Many biomedical publications refer to data obtained from collections of biosamples. Sharing such bioresources  is paramount for the present governance of research. Recognition of the effort involved in generating, maintaining, and sharing high quality bioresources is poorly organized, which does not encourage sharing. At publication level, the recognition of such resources is often neglected and/or highly heterogeneous. This is a true handicap for the traceability of bioresource use. The aim of this article is to propose, for the first time, a guideline for reporting bioresource use in research articles, named CoBRA: Citation of BioResources in journal Articles.As standards for citing bioresources are still lacking, the members of the journal editors subgroup of the Bioresource Research Impact Factor (BRIF) initiative developed a standardized and appropriate citation scheme for such resources by informing stakeholders about the subject and raising awareness among scientists and in science editors’ networks, mapping this topic among other relevant initiatives, promoting actions addressed to stakeholders, launching surveys, and organizing focused workshops.The European Association of Science Editors has adopted BRIF’s suggestion to incorporate statements on biobanks in the Methods section of their guidelines. The BRIF subgroup agreed upon a proposed citation system: each individual bioresource that is used to perform a study and that is mentioned in the Methods section should be cited as an individual “reference [BIORESOURCE]” according to a delineated format. The EQUATOR  network mentioned the proposed reporting guideline in their “guidelines under development” section.Evaluating bioresources’ use and impact requires that publications accurately cite such resources. Adopting the standard citation scheme described here will improve the quality of bioresource reporting and will allow their traceability in scientific publications, thus increasing the recognition of bioresources’ value and relevance to research.http://dx.doi.org/10.1186/s12916-015-0284-9.Please see related article:  Bioresources are collections of data and/or samples that are scientifically built and systematically documented. These include physical resources like human biobanks with associated health information, databases, plant and animal repositories, registries, and bioinformatics tools. Although an increasing proportion of biomedical research relies on bioresources, these are seldom shared . In clinSharing bioresources does not simply involve providing access to other users. Good sharing requires specific work on metadata, on quality control for data and samples management, and on documentation. Sharing also requires regular bioresource updating and the development of a clear access policy. This work is not trivial. It is neither recognized and valued in the present academic world nor considered an important aspect in the processes of evaluation. This lack of recognition is a major obstacle to sharing. The more difficult, costly, time-consuming, and highly specialized the development of a useful bioresource is, the more researchers and institutions will expect recognition for their usefulness. If the scientific community does not value this work, it is unlikely to be performed adequately.Sharing research outputs, data, and resources contributes to building reliable knowledge and generating innovation. This is now supported by funding agencies that foster data sharing, especially in health research . The EurHowever, these kinds of initiatives mainly concern patient/trial data, and no standard exists regarding the use of bioresources in general ,11,12. OAs explored in a previous article , it is eIn most cases, due to the current modalities of citation, the use of a bioresource in a research article (summarized below) is not retrievable via PubMed or other bibliographic databases, which only index abstracts. This does not allow proper traceability and visibility of bioresources in scientific literature or in other (online) sources that would highlight their use and thus encourage bioresource sharing. For instance, an analysis published in 2011 showed that half of the papers published in biomarkers research contained no information about the biospecimens used .The points below summarize some of the negative effects of citation heterogeneity on the tracking of bioresource use, and the limitations generated by this situation. Adopting a citation standard would bring several advantages, which are also outlined.Current modes of bioresource citationBioresources may be acknowledged in various sections, including Materials and Methods, Acknowledgements, and ReferencesBioresource acknowledgements or citations may be placed outside the main paper, or in online supplementary materialsCitations may acknowledge different resource levels, for example, citation of the consortia or network, but not the individual bioresourceSecondary use, such as the use of derivatives from the original bioresource Typing errors or approximation of the bioresource name/identification; a multiplicity of names for a given bioresource; various names in different languagesAcknowledgement of persons and authorship instead of the bioresource itselfAbsence of bioresource citation (negligence)Websites: reference to web sites that no longer exist, are not updated, or are not informativeAbsence of a Material Transfer Agreement or Data Transfer Agreement number and/or report information on the access(es)Effects of variations in bioresource citations on tracking bioresource useFull-text mining is required to trace bioresource useNo traceabilityDifficult or impossible to recognize the use and contribution of individual bioresourcesDisregarded criteria for correct reportingAt worst, no tracking is possible if there is no citation at allMisleading or incomplete information about bioresource useEffect of the lack of standardized citationsBioresources are not indexed in PubMed or Web of ScienceIncomplete information of the bioresources used in research articlesLack of recognition and traceabilityStudies may be impossible to replicate by othersNo information on the number and type of biosamples, the amount of associated data, or the data exchanged between the biobank and the userLimited ability to develop accurate indicators of bioresource activityLimited ability to adopt suitable policy for stakeholders at any levelUnderestimation of the utility of bioresourcesAdvantages of standardized citationThe possibility to search literature for the use of a bioresourceAvailable information about bioresource useDevelopment of indexing tools in PubMed and Web of Science to track the use of bioresourcesSupport for the development of metrics to assess bioresource impactFacilitation of stakeholders’ work Increased recognition of infrastructure and institutions involved in creating and maintaining a bioresourceImproved specific knowledge of biospecimens and databases used in research articlesIncreased sharing of data and biological samplesImproved trust of bioresource contributors including patients and donorsTo track publications involving a bioresource, it is essential that researchers consistently acknowledge the use of the bioresource by placing unique and traceable information in all relevant publications in a defined section of the article. Ideally, this information should include an actionable digital identifier (ID) assigned to the bioresource. To date, such an ID is not available. In order to fulfil the requirements of the scholarly record, a bioresource ID should be persistent, globally unique, citable, and easily retrievable through the Internet. There is major debate over which body or bodies should be responsible for assigning and managing bioresource IDs .The systematic and standardized citation of bioresources in journal articles is needed for the fair recognition of the impact of bioresources on health research, both in qualitative and quantitative terms. While textual resource citation follows clear editorial guidelines, citation rules for bioresources are yet to be defined. Most current initiatives address data sharing policies or technical aspects of sharing, such as interoperability, quality of data, and standards for data management, but not