of this law to protect our environment from pharmaceutical waste.- in this case the relationship between antibiotic use, resistance development and the environment. In order to improve the trustworthiness of our study, we used data triangulation during the analysis. Data was collected from different healthcare professionals including allopathic doctors, veterinarians and drug dispensers. The informants were from different geographical areas and socioeconomic environments, in this case proximity to sea/inland areas and urban/rural environments. During the coding procedure, both Oriya and English versions of the transcripts, and in some complex cases, tape recorded data, were used simultaneously in order to avoid misinterpretation of the full meaning. The authors of this study were from different educational backgrounds and countries, and each one brought a unique perspective to the study, enhancing its conformability. In the analyses, this factor served to broaden the interpretation and the final result is a negotiated outcome.A qualitative approach is the preferred method to explore an emerging concept Generally, the interviewees perceived that although behavioural and social environmental factors are major contributors to resistance development, changes in the physical and natural environment also influence development of antibiotic resistance through the occurrence of infectious diseases and consequent use of antibiotics. The authors feel that quantitative studies are needed to verify the perceptions of our interviewees regarding the interrelationships between environmental factors and antibiotic use and development of resistance. The authors have therefore initiated studies towards this end. The respondents also perceived that there is a lack of information about, and poor awareness of, what constitutes prudent use of antibiotics. They suggested a need for information, education, dissemination and proper implementation and enforcement of legislation at all levels of the drug delivery and disposal system in order to improve antibiotic use and prevent pharmaceutical contamination of the environment.The authors declare that they have no competing interests.KCS, AJT and CSL designed the study. KCS interviewed, transcribed and translated the interview transcripts from Oriya to English and made preliminary analysis. All authors contributed to the final analysis of the interviews. All authors have read and approved the final manuscript.1. What are the common indications of antibiotic prescribing/dispensing and factors influencing these? Probe: Common infectious diseases, antibiotics prescription and prior treatments2. What is your view on antibiotic resistance? Probe: Possible causes, drug quality, human and nonhuman use of antibiotics and their impact3. What is your view on environmental issues in relation to antibiotics? Probe: Antibiotic use and resistance development in relation to the environment, disposal of pharmaceutical waste and its impactThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/629/prepub


Reviewing and summarizing the treatment of HIV disease and its complications is a daunting task. Writing a textbook incorporating the rapidly evolving treatments and management strategies is even more difficult. In this third edition of AIDS Therapy, the authors have combined the efforts of international experts to fulfill this goal. As with every textbook, references are a little outdated; few references are more recent than 2006. The addition of online access to updates will possibly alleviate this problem, although the online version still lists the Department of Health and Human Services guidelines for antiretroviral use from October 2006.Excellent chapters cover the serologic diagnosis of HIV disease, primary care in industrialized and resource-limited countries, strategic use of antiretroviral agents, immune-based therapies, and special clinical settings. Although the management of pregnant HIV-positive patients is discussed, no individual coverage of pediatrics is provided.The text provides comprehensive reviews of each antiretroviral agent, summarizing pharmacology, adverse reactions, and clinical uses, and extensively reviewing major trials for each agent. For some of these agents, this represents a historical review of monotherapy without practical application. For example, a full chapter is devoted to zalcitabine, an agent that was discontinued in June 2006. For antiretroviral agents, the best summary, referred to as “recommendations for use,” is included in the last section of each drug chapter. Individual chapters describe opportunistic infections and malignancies, including their diagnosis, therapy, and prevention of these diseases. Variability in the length of these chapters does not always correlate with the importance of these processes. The inclusion of multiple charts and algorithms provides a useful approach to diagnosis and management. The last major section of the text provides approaches to specific syndromes including the major problems in patient care. These are excellent chapters and will be useful to clinicians evaluating specific syndromes. The lack of color pictures in the dermatologic and oral manifestations sections (even in the online version) is a drawback. The final chapters on drug administration and medications are useful tabulations of drug interactions, dosing, and adverse events.This is an excellent comprehensive source book for AIDS clinicians, although it should not be considered a rapid guide to treatment options. This is a text that will be useful for understanding the basis of our current drug therapy. In contrast, the chapters discussing specific disease processes or syndromes will be extremely useful for the busy clinician looking for a single source for these conditions.


Chronic Obstructive Pulmonary Disease (COPD) is among the leading causes of death in the world, and further increases in the prevalence and mortality are predicted. Delay in diagnosing COPD appears frequently even though current consensus guidelines emphasize the importance of early detection of the disease. The aim of the present study is to evaluate the effectiveness of a screening programme in general practice.Subjects aged 65 years and older registered with a General Practitioner (GP) in the eastern Copenhagen will receive a written invitation and a simple questionnaire focusing on risk factors and symptoms of COPD. Subjects who meet the following criteria will be encouraged to undergo spirometric testing at their GP: current smokers, former smokers, and subjects with no smoking history but who have dyspnea and/or chronic cough with sputum.The Copenhagen COPD Screening Project evaluates the effectiveness of a two-stage screening program for COPD in general practice and provides important information on how to organize early detection of COPD in general practice in the future. Chronic Obstructive Pulmonary Disease (COPD) is among the leading causes of chronic morbidity and mortality throughout the world. In 2002, COPD was the fifth leading cause of death in the world, and further increases in its prevalence and mortality are predicted -4. COPD 1 (forced expiratory volume in first second) associated with the development of the disease [Early detection of COPD is crucial for promoting smoking cessation and instituting pharmacological and non-pharmacological therapy before patients reach symptomatic and costly stages of disease. Smoking cessation is followed by a marked reduction in the irreversible accelerated decline in FEV disease ,4. Even  disease ,9-11. A  disease . This is disease . In gene disease -15. For  disease .The GOLD international guidelines for COPD, as well as national guidelines, advise spirometry as the gold standard for accurate and repeatable measurement of lung function. Primary care physicians are in an ideal position to detect early-stage COPD and perform spirometry to confirm the diagnosis ,9,11. ThIn previous studies, mainly two methods have been used to increase the rate of early diagnosis of COPD: screening of high-risk populations and case-finding. High-risk screening studies offer spirometry to all people in a selected population who meet certain criteria; often smokers, whereas case finding studies offer tests only to those who consult a GP for other health problems. Their advantages and disadvantages make them complementary approaches -24.Effective case-finding depends on patient contact with GPs. In 2005, approximately 15% of the Danish population had no contact with their own or other GPs . AlthougScreening and case-finding programs have mainly focused on smokers and former smokers. However, the present model also includes subjects with no smoking history, but with a history of dyspnoea and/or chronic cough with sputum -24,26-28The aim of the study is two-fold. First, we will assess if a short, mailed questionnaire, based on patient-reported information can serve as a first-level screening tool for the identification of individuals at risk for COPD. Secondly, we would like to assess if the self-administrated questionnaire can be used to prompt individuals at risk to undergo spirometric testing at their GP for an early diagnosis.This study is collaboration between the City administration of Copenhagen, Bispebjerg University Hospital, and GPs in the local area of Oesterbro. It will be performed in eastern Copenhagen, which has a population of 67,330 citizens and 56 GPs. All individuals, aged 65 years and older, registered with one of the 56 general practices will be selected for the study. The Capital Region will provide the subjects and their addresses from the Danish Civil Registration System (CPR), in which all Danish citizens have a personal identification number. All subjects from the study population will receive a short questionnaire in order to identify those at risk of COPD. The participating GPs will be asked to screen every subject at risk who requests an appointment for spirometric testing Figure . InclusiAll subjects will receive an invitation letter by mail containing a small booklet about the study and general information about COPD, its prevalence, and the relation between the disease and smoking. They will be asked to complete a questionnaire indicating their smoking status and potential COPD symptoms Figure . SubjectTo increase participation rates, advertisements will be placed in the local newspapers three times during the study period. The project manager will also visit local senior clubs to provide information on the project and to encourage subjects to participate.