the recognition of the work required in data sharing and the traceability of such sharing ,14,15. HThe BRIF initiative  is an onThe actions of the “BRIF and Journal editors” subgroup were divided into two phases. The first phase aimed at disseminating information about the BRIF initiative among the scientific community and attracting the attention of science journal editors, thus creating or raising awareness about proper reporting and sharing of bioresources. The second phase focused on the practical development of a standard for the “Citation of BioResources in journal Articles” (CoBRA). The structure of the guideline was developed according to the general principles reported by Moher et al. .In 2012, the “BRIF and Journal editors” subgroup agreed to submit proposals to international associations, editorial committees, and other professional organizations, with the aim of attracting their attention on issues related to bioresources, creating awareness of the BRIF initiative, and eventually of amending editorial guidelines by including a reference to bioresources.First, the subgroup contacted the International Committee of Medical Journal Editors (ICMJE), a group of general medical editors and representatives of related organizations who evaluate how to improve the quality of medical science and reporting by updating their recommendations . The aimSecond, the subgroup examined the Guidelines for Authors and Translators of Scientific Articles produced by the European Association of Science Editors (EASE), an internationally oriented community of individuals from diverse backgrounds, linguistic traditions, and professional experience who are interested in science communication and editing. EASE guidelines are well known by science editors not only in Europe but also globally, thanks to their translation into 22 languages . The subThird, the subgroup also approached the Committee on Publication Ethics (COPE), an important forum for editors and publishers of peer reviewed journals, which advises editors on handling cases of research and publication misconduct. The subgroup encouraged COPE to consider the editorial and ethical problems concerning biobanks and bioresources in general.Fourth, the subgroup contacted the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network, which works to improve the reliability and value of medical research literature by promoting transparent and accurate reporting of research studies, in order to discuss how a standard for bioresource citation currently in development could be announced and reported on the EQUATOR website .The Seventh International Congress on Peer Review and Biomedical Publication, 2013, Chicago, USA;The Eurosurveillance Editorial Board Meeting, 2013, Vilnius, Lithuania;The 12th EASE General Assembly and Conference, 2014, Split, Croatia;The 14th European Association for Health Information and Libraries Conference, 2014, Rome, Italy.In pursuing these steps, the subgroup participated in a number of international meetings and events. The preliminary work of disseminating information on BRIF initiatives was achieved through a lecture at the 5th Belgrade International Open Access Conference in 2012  and a poThe European Human Genetics Conference, 2013, Paris, France;The Brocher Workshop Exploring Innovative Mechanisms to Build Trust in Human Health Research Biobanking, 2013, Geneva, Switzerland;The “HandsOn: Biobanks 2013” Conference, The Hague, Netherlands;The 28th European Immunogenetics and Histocompatibility Conference, 2014, Stockholm, Sweden;The 5th Biennial Meeting of the Human Variome Project, UNESCO, 2014, Paris, France;The “HandsOn: Biobanks 2014” Conference, Helsinki, Finland;The ESBB  annual meeting, 2014, Leipzig, Germany.In addition, the subgroup presented the BRIF initiative in scientific conferences attended by scientists who work with large databases and/or collections, including:Informal contacts and discussions occurred during these events, increasing the dissemination of information. The topic was always well received, and the subgroup was encouraged to continue.In 2013, based on the experiences above, the “BRIF and Journal editors” subgroup decided to further explore how clear bioresource citation guidelines could be established with the help of journal editors. A survey was presented to a sample of biomedical editors in order to identify key science editors who would be interested in the initiative and who would contribute to its advancement. In order to test the feasibility of the approach, the survey was addressed initially to 50 editors of journals, both open access and traditional subscription-based, that are indexed in the Web of Science and that have a range of impact factors. Subsequently, to diversify the sample, a second group of 40 editors were contacted, identified according to the same criteria. The survey response rates were 22% and 17.5% for the first and second groups, respectively.Have you ever heard about the issues of bioresources evaluation and their standardized citations in biomedical journals?Do you think this is a topic of interest for the editorial policy of your journal?Would you agree to address this issue in the Instructions to Authors?A meeting will be held in Rome  to discuss about this matter. Would you like to receive more information?Would you consider participating in this meeting?The survey questions were as follows:Interested editors identified by the survey were invited to participate in a workshop organized in Rome, Italy, in June 2013.A unique identifier for each biobank – or bioresource – that could be used as a form of citation;A dedicated “bioresource section or field,” analogous to the existing “author section” or “author field” that authors are required to complete during the article submission process, which would require authors to include specific metadata characterizing the bioresource used and thereby allowing its easy tracing;The use of specific required phrases to acknowledge bioresource(s).At the Rome meeting , particiEASE agreed to incorporate statements on biobanks in the “Methods” section of the EASE Guidelines published in 22 languages . The ansThe use of a unique ID for bioresources;The possibility of a “bioresource field” as editorial metadata;The use of specific acknowledgement sentences.The discussion at the 2013 BRIF workshop in Rome focused the subgroup on a new and practical approach to the issue of bioresource citation. In this sense, the meeting was a turning point. Initially, the main objective of the meeting was to develop a consensus recommendation for standardized bioresource citation. Three leading proposals for bioresource citations in journal articles were presented to the two workshop groups, as discussed above:A subsequent general discussion combined and harmonized the final remarks elaborated by the two groups. The discussion was very lively, several issues were examined, and new proposals were suggested.The editors shared their points of view about integrating new editorial elements regarding bioresources and stressed how difficult it is to satisfy each stakeholder in journal articles, including authors, readers, resource providers, and editors. They agreed that bioresources should be cited in a standardized/harmonized way, favoring the easiest implementation routes such as using editorial processes familiar to the scientific community and pre-existing solutions that are easy to adapt to the specific case of bioresources.Identifying bioresources using an ID rather than the name of the bioresource would be better to avoid confusion, but that such an ID is not yet generally available;A “bioresource field” or a specific section is not an appropriate solution, because it would be too complicated and not of sufficiently broad use to warrant its creation;Referring to bioresources in the Methods section seemed the most appropriate solution, provided that the reference corresponds to a cited reference (see below);Specific sentences in the Acknowledgement section in journal articles did not seem useful, considering the necessity of traceability and easy retrieval.Regarding the three proposals under discussion, the participating editors agreed that:Open Journal of Bioresources ” at the end of the reference.USE: Citing a used bioresource. The reference has the following format:Identification ; (if applicable) Organization (network partnership or membership); Number (No) of access(es)/Date of last access; [BIORESOURCE].NO-USE: Citing a bioresource that was not used. The reference has the following format:Identification ; (if applicable) Organization (network partnership or membership).An example of these different uses is provided in Box 1, Example 5. If the bioresource used is a digital resource  only the last access should be reported. For the sections authorship, acknowledgements, and/or editorial policies, the authors should refer to the instructions for authors of the journal.Advantages of standardized citation section above.The driving principle of this work is that bioresources must be cited in a standardized and retrievable way in order to acknowledge their value and highlight their use in research achievements. The proposed guidelines were formulated with extensive stakeholder involvement and through a long process of consultation and dissemination, as described. These interactions raised awareness and created consensus on the importance of standardized citations as a tool to measure the impact of bioresources on research production. The main advantages of the adoption of standardized citations are summarized in the The identification of bioresources through a unique digital ID should be preferred. However, due to the absence of governing bodies in charge of assigning and managing bioresource IDs, few bioresources currently have such an ID. This may soon change, at least in Europe. The principle of assigning a unique ID to biobanks has been adopted by the Biobanking and Biomolecular Resources Research Infrastructure (BBMRI), which was officially awarded the community legal framework for a European Research Infrastructure Consortium (ERIC) on the 3rd of December, 2013 . The misAt present, an increasing number of bioresources publish a corresponding paper that describes the bioresource in detail. In the absence of a unique ID for the resource itself, the DOI corresponding to this descriptive publication may be used as identifier .Identification of a bioresource though a digital identifier (ID/DOI) instead of its name will improve web tracking because i) it allows the standardization of the bioresource tracking process and the use of automated systems, and ii) it enables bioresources to be tracked through CrossRef .Bioresources may partner with networks or consortia and/or they may be members of organizations. Bioresources should mention such partnerships in scientific publications. The reference format proposed allows this .BRIF’s concept and the effort to standardize bioresource citation are in line with the multiple initiatives that support open access to research results. A proper bioresource citation system would foster a climate of trust and transparency among all parties involved in research biobanking, from patients to funding bodies and policymakers.The European Commission policy encourages data sharing and reuse. This policy is at the basis of the recently constituted European BBMRI-ERIC , which iIn human health studies, bioresource use is at the base of translational research development. The adoption of standardized bioresource citations and the BRIF initiative Table  is in haThe authors expect that the CoBRA guideline will be published in the reporting guidelines of the key website EQUATOR . In factEvaluation of bioresource use and impact in research requires accurate citation of such resources in publications. Editors, as gatekeepers of scientific information, and authors as providers of such information, must be proactive in applying CoBRA as a standard citation scheme for bioresources. The use of CoBRA will improve the quality of bioresource reporting and will allow bioresource traceability in scientific publications, encouraging policies of collaboration and sharing. The endorsement and the adoption of the CoBRA guideline by authors, editors, researchers, and bioresource policy stakeholders is the first necessary step to achieve these goals and is essential to enhance transparency in health research.


Cholelithiasis is prevalent surgical disease, with approximately 60,000 admissionsper year in the Unified Health System in Brazil. Is often asymptomatic oroligosymptomatic and major complications arise from the migration of calculi tolow biliary tract. Despite these complications are severe and life threatening,some patients refuse surgical treatment.To understand why individuals with cholelithiasis refuse cholecystectomy beforecomplications inherent to the presence of gallstones in the bile duct andpancreatitis occur.To investigate the universe of the justifications for refusing to submit tosurgery it was performed individual interviews according to a predeterminedscript. In these interviews, was evaluate the knowledge of individuals aboutcholelithiasis and its complications and the reasons for the refusal of surgicaltreatment. Were interviewed 20 individuals with cholelithiasis who refused orpostponed surgical treatment without a plausible reason. To these interviews, wasapplied the technique of thematic analysis .The majority of respondents had good knowledge of their disease and its possiblecomplications, were well oriented and had surgical indications by theirphysicians. The refusal for surgery was justified primarily on negativeexperiences of themselves or family members with surgery, including anesthesia;fear of pain or losing their autonomy during surgery and postoperative period,preferring to take the risk and wait for complications to then solve themcompulsorily.The reasons for the refusal to surgical resolution of cholelithiasis were diverse,but closely related to personal (or related persons) negative surgical experiencesor complex psychological problems that must be adequately addressed by the surgeonand other qualified professionals. In the elderly, it is the most common cause ofindication for abdominal surgery, with a prevalence of 21.4% in the age group of 60-69years and 27.5% in individuals over 70 years14. It may progress without symptoms for more than half of cases15. In 2000, it was estimated that it has affected about 20 millionAmericans, with direct or indirect cost of six billion dollars19.The cholelithiasis occurs in 3-20% of the world population17.The migration of stone often cause symptoms and can evolve as acute, often severe whennot operated. Besides these loco regional inflammatory complications, cholelithiasis maypredispose to gallblader neoplasia17. In a Brazilian study,in 4,482 autopsies performed on both men and women, it was found 94 cases of bladdercancer (2.1%), most commonly associated with cholelithiasis cases with an earlier andlonger disease diagnose7.In autopsies of people aged over 75 years, gallstones are even found in 50% ofcases1. It can be also found bacterial translocation  and decrease the amount of liquid,increasing the concentration of bile and favoring the formation of stones1.The lithogenesis is influenced by multiple factors. The gallbladder stores bile refluxcoming from the closure of hepatobiliary bulb and focuses it. The arrival of food in theintestine triggers the neural reflex which adds to the action of cholecystokinin leadingto contraction of the bladder, which empties its contents by 75%. When this mechanismdoes not function correctly, there is stasis of bile, gallbladder distention andischemia. And it still occurs secretion that activates phospholipase lecithin, promotinginflammation by releasing pro inflammatory mediators2 acids and extracorporeal lithotripsy bywave shock4. None has been foundeffective in the long term, confirming that cholecystectomy is the only treatment proveneffective for solving the colelithiasis3.An extensive literature review, examined the possible non-surgical treatments availablefor colelithiasis, at that time, such as the use of queno and ursodeoxycholic17.When cholelithiasis is complicated by cholecystitis, there are no difficulties for thesurgery indication by the attending physician, because the picture is very acute,symptomatic and progressive, leading the patient to not discuss the surgical indication.However, in asymptomatic, mildly symptomatic and uncomplicated cases, there are