® spirometer will be available to each practice that needs one for the duration of the project. Spirometry will be performed by the GP or practice nurse/assistant. Subjects enrolled in a General Practice office that does not offer spirometry, are invited to contact the Health Care Centre in eastern Copenhagen for a lung function test. A specially trained project nurse will perform spirometry and forward results to the patient's GP, who is responsible for the interpretation of the test. All spirometry performed by GPs will be re-evaluated by an experienced physician at Department of Respiratory Medicine, Bispebjerg University Hospital. Written informed consent will be obtained from all subjects prior to spirometry.Spirometry will be performed using the different spirometers available in each practice; as not all GPs have a spirometer, an EasyOne1) will be measured, and the FEV1/FVC-ratio will be calculated. The FVC and FEV1 used will be the largest value obtained from any of three technically satisfactory tests that vary no more than 5% or 100 ml, whichever is greater. Post-bronchodilator FEV1/FVC and FEV1 measurements will not be performed at this occasion.Forced vital capacity (FVC) and forced expiratory volume in first second  is only conducted in 30% of patients diagnosed with COPD [Five studies have shown that implementation of spirometry in general practice is feasible if adequate training is used and interpretation of spirometry is provided -34. Howeith COPD . These rTherefore, prior to the screening, all GPs and their clinical staff will be invited to participate in a two-hour course that includes aspects of diagnosis and management of COPD, as well as training in performance and interpretation of spirometry. Continuous technical and methodological support is available to the participating GPs through the screening period. The course and ongoing support will be carried out by a physician from the Department of Pulmonary Medicine, Bispebjerg University Hospital, and the project leader.In addition to the course, all GPs will receive written instructions on how to perform spirometry and interpret results and on medical treatment and referral procedures for pulmonary rehabilitation in accordance to the GOLD-guidelines. They will also receive a list of names and identification numbers for patients invited to participate.All nurses and home helpers at Home care Oesterbro will be invited to participate in a two-hour course that will include a short introduction to the project, information on symptoms of COPD, treatment, and how to help COPD patients to cope with daily life. The course will be carried out by a specialised nurse in COPD and the project leader. The purpose is to increase participation; patients receiving home care will typically be the weakest of the invited population and some may need help to respond to the invitation letter.A calculation of the expected patient volume is shown in figure To estimate the effectiveness of the questionnaire as a first-level screening tool for the identification of subjects at risk, we will look at the response rates to the questionnaire and the number of subjects at risk. Secondly, we will measure the interest in undergoing spirometry among high-risk subjects as measured by the answers to the questionnaire and the number of spirometries performed. In regard to the number of performed spirometries, we will compare participation rates among those who have been told to contact their GP and those who have been told to contact the local health care centre. Finally, we will assess the prevalence and severity of COPD among subjects who undergo spirometry.To analyse the response rate to the questionnaire and the number of people at risk, descriptive statistics will be used. The association between individuals expectation to undergo spirometry and patient characteristics will be evaluated as well as the association between having spirometry performed and patient characteristics. Logistic regression will be used to estimate the odds of expected participation and actual participation (spirometry) with age, sex and smoking status as the independent variables. Comparisons between the group told to contact their GP for a test and the group told to contact the health care centre will be made with Chi-square tests. Finally the prevalence and severity of COPD will be estimated with descriptive statistics.The study will be conducted according to the principles of the Helsinki declaration. The study is approved by the Danish Scientific Ethics Committee under ref. no H-B-2007-057, by the Danish Data Protection Agency and by the Committee of Multipractice Studies in General Practice under ref. no: MPU 16-2007.The study will be completed between February 2008 and February 2009.The current study will be able to assess whether a short, mailed questionnaire based on patient-reported information can serve as a first-level screening tool for the identification of subjects at risk of COPD. Secondly it will be able to illustrate whether a focused questionnaire can prompt individuals at risk to undergo spirometric testing at their GP for an early diagnosis. It will be more economically efficient than broad population-level screening for COPD and reach a larger population than is possible through case-finding alone. By including not only smokers, but also former smokers and individuals with no history of smoking, but with a history of either dyspnea, chronic cough, or both, we will reach the largest possible population at risk.The authors declare that they have no competing interests.AML drafted the manuscript. AML, VB, VG, BN, MSØ and AF participated in the design of the study. AF and AML obtained funding for the project. AML, VB, VG, BN, MSØ and AF read, commented, and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/524/prepub


Anopheles mosquitoes) shifting from their traditional locations to invade new zones is an important concern. The vision of this study was to exploit the sets of information previously generated by entomologists, e.g. on geographical range of vectors and malaria distribution, to build models that will enable prediction and mapping the potential redistribution of Anopheles mosquitoes in Africa.Malaria is rampant in Africa and causes untold mortality and morbidity. Vector-borne diseases are climate sensitive and this has raised considerable concern over the implications of climate change on future disease risk. The problem of malaria vectors (Anopheles mosquitoes. The same parameters were used in determining the ecoclimatic index (EI). The EI values were exported to a GIS package for special analysis and proper mapping of the potential future distribution of Anopheles gambiae and Anophles arabiensis within the African continent under three climate change scenarios.The development of the modelling tool was carried out through calibration of CLIMEX parameters. The model helped estimate the potential geographical distribution and seasonal abundance of the species in relation to climatic factors. These included temperature, rainfall and relative humidity, which characterized the living environment for These results have shown that shifts in these species boundaries southward and eastward of Africa may occur rather than jumps into quite different climatic environments. In the absence of adequate control, these predictions are crucial in understanding the possible future geographical range of the vectors and the disease, which could facilitate planning for various adaptation options.Thus, the outputs from this study will be helpful at various levels of decision making, for example, in setting up of an early warning and sustainable strategies for climate change and climate change adaptation for malaria vectors control programmes in Africa. Anopheles species: Anopheles gambiae, Anopheles arabiensis and Anopheles funestus are considered to be the major vectors most responsible for malaria transmission. The first two species belong to a group called A. gambiae complex, which is considered to be the most efficient malaria vector in the world [The Anopheles mosquitoes are the worldwide known vectors of malaria. In Africa, three he world . Actual Anopheles. Lindsay et al [Anopheles species occurrence in Africa using climatic and distributional data. Coetzee et al [A. gambiae complex . The approach was based on relating ecological niches of species point occurrence data to electronic maps of relevant ecological dimensions in order to produce rules that describe the potential distribution of the species [Pioneer work on malaria vector distribution ,3 only ray et al  attempteee et al  mapped A species .Anopheles mosquitoes [Anopheles distribution range shifts are more likely to occur than range expansions. It is then clear that one of the major threats for the current functioning of the world is the uncertainty about the effects of global climate change. Working knowledge of where malaria vectors specially occur and will potentially occur in the future under climate change scenarios is very essential for the malaria control programme managers and policy makers. Entomologists and malariologists throughout the African continent have collected distributional and biological data. This study aims to make use of these records to increase the understanding and produce potential future distributional maps for two members of the A. gambiae complex; A. gambiae and A. arabiensis under different climate change scenarios. The CLIMEX model, which is a platform, designed to infer species responses to climate from observations on their geographical distribution and seasonal phenology was used for the effect [Early hypothesis about climate change and vector-borne diseases in general proposed that increased temperature and precipitation could facilitate the emergence and persistence of squitoes . Furthersquitoes . A recensquitoes  has addee effect ,10.The distributional records for malaria vectors used in this study came from the ARMA/MARA website , recent The African climate is diverse and varied. It is diverse because it ranges from humid equatorial regimes, through seasonally arid tropical regimes, to sub-tropical Mediterranean type. By this diversity, it demonstrates different degrees of spatial variability, particularly with regard to rainfall . The tem- The band of latitudes centred on the equator was considered as the equatorial zone and the winter and summer seasons were defined with reference to the equatorial zone and the day of the year.- To the north of the equatorial zone, summer was defined as the days from March 2 - September 30, with winter being the rest of the year. Reinforcing the same argument, south of the equatorial zone, the situation was the reverse.Anopheles mosquitoes to temperature and rainfall. The temperature, rainfall and humidity are important determinant factors for the Anopheles distribution. A little increase in temperature leads to an increase in the mosquito's development and the adult frequency of blood feeding [Anopheles breeding and survival are determined and characterized by rainfall and humidity. In relation to these criteria the following scenarios were chosen:Two major reasons guided the choice for the climate change scenarios; the first was linked to African climate as mentioned earlier and the second, the response of  feeding . The Anoa) Scenario 1: A rise of 2°C Africa wide temperature, and 10% increase of summer rainfall and 10% decrease in winter rainfall.b) Scenario 2: A 0.1°C rise in summer and winter maximum and minimum temperatures per degree of latitude, and a 10% increase in rainfall in summer, and 10% decrease in winter.c) Scenario 3: A rise of 4°C Africa wide temperature, and 20% increase of summer rainfall and 20% decrease in winter rainfall.Many theories accounting for the abundance, distribution, change and variation of species population have been proposed. They can broadly be divided in two classes; the first class regrouped those that view climate either directly or indirectly through its interactions with species-specific characters, as the major determining factor , and theA), with the annual stresses that limit survival during the unfavourable season (SI) and with the limiting interacting factor between stresses (SX) [The platform applied is called CLIMEX. The model theory is generally based on the species estimated responses to temperature and moisture. The CLIMEX model estimates are founded on the assumption that if you know where a species lives, you can infer what climatic conditions it can tolerate. In other words, CLIMEX attempts to mimic the mechanisms that limit species geographical distributions and determine their seasonal phenology and to a lesser extent their relative abundance ,10. It dses (SX) . These iW and MIw are the weekly temperature and moisture respectively, 52 is the number of weeks in a year. CS, DS, HS and WS are the annual cold, dry, heat and wet stress indices respectively. CDX, CWX, HDX and HWX are the annual cold-dry, cold-wet, hot-dry and hot-wet stress interactions indices respectively.Where: TIThe locations with positive values for EI are suitable for a species, and the larger the value of EI, the more suitable the location. As few climates are 100% suitable throughout the year, the value of EI will rarely reach its potential, thereby limiting the maximum value of EI .Anopheles species population growth rate, the developmental threshold temperature and moisture levels. The CLIMEX model parameters were repeatedly adjusted and the function "Compare location", which describes the potential geographical distribution of a species, as limited by climate was re-run until the estimated potential Anopheles species range best matched the observed or known distribution.In building the model, the usually observed geographical distribution data from African countries belonging to the sub-Saharan region was mapped in accordance with each chosen A. gambiae and A. arabiensis) under prediction only occur in Africa and in no other location in the world. Soper and Wilson [A. gambiae complex in north-eastern part of Brazil around 1930 to 1940 to have been via accidental introduction. Therefore, the opportunity of using South America for the developed model validation became possible and practical. The parameters estimated from the building exercise were then used to run the "Compare location" function in South American region for predicting the Anopheles species potential distribution in north-eastern parts of Brazil. This and the building exercises were successively repeated by slightly adjusting parameters until a 'good fit' for the known distribution in Africa and mentioned location in South America, was obtained respectively.In order to test the model's predictive capability, it was initially intended to use independent data; meaning records that do not have any connection with the information applied, for model parameters estimation. However, this intention encountered difficulties as the two species  represent unchanged zones in terms of species suitability. In all circumstances, these regions are few, proving that changes in African malaria vectors distribution under rising temperature and rainfall variability is real. The EI values vary from (0 - 40) and from (0 - 100) and (-70 - 70) for A. gambiae complex was imported to Brazil. During that period, the A. gambiae was yet to be recognized as a complex of multiple species, and the real identity of the member of the complex that was responsible for malaria transmission in the area remained unidentified, and speculations have been made that the species that invaded the area was either A. gambiae or A. arabiensis. In validating the model, it was suggested and established that the A. gambiae species was likely responsible for the deadly malaria outbreak in southern eastern Brazil around the 1930s  outside its normal area of geographical distribution as was illustrated during the model validation. The present research has guided us in suggesting that A. gambiae is most likely to be the species responsible for the 1930's malaria outbreak in Brazil. Another range extension of a member of the A. gambiae complex occurred in about 1942 into Upper Egypt [A. gambiae was a complex. In the light of this study, the probable species concerned with the range expansion in Upper Egypt could have been the A. arabiensis. This argument is based on the fact that the northern limits of distribution for A. arabiensis in the Nile Valley are normally in the northern part of the Sudan. Seasonal climate fluctuation may easily favour the species invasion in neighbouring regions, and it is also possible that similar unrecorded invasions have occurred in the past and may continue to occur in the future.In the past years, a member of the er Egypt . As in BAnopheles species existence. However, it is the only factor with available global data that provides an initial estimate of the potential range of Anopheles species. The present study should rather be seen as an illustration of the substantial influence, which