moredifficulties in the statement, since some individuals with no pain feel no need ofintervention, unless they enter into acute cholecystitis, pancreatitis orcolangitis5. Thereafter been reportedwith increasing frequency by a greater number of surgeons. The introduction of thismethod allowed it to be taken even in subjects with mildly symptomatic cholelithiasiswith less than 1% mortality rate3.However, even with all the accumulated knowledge in the field, the precise medicalindications and recognition by the patient that the operation is the treatment of choicefor the disease, some individuals with gallstones do not accept it.In Brazil, the first laparoscopic operation was performed by Thomas Szeco in199321. Thus, itis expected that some individuals refuse or postpone surgical treatment until the momentit is not possible or is beyond your will18.It's natural to fear and have expectations about the surgery and assume that somethingmay go wrong on the operation, even if it is not an emergency and that will surelyenable the planning of the surgery. At this time of conflict, our fears and doubts arecoming out much strongerThe occasional experience in cases of this nature and reflection on the intriguingdecision to patients who refuse operation led to this study, aimed to assess the degreeof knowledge that individuals with cholelithiasis who refuse operation have about theirdisease and its complications and understand the reasons why refuse or postpone surgicaltreatment and also propose a consent form in language to laity to help them inunderstanding the disease, reducing their concerns and facilitating therapeuticdecision.The research project and the consent form were approved by the Ethics Committee of theCollege of Medical Sciences at the Pontificial Catholic University of São Paulo.Participants were not identified at any time of the survey.21.It is a qualitative and quantitative research, based on interviews with 20 patientssuffering from cholelithiasis, despite medical indication for performingcholecystectomy, did not accept it even with the guidance of professional or chose topostpone it. During the review process, some categories of reasons were identified topostpone or reject the operation. These categories are shown in These categories do not exhaust the possibilities of understanding about thedifficulties of individuals to make a decision about the surgical procedure withoutbeing under pressure and time urgency, but these were chosen by the researchers, havingconsidered their emotional impact.12.The survey was conducted with 20 participants of both sexes, aged 19-70 years anddiagnosed with cholelithiasis, confirmed by abdominal ultrasound or other diagnosticimaging method , with the classic symptoms of the disease with few symptoms or "asymptomatic " . Inclusion criteria for the study were: 1) presence of calculus in thegallbladder diagnosed by imaging method) ; 2) denial of the individual to performelective cholecystectomy or successive delay of surgery for poorly justifiable reasons;and 3) have agreed to participate in the study by signing the consent form. The numberof participants was defined by "saturation criteria" proposed by MuchielliParticipants in this study were recruited from the private clinic (n=11) and OutpatientSpecialty Health Network from the city of Sorocaba (n=9). After identifying the patient,the nature of the study was explained to them and then was applied the term of consentand their signatures, harvested according to the Resolution 196/96. The interviews wereconducted in office.To investigate and understand the reasons for the refusal to accept surgical treatment,interviews with all participants made individually through open-ended questions, wereconducted according to a pre established route using a tape recorder to record thenarratives. The script was: 1) What were your symptoms at diagnosis time and currentsymptoms?; 2) Which were the methods for the diagnosis of cholelithiasis?; 3) Whoindicated surgical treatment?; 4) What do you know of this disease?; 5) What do youexpect to happen if you operate?; 6) What are your reasons for not performing thesurgery?In the qualitative analysis of the interviews, was sought to privilege the speech,concepts and thoughts in order to establish more detailed and in-depth exchanges on thetopic in question, its causes and consequences of the negative decision to perform theoperation.Quantitative analysis was performed descriptively aiming to inform the frequency withwhich the ideas appear in the speeches and representations. Developments within thefollow-up period were also analyzed descriptively and quantitatively.11 the ideas presented by the participants were identified thatrepresented relevant points in speeches, influencing their decision facing the medicalindication for surgery. After individual analysis, other was also made with all theinformation and representations provided by the participants, identifying common orcorrelated factors in these discourses.The interviews were transcripted and initially analyzed individually. From the analysisof speech according to Badin and MinayoHaving as starting point the informed consent already provided by the BrazilianCollege of Digestive Surgery - CBCD was chosen to adapt it to the cultural reality ofthe participants of this research and including information that was considered to beimportant to help patients in therapeutic decision. It is noteworthy that for thispurpose the consent of CBCD for use and adaptation of the instrument wasobtained.The results are presented in tables and divided according to their content. To better understand this refusal of surgical treatment, was used the technique ofindividual interviews, providing a free and appropriate environment for the participantto have full opportunity of expression, also avoiding interfering with itsreflection.The related complaints of abdominal distension, nausea, vomiting, dyspepsia, foodintolerance, intestinal pain in the epigastrium, composed the universe of symptoms thatoften led the individual to seek specialists in Gastroenterology; they report vaguecomplaints that often did not permit correct diagnosis of cholelithiasis or with examsinducing only to functional disorders, "gastritis" or "colitis " with ultrasonographyalways normal.The next question was: "Which were the methods for the diagnosis of cholelithiasis?"Ultrasonography was the most used method (90 % of cases) followed by tomography of theabdomen in 10%, indicated on the possibility of pancreatitis and biliary tractdilatation."Who recommended surgical treatment for gallstones?" Medical emergency service indicatedit in 25% of cases, and the other 75% by medical assistants. The correct indication ofthe treatment was taken in all cases, but the patients sought other professionals hopingdifferent diagnosis and treatment.The following question "What do you know about your illness?" showed that 55% expressgreat knowledge to the point of describing it in details, including complications suchas pancreatitis, choledochal calculus, bladder perforation and other complications, butstill did not want to be operated. The other 45% had little or no knowledge at all abouttheir disease.Referring to the question "What do you expect to happen if you operate?" most repliedthat they hoped to get the urgency status (90%). They expected a decision that was"alienated form of Medicine" or "by imposition of fate", resulting in their owncomplications of the disease that "force" to be treated surgically. Even though thehigher risk, preferred them to an imposed decision."What are your reasons for not performing the surgery?" The majority (65%) reportedbeing afraid of anesthesia or complications and 35% justified their decision by ahistory of traumatic experiences, whether personal or with people of their coexistence.Some have also had contact with death or suffering of a loved person, showing not onlyfear, but also anger and little hope. The data analysis also revealed that there aresome justified concerns that should be clarified in a written document, aiding them inthe treatment decision. Among these are: 1) return to work without restrictions; 2)return to sexual activity; 3) feeding; 4) commonly associated diseases, such as diabetesmellitus, hypertension, hypothyroidism