the direct effects of climate change may constitute to malaria vectors redistribution in Africa. The results presented here should be interpreted as an indication of the sensitivity of malaria vectors to global climatic changes, particularly temperature rise. More elaborate future risk assessments of climate change on malaria vectors in Africa will ultimately need to include: 1) the global climate-based analysis, 2) local socioeconomic and environmental factors, 3) biotic processes such as competition and predation. These new components will add to comprehension and provide better guidance in taking sustainable and efficient preventive measures for malaria control. Other climate-related disasters such as floods are not to be neglected. This type of event may change the dynamics of malaria vectors by creating conditions that allow proliferation and enhance mosquito-human contact.No claim is being made that climate alone is the main determinant factor for Anopheles species capable of transmitting malaria lived, however the disease has disappeared. In some countries, such as the USA, this was attributed to population shift from rural to urban areas, improved housing and nutrition, better water management and living standards and greater access to medical service [It should be emphasized that, the presence of malaria vectors within a region does not automatically translate to the disease. There are many countries in the world where other  service . If by aAnopheles species most responsible for malaria transmission in Africa. They will permit efficient planning of strategies for targeted control or further sampling, detection of competitive interactions, identification of areas in which particular species are potentially involved in malaria transmission, and estimation of risk of introduction to other parts of the world. Informed decisions and actions on these matters is imperative with the changing climate where even traditionally unsuitable areas for Anopheles mosquitoes and malaria have been invaded by the vector and the disease.It is essential to recognize here that there are major malaria control efforts underway at present in Africa; and indicators demonstrate remarkable success in malaria control in selected countries in West, East and Southern Africa . HoweverThe authors declare that they have no competing interests.HEZT developed the research proposal, participated in its design and drafted the manuscript. RYMK participated in the implementation and validation and helped to draft the manuscript. PZY provided the funding, coordinated the work and participated in the manuscript write up. All authors read and approved the final manuscript.


Medical and scientific researches in the last few years have become increasingly global, cross-national, cross-cultural, and collaborative. Today, one fifth of the medical and scientific papers have international coauthors. This reality is a reflection of globalization of modern day life and easy communications and movement of health professionals and patients. International collaboration is emerging as a norm and is an accepted form of current research environment. It is strongly encouraged by funding agencies.et al.[The sheer volume of international collaborations has been increased substantially during the last 20 years.2 This inet al.However, majority of these collaborations are still disorganized efforts, and they vary according to the centers and universities they are originating from. There are no coherent international collaborations, and many failures have been reported. We can summarize the patterns of collaboration as follows:Short-term project-oriented collaboration, where a few centers in different countries are working together for one project. This is often controlled by the availability and the policy of funding agencies.Long-term collaboration, forming an ‘alliance’ between research organizations who share the same interest. There are no rules to govern these activities, which are carried out on an ad hoc basis. It is most likely to happen amongst people who have trained in the same center or are sharing the same interest.Organized international collaboration, which is usually initiated by centers of excellence trying to find new research  opportunities in a promising emerging market. We are seeing an increase in this form of collaboration, where centers of excellence in the developed countries are opening research offices to facilitate and enhance continuous collaborations. These centers are targeting opportunities in many developing countries such as the Middle East, China, and Southeast Asia.The large, learned scientific societies are now an accepted platform of international collaborations. American Thoracic Society is an example. It attracts delegates from all over the world, and it has become more international than ‘American.’ The 2007 American Thoracic Society conference in San Francisco was attended by over 16,000 people from 90 countries. Unfortunately, most of the sponsorship and attendance is governed by commercial interest of the pharmaceutical companies rather than scientific motivation and need. There is also a trend emerging whereby these regional societies are forging a very close scientific collaboration with each other, for example, the close association of American Thoracic Society and European Respiratory Society, which results in many combined guidelines and expert documents. Many such collaborations are present in the genetic field of infectious diseases, but mosthttp://www.who.int/respiratory/gard/en/; and Global Strategy for Asthma Management and Prevention http://www.ginasthma.com/.International cross-border activities such as the Global Alliance Against Chronic Respiratory Diseases (GARD) A growing interest towards conducting clinical trials and involving developing countries, where commercial organizations, in particular, pharmaceutical companies, are becoming increasingly active in this field.www.pvri.info), which includes equal partnership of experts and researchers from the North and the South.There is an increasing trend of establishing an equal partnership with scientists from both the North and the South. For example, we have noticed the need to collaborate in ‘pulmonary vascular disease’ on a global scale. This condition started to attract attention, and more patients were diagnosed as therapies started to be available. Although the condition may affect less than 150,000 people in the west, it is far more common in the developing world (with an estimate of more than 25 million people) because of the other etiological factors which are not seen in the western environment. Unfortunately, the commercial power in marketing drugs has helped in shaping the condition to the extent that it only reflects the interest of a few in the North and hinders progress of the many. This situation prompted the formation of a virtual institute for pulmonary vascular diseases,  was formed http://www.g-i-n.net/. This network aimed at promotion of systematic guideline development and implementation which ‘seeks to improve the quality of health care by promoting systematic development of clinical practice guidelines.’ There are also other similar organizations aiming to develop, teach, and promote evidence-based health care and provide support and resources to anyone who wants to make use of these, such as Oxford Centre for Evidence-based Medicine http://www.cebm.net/.The ethical issue is the most important issue involved in cooperation with the developing world. This is a very complex subject, and it was reviewed by Varmus and Satche and others.9-11 AlthFunding is a big issue which needs to be considered seriously considering that more than 90% of the world's ‘potential years of life lost (PYLL)’ belong to the developing world, but it attacks less than 10% of global research funds.14 IndeedWhile minimum research capacity may exist in many developing countries, the fact that lead institutions, as well as study countries, are concentrated in a handful of centers attests to great disparities in research capacity. Mechanisms must be introduced to ensure investment in a research capacity, particularly infrastructure research capacity such as research nurses and research associates.Careful consideration of the cultural, social, and intellectual properties of the developing countries has played a part in maintaining a successful research partnership. Patenting of biological materials, including plants, animals, and even discoveries, made in the developing countries, whether due to existing knowledge of the local and indigenous people or by considerable input from local researchers, is becoming a key issue of contention between multinational companies and health care campaigners and other campaigners . As a gen18In conclusion, research collaboration is an enormous and powerful tool which provides mutual benefits to all parties. It needs careful planning and considerable thought to the diversity of the human society. The North-South collaboration can be strengthened by promoting further involvement of countries such as Germany, France, Belgium, and Spain in funding, supporting, and leading research in developing countries.


This study aimed at evaluating face and content validity, feasibility and reliability of process quality indicators developed previously in the United States or other countries. The indicators can be used to evaluate care and services for vulnerable older adults affected by cognitive impairment or dementia within an integrated service system in Quebec, Canada.®/University of California at Los Angeles (UCLA) appropriateness method, a two-round Delphi panel, was used to assess face and content validity of process quality indicators. The appropriateness of indicators was evaluated according to a) agreement of the panel with three criteria, defined as a median rating of 7–9 on a nine-point rating scale, and b) agreement among panellists, judged by the statistical measure of the interpercentile range adjusted for symmetry. Feasibility of quality assessment and reliability of appropriate indicators were then evaluated within a pilot study on 29 patients affected by cognitive impairment or dementia. For measurable indicators the inter-observer reliability was calculated with the Kappa statistic.A total of 33 clinical experts from three major urban centres in Quebec formed a panel representing two medical specialties  and seven health or social services specialties , from primary or secondary levels of care, including long-term care. A modified version of the RANDInitially, 82 indicators for care of vulnerable older adults with cognitive impairment or dementia were submitted to the panellists. Of those, 72 (88%) were accepted after two rounds. Among 29 patients for whom medical files of the preceding two years were evaluated, 63 (88%) of these indicators were considered applicable at least once, for at least one patient. Only 22 indicators were considered applicable at least once for ten or more out of 29 patients. Four indicators could be measured with the help of a validated questionnaire on patient satisfaction. Inter-observer reliability was moderate (Kappa = 0.57).A multidisciplinary panel of experts judged a large majority of the initial indicators valid for use in integrated care systems for vulnerable older adults in Quebec, Canada. Most of these indicators can be measured using patient files or patient or caregiver interviews and reliability of assessment from patient-files is moderate. Large variations in the quality of health care and services may affect all parts of the population . HoweverThis research aims at evaluating the quality of health care and services provided to vulnerable older adults within integrated service systems . The resSince PQIs cannot be transferred between countries without a prior validation, and often translation, to take into account variations in language, culture, and practice, PQIs developed by ACOVE and PQIs from other sources had to be validated before implementation in integrated service systems in Quebec . To our This research on quality assessment for vulnerable older adults in integrated service systems is guided by a conceptual framework to ensure a meaningful and rigorous quality evaluation and improvement . As a prThe quality framework was used during the selection process to identify appropriate PQIs for each quality dimension, making sure that all dimensions of the framework could be assessed by PQIs, at least to some extent. Quality can be measured by process or outcome indicators . ProcessTwo of the authors , having long-time experience with English to French translation of health services related content, translated the 82 indicators into French. A revision by the research team was carried out for all translated material. No back translation method was used since some modifications of the indicators were to be expected during the validation process.® UCLA appropriateness method. This method is a modified Delphi panel, which was privileged since it has successfully been used to develop [The validation process followed a slightly modified version of the RAND develop ,36 PQIs  develop . PQIs weGiven the interdisciplinary approach, the panel of 33 members represented nine clinical fields, namely medicine or geriatric medicine (n = 9), nursing (n = 6), occupational therapy (n = 3), psychology (n = 3), neuropsychology (n = 2), pharmacy (n = 4), nutrition (n = 3), and social work (n = 3). The investigators recruited expert practitioners from three major urban centres in Quebec, i.e. Montreal, Sherbrooke and Quebec City, who worked in ambulatory, hospital and long-term care settings. Recruitment criteria were a minimum of five years of clinical experience with a geriatric clientele and ongoing involvement in integrated care for older adults (75 years and older). The PQIs were validated during two rounds of panel consultation where panellists individually rated the PQIs and returned their ratings by mail.The panellists were asked to validate those PQIs that corresponded to their field of expertise, using a form for each PQI. Physicians were asked to validate all 82 PQIs. The forms contained the original English version and the French version of the PQI, its source, the criteria, the judging scale, and a summary of the scientific evidence supporting its use. Panellists indicated their agreement with the five criteria on a rating scale from one to nine, with one signifying complete disagreement and nine complete agreement ) and had a diagnosis of cognitive impairment/dementia  [® corporation and a version has been developed which applies to any size of panel: it is called the InterPercentile Range Adjusted for Symmetry (IPRAS) [For an indicator to be judged  author) . The int (IPRAS) . Accordiinappropriate. In all other cases, the indicator was judged uncertain.For any given indicator, if the panel's median score was in the lowest tertile of the scale or between 1 and 3, and if there was agreement among panellists, then the indicator was judged uncertain, it was resubmitted for a second round of validation. Indicators judged inappropriate were rejected. Final acceptance of an indicator after the second round was limited to those judged appropriate. However, if, after the second round, an indicator was judged uncertain only by physicians and appropriate by the other health care professionals, or vice-versa, an additional statistical measure was calculated. This measure was the rate of acceptance, i.e. the number of all panellists having indicated an agreement with the indicator , divided by the number of panellists having rated this indicator. If this rate of acceptance was above 80% in the group having judged the indicator as uncertain, and the other group had rated it appropriate, the indicator was accepted.If an indicator was judged appropriate and modifications were only minor corrections to wording, it was accepted without resubmission. If the modification was major or if the indicator was judged Inter-observer agreement was assessed for those PQIs, which were considered applicable and evaluated by both observers (study nurses) at least once for the same patient. A SAS algorithm was created for each indicator according to the requirements for the indicator and regarding the information retrieved from the patient's medical file into the abstraction form. This algorithm allowed to decide whether the indicator was met or not. An overall Kappa statistic was calculated for the agreement between the two observers on whether applicable indicators were met or not.All 33 panellists completed the two rounds of validation. Out of the initial 82 indicators submitted to the panel, 72 (88%) were accepted after two rounds of submissions (see Table All but two out of 72 accepted indicators were measurable either by patient/caregiver interview (four indicators) or from medical files of patients in public  and private (doctor's offices) settings (66 indicators)  of the translated PQIs appropriate for use in clinical context within integrated service systems in Quebec, Canada. Measurement of 97% of the accepted indicators is feasible, either by review of photocopies of patient files, performed by study nurses, or via patient's or caregiver's interviews. Reliability can be considered as moderate, given the observed Kappa value, and may be amenable to improvement by increase of training of the study nurses from four to seven days.