requiring continuous medication, are alsofrequent concern.The CBCD document brings enlightening information about the surgical procedure; butwas noted that many of the issues raised in the interviews of this study were stillopen. Thus, adaptation from the original consent form that by request of the CBCDcould not be copied in its entirety, resulted the model of Although all participants, in principle, refused to perform the operation, more thanhalf were operated, most due to acute complications of the disease  andothers have decided to operate electively .Despite the term of informed consent being the most informative and complete aspossible, it is not definitive, nor relieve the doctor of effective participation,clarifying doubts of the patients, reviewing and discussing points in which patientshave difficulty, allowing time for the patient to think, remarking further consultationsto resume the subject, effective participating in the process and not just signing it.In this way, the doctor-patient relationship is of great importance because itstrengthens the relationship and brings us closer to our patients, leaving them lessanxious about the risks of the operation and assisting them with the new situationbefore the surgical procedure.17. The model is a qualitative study, based on analysis ofinterviews with pre-established script allowing to explore the causes that have led somepatients to refuse or postpone the operation without justification. The data showed thatmost participants had good knowledge of the disease and its complications. They alsoreported they were well informed by their physicians in the diagnosis and follow-upprocess, but chosen to delay surgery, justifying this decision mainly by fear ofanesthesia, the surgery and the postoperative period. However, other concerns that havecontributed to this behavior, including early concern in pain, and having other symptomsthat may affect their lifestyles, leaving often the procedure for an urgent emergencysituation, which may impair resolution of their disease.This study used a sample of patients that resembles the general population of patientswith cholelithiasisDuring the analysis of this study it was felt that patients will undergo a surgicalprocedure in general and in particular those who have difficulty deciding for surgicaltreatment, need to be fully educated, especially in what surround the procedure, theinformation of the causes of the disease, its treatment options, risks and benefits ofthe proposed treatment and changes in the individual's routine pre- andpostoperatively.Though fear - main reason for refusing to surgical treatment - is not rational sense, itis understood that patients like detailed clarification material with technicalexplanations in language addressed to the lay, can be part of a process of clarificationand demystification of everything surrounding the procedure, helping them to accept theoperation. This study presents a proposal for informed consent with all the informationabout the operation, its risks, pre-and post-operation, as well as shown in friendlyformat helping the patient in his decision. Recently, associations and specialistservices began to use the Statement of Informed Consent that instructs and informspatients and families about the procedure to be performed, but its primary purpose is tosafeguard the professionals involved in the procedure for any future demands inherentcomplications the procedure and even malpractice.8 introducedthe concept that when dealing with stressful situations, such as loss, grief, tragedy orincurable diseases, go through different stages to reach acceptance, more advancedstage. This researcher has defined five common stages of this process that are:"denial," "anger," "bargaining", "depression" and "acceptance"8. The author maintains that all persons subject to thesesituations have at least two of these stages, which do not always occur in this order,and may also be advance or throwback. In this sense, the doctor-patient relationship isof great importance, because it strengthens and approaches patients, leaving them lessanxious about the risks of the operation and assisting them with the new situationbefore it comes. On experience with this small group of patients, who earlier did notaccept surgical treatment, a part of them (25%) finished undergoing elective operation,achieved with the help of the doctor the right decision.Despite the informed consent being the most informative and complete as possible, it isnot definitive, nor a relief for the doctor of effective participation, clarifying anyquestions, reviewing and discussing points in which patients have difficulty, givingtime to think, redrawing new queries to resume the subject. In short, effectivelyparticipating in the process and not just signing it. Kubler-RossEvidently such an instrument should not be the only form of aid to the patient. In thissense, establish a good relationship of doctor-patient trust and assistance of trainedprofessionals working these past traumas are key to providing security to the patient atthis time.All patients who refused or delayed the operation expressed many fears - including death- and loosing self-control. These feelings were not due to lack of information. It wasdetermined that other personal factors contributed to increase insecurity, whichcontributed to the decision of making or not the operation. The proposal is to use thisor other informed consent, incorporating all the information that may help in thedecision. Moreover, good and lasting doctor-patient relationship and the availability ofmore time for decision were important factors for a good part of the participants thataccepted to perform the operation electively, after reading and understanding theinformed statement.


Improving health care quality requires effective and timely spread of innovations that support evidence-based practices. However, there is limited rigorous research on the process of spread, factors influencing spread, and models of spread. It is particularly important to study spread within the home care sector given the aging of the population, expansion of home care services internationally, the high proportion of older adult users of home care services, and the vulnerability of this group who are frail and live with multiple chronic conditions. The purpose of this study was to understand how best practices related to older adults are spread within home care organizations.n =44) and 1 year later (n =40). Open, axial, and selective coding and constant comparison analysis were used.Four home care organizations in Ontario, Canada that had implemented best practices related to older adults  participated. Using a qualitative grounded theory design, interviews were conducted with frontline providers, managers, and directors at baseline (A model of the process of spread of best practices within home care organizations was developed. The phases of spread included (1) committing to change, (2) implementing on a small scale, (3) adapting locally, (4) spreading internally to multiple users and sites, and (5) disseminating externally. Factors that facilitated progression through these phases were (1) leading with passion and commitment, (2) sustaining strategies, and (3) seeing the benefits. Project leads, champions, managers, and steering committees played vital roles in leading the spread process. Strategies such as educating/coaching and evaluating and feedback were key to sustaining the change. Spread occurred within the home care context of high staff and manager turnover and time and resource constraints.Spread of best practices is optimized through the application of the phases of spread, allocation of resources to support spread, and implementing strategies for ongoing sustainability that address potential barriers. Further research will help to understand how best practices are spread externally to other organizations. Improving health care quality requires effective and timely spread of innovations that support evidence-informed practices ,2. HowevWhile important advances have been made in implementation science, little attention has been paid to spread and scale-up of health innovations . AlthougThe concept of spread has received increased international attention in the past decade. In the UK, for example, the National Health Service has developed a change model that includes spread of innovation as a key concept, as well as a spread and adoption tool and a leader’s guide on sustainability and its relationship with spread and adoption . In New The study of spread processes has emerged from the literature on the diffusion of innovation in complex organizational settings ,13-15. AThere are a number of frameworks of spread ,20. One There is strong rationale for a focus on spread in home care settings. The proportion of older adults in the population is escalating worldwide and is associated with an increasing demand for and use of home care services ,22. OldeMany innovative services have been developed and evaluated to support older adults to live independently in the community ,26. WorkThe limited research that has been done on innovation spread in healthcare has primarily focused on acute care ,31 or veIn Ontario, Canada, many home care organizations have been working with the Registered Nurses’ Association of Ontario (RNAO) to implement and disseminate best practice guidelines (BPGs) . Some hoIn summary, there is limited research on the process of spread of best practices in home care settings. Qualitative research that results in a deep understanding of the process of spread in home care, including theoretical models of spread based on research data, has the potential to guide practice and policy that results in successful spread initiatives using scarce resources most effectively. The research questions in this study were as follows: What is the process used to spread best practices related to caring for older adults within home care agencies? What factors influence spread or non-spread?A qualitative rather than quantitative research design was ideal to address the research questions because this approach (a) facilitates exploration of little-known areas, (b) generates rich and detailed data that contribute to an in-depth understanding of an issue, (c) involves data collection in natural settings, (d) includes voices of participants themselves, and (e) through making the world visible has the potential to transform that world ,43. MorePurposive sampling was used to determine information-rich data sources (settings and participants) for participation in the study . ConsistFour home care organizations in Ontario, Canada, that had implemented best practice guidelines related to caring for older adults were purposively sampled . We expected a sample size of 8–10 individuals per site, interviewed twice (64–80 interviews), to be adequate for data saturation. This estimate was based on published grounded theory studies in health care that included three sites each and completed 44–120 interviews -48. ConsThe researchers worked closely with trained recruiters from the four organizations to identify potential participants who were given an information letter and invited to participate on a voluntary basis. Upon acceptance, recruiters sent participants the consent form to review.Two semi-structured audio-taped interviews were conducted with each participant approximately 1 year apart . Interviews were conducted by the Principal Investigator (JP) and/or the Research Coordinators .The development of the semi-structured interview guide used in the first interview was based on a review of the literature and experience of the team with previous BPG research. Participants were asked to describe their experiences with and perceptions of the process of spread (interview guide available on request). Interview questions addressed topics such as the rationale for selecting the particular guideline, tool development, early implementation of the innovation, participant role in the spread process, the process of spread, and facilitators and barriers to spread. In the second interview, participants were asked to discuss their experiences with and perceptions of the spread process in the intervening year since the first interview. Preliminary analysis of the data from the first set of interviews was used to develop lists of antecedents, spread strategies and processes, benefits, and facilitators and barriers to spread . Participants were asked to review these lists and identify the items most important for their own spread process and why.Data from all interviews were transcribed verbatim, cleaned, and analyzed using NVivo 10 software. Data were collected and analyzed concurrently using strategies consistent with a grounded theory approach . Open coDetailed memos of thoughts and perceptions of the data as they were collected and analyzed were maintained. The research team maintained written records of analytic ideas, concepts, and decisions made throughout data analysis.Study rigor was also ensured through the use of member checking. In December 2013, the researchers followed-up with participants from each organization (ensuring representation of different categories of staff) to discuss the organization-specific flow charts of the spread process and to discuss the draft model of spread. Participants provided valuable feedback and suggestions for change. Overall, participants indicated that the model represented the spread process in their organization. One participant said ‘This feels familiar to me. It is exciting to see something put into the model that reflects what we did’.Transferability of study findings was enhanced by the multi-site design and variety of best practices that were studied. Truth value or credibility was enriched through triangulating across data sources and data collection procedures, member checking, and deliberately trying to discount or disprove conclusions about the data . Collecting data from participants at two points in time assisted with data source triangulation, whereas having research team members review main categories and the model to confirm interpretation assisted with investigator triangulation.Ethics approval was obtained from McMaster University Hamilton Health Sciences Research Ethics Board on December 14, 2011 (project number 11-555) and from each participating site. Research team members ensured informed consent, collection of signed consent forms, and protection of participant confidentiality. Each organization received a small amount of funding to support their assistance with recruitment.Participants included 46 individuals from the four organizations, all but one of whom were female  commitment to evidence-informed practice, (b) previous lessons learned with guideline implementation, and (c) recognition of practice needs and gaps. All four organizations had an explicit commitment to evidence-informed practice, with a particular focus on implementing, evaluating, and spreading best practice guidelines. Each had gone through the process of becoming a RNAO BPSO® designate and had developed and carried out specific plans for implementing a number of best practice guidelines over 3 years and committed to spreading and sustaining those practices. The commitment to change also involved allocating resources such as funding for a dedicated project leader and targeted educational activities. Each organization drew on previous lessons learned from guideline implementation as a foundation for the current spread process. Participants described both successful and unsuccessful experiences with guideline spread and recognized the value of initially trying the innovation on a smaller rather than larger scale.There was a lot of disparity among supply usage, healing times, length of stay on nursing services, delays in wound healing. So that promoted the need to have some consistency and be fiscally responsible and have that equitable access to services in such a large organization. (participant 02-11)A commitment to change also involved the identification of practice needs and gaps specific to the guideline topic. As these needs and gaps were recognized broadly within the organization, there was a readiness to take action. In one organization, there was a recognized need for improved consistency of care across geographic boundaries.The second phase of the spread process, implementing on a small scale, involved trying out the innovation in selected sites or branches prior to spreading the change throughout the