®/UCLA quality indicators for primary care could be transferred and validated for use in the UK [In other studies on the transfer of PQIs from one country to another, proportions of accepted indicators varied. Marshall reported that 56.3 % of US RANDn the UK . In a stn the UK . ACOVE in the UK . CarefulTo our knowledge, this is the first report on the transfer, validation and adaptation of PQIs for the care of vulnerable older persons treated within an integrated service system, characterized by a single point of entry, case management, geriatric assessment and a multidisciplinary care team. The multidisciplinary selection and evaluation of face/content validity of the PQIs allowed to take into account the vision of quality of care of all health and social care professions involved in the integrated service system. The resulting indicator set, for which feasibility of measurement has been demonstrated and reliability is moderate, covers all dimensions of the comprehensive conceptual framework for quality guiding this research. Coverage for access is somewhat limited, since only a few PQIs for this dimension could be identified in the literature. To fully explore the dimension of patient- and caregiver-centeredness, satisfaction of patients and caregivers may be assessed as well. To this end, a validated questionnaire on patient satisfaction from prior research was used in the present project . Thus, cThis project is limited to indicators for vulnerable older adults affected by cognitive impairment/dementia. However, efforts are under way in the province of Quebec to validate other PQIs, for example on care for mobility problems. Such efforts should permit to eventually cover all highly prevalent health problems among vulnerable older adults. Also, since the feasibility study was carried out as a pilot project, the number of patients for whom medical files could be assessed was limited to 29. This relatively small number may explain why the number of PQIs, which could be assessed using information from medical files, was limited to 63 out of 72. The restricted number of patients may also be the reason why the number of indicators applicable to more then ten patients out of the 29 was limited to 22 PQIs. Furthermore, several indicators, which theoretically applied to all patients, were not assessed for all patients by both nurses, e.g. PQIs E1, E6 and E7. This discrepancy is reflected in the moderate Kappa value for reliability and suggests improved training of nurses for future research. The information abstraction forms could also be improved using comments from the nurses. A large-scale research project aimed at assessing care of vulnerable older adults with validated PQIs would include a much larger number of patients. Results from such a project may permit to distinguish indicators, which consistently apply to a majority of patients from indicators, which only apply to a small minority. In light of these results, efforts to implement the indicator-set in a continuous quality improvement program may then be limited to the more prevalent indicators. In such a project, the cost per patient for assessment of PQIs may decrease to some extent, given greater training effects for nurses. Once electronic patient files will be available, quality assessment with PQIs via medical data from patients may become economically much more feasible. Finally, one has to caution that a face and content validation of PQIs by clinical experts on the distinction of good quality from bad quality services may not necessarily and easily permit to characterize all aspects of good quality care in the vulnerable older adults' lives.This research shows how a set of 72 PQIs for the integrated care of vulnerable older adults can be built by starting out with a quality framework, adapting and then validating PQIs developed elsewhere previously. It further demonstrates that accepted indicators are measurable using medical files of patients from several public and private health care facilities. Finally it shows that the reliability of such PQIs is moderate. PQIs for other highly prevalent health problems affecting vulnerable older adults are presently validated in Quebec and integration of services for these patients is implemented throughout the province. The next step should therefore be a large-scale study assessing care for vulnerable older adults across the province. Thus it will be possible to isolate distinct quality problems in distinct administrative territories. The ultimate goal of this research endeavour is to assess the impact of interventions aimed at continuous quality improvement with the help of PQIs and possibly outcome measures.The author(s) declare that they have no competing interests.EK is a pharmacist and epidemiologist who coordinated most of the phases of this study. She supervised and collaborated in all data analyses and wrote all drafts of this paper. AT is the principal investigator of this research who conceived all parts of this project and contributed to all its stages, including all drafts of the paper. DM is a co-investigator, contributed to all stages and several drafts of the paper and supervised the training of the study nurses and the data collection in the pilot study. LC is a co-investigator and contributed to all stages of the validation process, most significantly to the conceptual framework. M-JK, PL and LR are co-investigators and contributed to the validation process, the planning of the pilot project and drafts of the paper.SI is a psychologist, contributed to the indicator selection, particularly regarding indicators on social work, to the validation process, the planning of the pilot project and drafts of the paper. SP contributed to the planning of the pilot project, coordinated its data collection and contributed to all drafts of the paper. ZB is a statistician who performed all data analyses for this project and contributed to the paper. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:Appendix. Set of process quality indicators from the ACOVE project and other sources accepted as appropriate and measurable from patients' medical files or by interview.Click here for file


Since 2002, market studies have predicted a physician shortage with an increasing need for future subspecialists. A Residency Review Committee (RRC) rule that restricted sponsorship of fellowships was eliminated in 2005, but the influence of this change on the number of fellowships is not known. We believed that the rules change might make it possible for community hospitals to offer fellowships. Our objectives were to determine the extent of change in the number of fellowships in university and community hospitals from 2000 through 2008, both before and after the RRC regulation change in 2005, and to determine whether community hospitals contributed substantially to the number of new fellowships available to internal medicine graduates.We used archived Accreditation Council for Graduate Medical Education (ACGME) data from July 2000 through June 2008. The community hospital category included multispecialty clinics, community programs, and municipal hospitals.Of the 94 newly approved internal medicine subspecialty fellowships in this time period, 59 (63%) were community sponsored. As of 6/02/08, all were in good standing. Thirteen programs were started as a department of medicine solo fellowship since 2005. The number of new programs approved between 2005 and 2008 was roughly three times the number approved between 2000 and 2004.The number of subspecialty fellowship programs and approved positions has increased dramatically in the last 8 years. Many of the new programs were at community hospitals. The change in RRC rules has been associated with increased availability of fellowship programs in the university and community hospital setting for subspecialty training. Since 2002, market studies have predicted a physician shortage with an increasing need for future subspecialties. The Bureau of Health Professions report on physician supply and demand projects that, by the year 2020, the growth and aging of the United States population will increase the demand for physicians by 22 percent, with substantial increases in demand for subspecialists.Recommendations for increasing subspecialty training include increasing the number of fellowship programs, reducing the time needed to complete the training, and offering incentives to physicians entering a particular subspecialty.We believed the 2005 change in RRC requirements would lead to an increase in the number of fellowships and institutional sponsors. We also believed community hospitals would sponsor additional fellowships as a result of this rule change. Our objectives were to determine the extent of change in the number of fellowships in university and community hospitals from 2000 through 2008, both before and after the RRC regulation change in 2005, and to determine whether community hospitals contributed substantially to the number of new fellowships.The Accreditation Council for Graduate Medical Education (ACGME) Internal Medicine RRC lists all of the Internal Medicine fellowships sponsored in the U.S.The data were extracted from reports listing newly accredited fellowship programs by year. We distinguished community programs from non-community or university programs. We classified as university programs all programs listed as such by the Association of Program Directors in Internal Medicine, which included one sponsoring hospital for each medical school. In addition, we considered any federally sponsored program as a university program because of the similarities to university programs and lack of features common to community programs. For example, military and Veterans Administration programs’ organization, priorities, and relationships with medical schools are similar to university programs and unlike community programs. Thus, universities in our classification included traditional universities, military, and Veterans Administration-sponsored institutions. All other programs, including community programs, multispecialty clinics, and municipal programs, were considered community programs.We looked at the major fellowships in hematology, oncology, hematology/oncology, pulmonary, critical care, pulmonary/critical care, endocrinology and metabolism, gastroenterology, cardiovascular disease, nephrology, rheumatology, geriatrics, and infectious disease. We did not include sub-subspecialty fellowships, such as cardiology angioplasty, in our analysis. We also looked at the current status of all new programs introduced between July 2000 and June 2008 to determine if any were not in good standing.We used the number of programs and fellowship positions accredited as of July 2000 as a baseline for analyzing the trends in fellowship training between July 2000 and June 2008.Ninety-four new subspecialty programs were accredited between July 2000 and 2008 as of the January 2008 meeting of the Internal Medicine RRC . CardiovNew York, with 19 new fellowships, was heavily represented in terms of new programs. Florida had 11 new fellowships, followed by California with 6 and Ohio, Michigan, and Texas with 5 each. Prior to the 2005 regulation change, there were four solo fellowships, all in community programs. Between July 2004 and June 2008, 13 institutions became sponsors of solo fellowships, with 12 of the 13 in community programs.All 94 new programs are in good standing according to the current RRC website.Community hospitals sponsored 28% of the total subspecialty fellowships in 2007. The greSince 2000, the prediction of staffing shortages in medical subspecialties have led many subspecialty organizations to call for an increase in fellowship positions. The American College of Cardiology cited a growing shortage of cardiologists that would impair patient access to care and hinder cardiovascular research programs as academic cardiologists devote more time to patients.No consensus has been reached regarding the best solution to the projected physician subspecialist workforce shortage, but many groups are proposing recommendations to increase the number of subspecialists.Besides the benefit of meeting anticipated workforce needs, additional fellowships meet the requirements of internal medicine graduates who are increasingly demanding the option to subspecialize. The lack of subspecialty training after residency may adversely affect a hospital's residency programs. The change in rules has allowed the rapid expansion of solo fellowships, which is a benefit to the hospitals sponsoring them and also to the graduates filling the positions.Our data show a dramatic increase in fellows and fellowship sponsorship in this last decade, particularly in the last four years since the RRC changed the special requirements. This impact has happened in places where there are many community programs, such as New York State, and the bulk of the new programs are in community hospitals, many of which are sponsoring fellowships for the first time. There has been an anecdotal perception that the RRC does not favor community hospital fellowships and that loss of accreditation after early accreditation visits would be an issue for various reasons, including not fulfilling research requirements. However, this does not appear to be the case. None of the recently accredited fellowships have been identified with problems as of 2008.This study confirms that the change in rules in 2005 has allowed a substantial expansion of subspecialty fellowships available to internal medicine graduates. Community hospitals have increasingly contributed to this expansion in programs as a result of the change in rules, adding to the subspecialty training choices available to internal medicine graduates.


Addictive behavior is any activity or behavior that has become the major focus of a person's life to the exclusion of other activities, or that has begun to harm the individual or others physically, mentally, or socially. Addictive behavior increases the risk of disease and/or associated personal and social problems. They are often experienced subjectively as “loss of control”, that is, the behavior continues to occur despite volitional attempts to abstain or moderate use. Addiction implies psychological dependence, physical dependence, and a set of withdrawal symptoms if the substance is unavailable. There arSubstance-related disorders have become matters of global concern because of impact on individual health, familial and social consequences, criminal and legal problems, and the effects on national productivity and economy. All the problems from use to dependence and from the most innocuous substance like tea/coffee to the most hard substances, contribute to the cost that the human society or a particular nation has to bear. In India, although alcohol use in ancient times and cannabis/affim (opium) in more recent times have been known and reported for some time, substance use problems have been recognized to have a significant importance as a public health problem only very recently. They are of particular concern among slum dwellers, transport workers, and youth.Tobacco is the substance most easily accessible worldwide as well as in India. About one-fifth of the Indian population abuse tobacco, about 70% of this in the smoking form. Passive An estimated 34–42% of adult Indian population reports having used alcohol in their lifetime; 5–7% has been estimated to be abuser of alcohol; and 10–20 million persons have been estimated to be in need of treatment for dependence. A survey in India revealed that medical professionals had a higher rate of use and heavy use than general population.With respect to heroin, India has now changed from being a transit country to a user country. General population surveys in India show opioid abuse rate as high as 24.8%. Another great concern especially with injectable opioids is spread of AIDS. Further, cannabis abuse in general population in India is 33% and abuse of tranquilizers is as high as 54%.[‘The Drug Deaddiction Program’ was started in 1987–88 with the establishment of five deaddiction centers in central institutions, viz. AIIMS, New Delhi; Dr. RML Hospital, New Delhi; Lady Harding Medical College and Hospital; New Delhi; JIPMER, Pondicherry; and PGI, Chandigarh. The center at NIMHANS, Bangalore was established later as the sixth center. More recently, in 1999, a separate deaddiction center with inpatient setup was started in Central Institute of Psychiatry, Ranchi. The Ministry of Health and Family Welfare is mainly involved in providing treatment services to the addicts, whereas the Ministry of Social Justice and Empowerment deals with other aspects of the problem like awareness creation, counseling, and rehabilitation. From 1992–93, the scope of the scheme was enlarged to include assistance to State Governments/Union Territories for developing deaddiction centers in identified medical colleges/district-level hospitals.Treatment of substance-use disorders typically involves a combination of pharmacotherapy and psychosocial interventions. Techniques for medically assisted detoxification are widespread and effective. The following are the different strategies that are found useful in management of substance dependence.Published reports have consistently failed to find any difference in outcome between long and short inpatient detoxification programs. Clients can usually complete home detoxification in 5–9 days. In ideal circumstances they are visited twice daily for the first three days and medication is supervised by a relative. Clients are breathalyzed and medication withheld if they have consumed significant amounts of alcohol.Brief interventions are short, focused discussions (often of less than 15 minutes) that can reduce alcohol consumption in some individuals with hazardous drinking. They are designed to promote awareness of the negative effects of drinking and to motivate change. Brief interventions were shown to be moderately effective in the nontreatment-seeking groups, especially for those with less-severe alcohol problems.This is a great debate. The goal of controlled (moderate or nonproblem) drinking usually includes some limit on alcohol consumption  provided that drinking does not lead to signs of dependence, intoxication, or social, legal and health problems. This runs contrary to the abstinence-based philosophy of Alcoholics Anonymous. Controlled drinking may be an option for young, socially stable drinkers with short, less-severe drinking histories. An individual's belief that controlled drinking is an achievable goal is also a good prognostic factor. Most authors agree that controlled drinking should not be recommended for people with heavy dependence. Controlled drinking is an attractive option for public health strategies aimed at nondependent problem drinking. This principle can also be tried for other substances.Based on Minnesota model, they involve the recognition that alcoholism is a relapsing illness that requires complete abstinence. Clients acknowledge the problems due to their alcoholism and are encouraged to attend 90 meetings in 90 days. Participants may engage the support of a sponsor who is an AA member who has been sober for at least one year. Similarly, there is narcotic anonymous for opioid addicts and nicotine anonymous for nicotine dependents. The evidence suggests that this twelve-step approach is at least as effective as most structured psychotherapies but not superior to any alternative treatments.Motivational enhancement therapyCognitive behavioral therapySocial skills trainingCommunity reinforcement approachSocial behavior and network therapyContingency managementCue exposureIt requires prolonged residence (often 12–18 months) and it is extremely expensive. Most studies of therapeutic communities are conducted without control groups and the lack of randomization probably leads to selection bias in favor of more motivated patients.Disulfiram, naltrexone, and acamprosate are currently the only treatments approved for the management of alcohol dependence. Other drugs which have been used for the same are topiramate, citrated calcium carbimide, SSRIs, tiapiride, nalmefene, metronidazole, and ondansetron. The oldest among these is disulfiram, being used from 1950s. Naltrexone was launched in India in 1998 and acamprosate in 2002. However, none has been proved to be significantly better than the other agents. In other words, all are equally effective.[Bupropion has been said to be the first line drug for nicotine craving. Another first line agent is nicotine itself, in the form of gum, inhaler, lozenge, patch, and nasal spray. Clonidine and nortriptyline are said to be the second line drugs. But the success rate with each of these drugs is marginal.Sustained release bupropion is also considered to be effective as anticraving agent in cannabis dependence. Nefazodone also significantly reduces cannabis withdrawal related anxiety and muscle pain, while having no effect on dysphoria. The embryonic work on CB1 selective cannabinoid receptor antagonists such as SR141716 (rimonabant) has demonstrated that it successfully blocks the acute psychological and physiological effects of smoked cannabis in experienced human consumers and is well tolerated. There has been even less work on the use of cannabis agonists. However, this is a promising area for future research as a number of oral and inhaled THC preparations are being developed for medical cannabis trials.Maintenance treatment is increasingly emphasized as the main therapy of opioid dependency. Abstinence-oriented therapy is nevertheless an important alternative, mainly psychological, and has considerable advantages for those benefitting from this strategy. Methadone or buprenorphine in tapering doses are used for detoxification along with α2 adrenergic agonists like clonidine or lofexidine. Time-limited agonist therapy is a specific approach using agonist stabilization as the basis for therapeutic interventions preceding tapering off of the maintenance therapy. The preventive effect of naltrexone and other antagonists is well known but the attrition rate is very high. It is also feasible for addicts to be introduced to naltrexone by detoxification under anesthesia or sedation.As elaborated above, substance use is affecting a disproportionately large section of people of India. The prevalence is more than that of all severe mental disorders combined. When it comes to health problems, it should not be gauged merely by its prevalence, but by the health burden and social cost that it wreaks on the society. Psychiatric comorbidities like mood, anxiety, and psychotic disorders are also very commonly associated with substance dependence. Thus drug addiction is a titanic problem that needs special clinical attention.Today we are equipped with an arena of treatment strategies, both pharmacological and nonpharmacological. What we need is just an improvisation in its implementation. Treatment can be better systematized when addiction medicine is upgraded as a specialty. The specialty section on addiction medicine needs to fulfill the following aims and objectives.Promote and advance the bio-psycho-social contributions to the science and practice of addiction medicine in all its different manifestations.Promote the improvement of the health of persons directly or indirectly impacted by substance-related problems.Promote prevention, control, treatment, and relief of all substance-related problems, as well as conditions which constitute high risk for potential drug-related problems. This involves encouraging and enabling the members of the society to explore and pursue ‘evidence based’ treatment strategies and prevention methods. This includes liaison with other stake holders, including but not limited to government agencies overseeing health, social justice and welfare, and finance and human development; nongovernmental agencies involved in direct care of persons with substance abuse.Promote other medical specialties and primary healthcare providers. This also requires sharing the expertise of members of the society and other professionals involved in diverse fields such as school mental health, community based rehabilitation, epidemiology, drug trials, maintaining disease registries, to mention a few.Actively engage in advocacy in order to influence policy making and legislation, keeping in mind that substance-use disorders and their consequences constitute a grave public health disorder which imposes an unacceptably severe burden on the health and well being of the people of India.Formulate and recommend standards of treatment and rehabilitation of persons or populations affected directly or indirectly by substance-use disorders. In addition, it will be necessary to obtain recommendations for syllabi and commission resources for the education and training of medical and nonmedical personnel involved in the field.Safeguard the interest of psychiatrists and fellow professionals engaged in the practice of addiction medicine in India.Promote research in the field of addiction science with a focus on translating the benefits of research to the bedside and propagate the use of evidence-based interventions in the daily delivery of mental healthcare.The following are some of the activities that are being suggested as functions of specialty section of addiction medicine:A web portal, linked to the web page of the Indian Psychiatric Society, which will initially host information of relevance to the practice of addiction medicine in India, with direct and indirect links to published or unpublished scientific papers, databases, treatment protocols, available treatment agencies, online resources, etc; and later e-learning sites for online education and training.Coordinating Continuing Medical Education (CME) pertaining to the aspect of the science and practice of addiction medicine, with special emphasis on underserved areas like the northeastern states, Andaman and Nicobar Islands, etc.Enabling and commissioning position papers on the impact of substance abuse in India, with a view to influence public policy.Engaging with relevant organizations to promote demand-reduction strategies, such as the police to prevent drinking and driving, primary health providers, and emergency rooms for early detection and brief interventionPursuing the aim of working to safeguard vulnerable populations, for example, inoculating children and adolescents through skills training and sensitizing physicians and pharmacists to prevent over the counter drug abuse.Examining the possibility of creating a national registry, using standardized data-entry protocols.Substance-use disorders form more than 20% of the case load of psychiatric practitioners. However, practitioners have an attitude of therapeutic nihilism toward the addicted patient. This may be due to various reasons like lack of education about alcohol and substance abuse, attitude of hostility or aversion toward alcoholics, inability or discomfort to deal with the associated psychosocial issues, and learned pessimism about treatment – especially based on experience treating late stage alcoholics. However for effective outcome, early identification and treatment should be the goal. This is possible with more sophistication in the science of addiction medicine. Thus, evolving of a specialty section of addiction medicine is the need of the day.