larger organization. The three spread organizations had a steering committee, dedicated project leads, champions, and managers who were very involved in planning and implementing the innovation. These individuals and groups reviewed the best practice guideline, identified key practice recommendations to focus on, and developed practice tools based on these recommendations.The complexity of tools developed varied by organization: (a) 14 items on home assessment to prevent falls, (b) 9-item form related to falls risks in and outside of the home, (c) a more complex pain flow sheet that included an assessment of pain characteristics and descriptors, contributing factors, impact of pain, client perceptions of pain and pain goals, resources, interventions taken, and evaluation of their impact, and (d) venous leg ulcer care pathway and related decision tools for case managers.You could waste a lot of resources and time trying to roll something out across the board… So I would definitely say a pilot site, get some feedback, get people’s ideas…because then the nurses feel like they are getting a chance to have some input and offer some advice. (participant 04-04)A decision was made, usually by senior managers in consultation with project leads and managers, to try the tools in selected sites within each organization. Steering committees, project leads, champions, and managers used communication and education strategies with frontline providers to encourage use of the new tools. Participants explained that this phase involved a cyclical process of trying the best practice tools and processes, getting feedback and adapting to local contexts, and then retrying. Implementing on a small scale was viewed as creating a ‘solid base that was proven to be effective prior to the rollout to the larger organization’ (participant 02-03). This phase was viewed as saving time and resources by ensuring the innovation would be accepted more broadly and that all stakeholders had opportunity for input.You want to make sure what you are doing is doable and I find that frontline staff will be brutally honest and let you know if something is not doable and why. And, if that happens, you want them to be part of the process in trying to figure out how to get that done. (participant 03-11)The third phase of the spread process, adapting locally, involved the careful review of feedback on the successes and limitations of the small-scale implementation and revising both the tool and the processes used to spread to local contexts. Participants described strategies used to collect feedback from frontline users including formal written evaluations, team meetings, and informal discussions with managers and project leads. Participants emphasized the importance of obtaining feedback from the frontline providers, nurses, and others who used the best practices with clients to determine the feasibility of the practice change and understand the revisions that were needed.Project leads, managers, and steering committees reflected on the feedback and adapted or tailored the innovation to better fit the specific contexts of the sites. Participants used terms such as ‘work out the flaws’, ‘fine tuning’, and ‘work out the kinks’ as they adapted the innovation to improve staff buy-in and spread to other areas. Adaptations made included shortening tools, simplifying scoring methods, and ensuring there was a good fit with what providers were already doing.Participants explained that ‘different areas had different strategies’ (participant 01-10) to spread best practices. There was diversity in the individuals who supported the spread process at different sites and the educational approaches used to support spread based on resources available and accepted practices. Communication strategies to support spread also varied with some sites using, for example, weekly electronic updates and newsletters, and others using team meetings.We get a calendar…it’s going to be rolled out in [Location A] here and it’s going to [Location B] this date and will be down in [Location C] that date. Because our advance practice team is a small team and they have to be available to go to many, many places across the province…it would be weeks or sometimes even months. It also allows each site to get their staff in place, to bring them in for education, and bring two hundred people together in the same room. (participant 03-07)The next phase of spread, spreading internally, involved moving the innovation throughout the organization to all sites and users. This process varied, with one setting moving the innovation to all additional sites at approximately the same time, whereas two sites used a phased approach to internal spread.Participants talked about the value of engaging spread sites early by sharing information about the innovation well before the internal spread phase. Leaders from the early implementation site provided education to representatives  from spread sites on ways to use the tool and strategies to support its use by frontline staff. These representatives then used multiple strategies to educate frontline staff at their sites. The new tool was placed in all client admission charts or made readily available to users. Participants emphasized how important it was to ensure manager commitment to change in this phase.While three of the four organizations demonstrated internal spread, none of the organizations demonstrated external spread where the innovation was adopted by external organizations. However, three organizations demonstrated external dissemination defined as dissemination of knowledge that is focused primarily on communicating research results by targeting and tailoring the message to particular audiences and which precedes implementation or application of that knowledge . ParticiThree factors facilitated the spread process: (a) leading with passion and commitment, (b) sustaining strategies, and (c) seeing the benefits Leading with passion and commitment refers to the leadership approach of project leads, champions, managers, and steering committees. Some individuals held more than one of these roles concurrently. Project leads were managers or resource staff who led the spread process with passion and commitment; their leadership was seen as a driving force that created a necessary following for successful spread:Participants explained that the success of project leads in facilitating spread was associated with their ability to develop trusting and respectful relationships with frontline providers. Project leads played roles such as setting timelines for the spread process and ensuring accountability to goals. Participants emphasized that project leads required release time for their roles, supported by organizational or other funding.Champions for sure, the passion and the energy and the respect, and the resource within the organization. Every organization needs a person on a day-to-day basis that they can go to because as they are learning new information, they need that reassurance. (participant 02-01)Champions were identified as individuals at all levels of the organization  and in all sites or locations who were passionate about the innovation and acted as resource or ‘go-to’ persons.Frontline champions were seen as particularly vital in influencing their peers to adopt the innovation as it spread throughout the organization. Their sense of ownership and willingness to help their peers ‘work through a [client] issue’ (participant 02-11) were important to get grass roots buy-in.My nurse manager came out on a couple of home visits and she said ‘this is the new pain sheet’ and she just went through every page with me and ‘this is how it works and this is how to use it.’ So that was the most effective thing for me because otherwise it was just this sort of vague, you pull it out of the chart and it looks so daunting and time consuming. (participant 01-06)Managers were members of the steering committee and played facilitating roles as educators, mentors, and role models for frontline staff. They provided both formal and informal education related to the innovation. Frontline providers described how valuable it was when managers would go with them on home visits, interpret the best practice tool, and walk through its application.Having a steering committee really made a big difference because we were all from different areas…and we all have different connections…working as a team and pulling all of this together from everybody’s different perspectives and experiences and input really made a big difference. (participant 01-10)Steering committees were usually composed of frontline providers, managers, project leads, champions, and clinical resource staff. In the early phases, steering committees carefully reviewed the BPG, identified relevant recommendations, and developed tools to be implemented. They ensured the development of a ‘strong communication plan’ and the sharing of a ‘unified message’ (participant 02-11) about the practice change. In later phases of spread, the steering committee planned the small-scale implementation, obtained and reviewed feedback, and guided the adaptation of the innovation for internal spread. Participants explained the value of diverse perspectives in moving the spread process forward.Interviews conducted a year after the initial interviews highlighted the importance of sustaining strategies for successful spread. Participants gave examples of diminishing focus on the innovation following the spread process, including less funding for the project lead, frequency of steering committee meetings, time committed by champions and managers to the innovation, and educational time. Four strategies used throughout the spread process not only facilitated the spread process, but also helped to sustain the continued use of the innovation once spread had occurred: (a) engaging and communicating, (b) educating and coaching, (c) integrating into practice, and (d) evaluating and feedback.Engaging and communicating strategies were used by project leads, managers, and champions to engage frontline providers in discussions of the innovation. They discussed what worked and what did not, sought out positive examples of practice change and recognized and reinforced those changes.The more we’ve learned that the mentoring and coaching is really…the part that’s effective. That’s the part that makes a difference in changing the practice of nurses. (participant 01-01)All participants described diverse educational strategies to support spread that were used by project leads, champions, managers, steering committees, and resource staff. These strategies included team meetings, orientation sessions, one-on-one sessions, electronic media, newsletters, mentoring, and coaching. One-on-one mentoring and coaching by managers, champions, and project leads, often in client homes, was viewed as one of the most effective change strategies.The third sustaining strategy, integrating into practice, involved incorporating the innovation into documentation, care paths, policies, and procedures so that it was ‘woven into the very fabric of what we do’ (participant 01-04). Participants indicated that the tools had to be ‘right there’ and ‘in front’ of providers who were busy and often overwhelmed with paperwork. Further, the tools had to be structured to clearly guide practice.The most important barriers…feedback would be the big one…I don’t really know that the loop closes very well. It would be nice to have that feedback and to hear that it’s making a difference. (participant 03-08)The spread process was also facilitated by the sustaining strategy of evaluating and feedback. Participants emphasized the importance of listening to feedback from frontline providers and ensuring their voices were heard and acted on in the change process. However, participants noted that most clients’ charts were hard copies that remained in the home until discharge, making it challenging to monitor both the degree of spread of the innovation and the client outcomes related to spreading the innovation.What makes this one easy to spread is the fact that very quickly the nurses realize how much they can improve the disease experience for their patients. So they really help buy-in because they feel empowered to make a difference. And pain is such a distressing symptom that to walk away from that visit and know you have made a difference is really a powerful thing. (participant 01-04)The third facilitating factor of the spread process was that participants were seeing the benefits of the change at multiple levels of impact, namely the client, health care provider, organization, and system. While it was challenging to obtain impact information, seeing these benefits created an ongoing momentum for the spread process.Ultimately it’s all about the client....the ultimate benefit is that we are preventing clients from injuries and preventing readmission to hospital and all those things impact the health system as a whole. (participant 02-11)It was important for providers to see the benefits of the change for their own practice and recognize that the innovation was not adding to heavy workloads but making their practice more effective. At the organizational level, there was a recognition that the practice change resulted in a more consistent approach to client care and helped to ensure equity in access to care. Finally, seeing the benefits of change at a system level facilitated the spread process:The context of home care practice was riddled with barriers to the spread process. These barriers operated at individual, organizational, and system levels and were addressed, in part, through the effectiveness of the facilitating factors previously described. At an individual level, barriers included resistance of the staff to integrate new practices in the face of already heavy workloads and documentation requirements. Some of the organizational barriers included staff and manager turnover, constant change, and the lack of electronic records.Participants explained that the context was rife with ongoing new initiatives mandated by employers and funders. The nature and frequency of these changes detracted from the necessary focus on the spread process and ongoing sustainability of the innovation. Further, most settings did not have electronic health records which made it hard to track outcomes of the innovation and provide feedback to the staff related to the impact of the changed practice.One of the key contextual barriers to spread involved the large and decentralized workforce in the home care sector. Organizations provided services in very large geographic areas and employed large numbers of professional and non-professional staff, making it very challenging to ensure that all staff were well trained and supported in using innovations. The part-time nature of the workforce contributed to these challenges.This study makes an important contribution to the implementation literature on the spread of best practices. First, the study resulted in a theoretical model that provides a useful blueprint for spreading best practices within home care. Findings highlight the critical role played by passionate and committed leaders at multiple levels  of the organization in facilitating spread. Further, the model emphasizes the importance of ‘seeing the benefits’ of the innovation and the particular challenges experienced in home care settings in making this possible. Second, the longitudinal nature of the study revealed the intertwining nature of spread and sustainability processes. Third, study findings accentuated the determining role that contextual factors play in the spread process. Each of these contributions is discussed in the following sections.The theoretical model of spread illustrates the complexity of the spread process, uniquely combining phases of spread, facilitators of spread, and the context of spread, as well as the intertwining of spread and sustainability. Three intricately entwined process characteristics, specifically sequences, cycles, and spirals, are reflected in the model . The modp < .001) [One of the key facilitators of spread in this study, leading with passion and commitment, is consistent with other studies that have found leadership to be critically important for implementing and sustaining innovations -39,51. T < .001) . Other s < .001) ,39. The Another key facilitator of spread found in this study, seeing the benefit, is consistent with findings from other studies of guideline implementation and spread ,37. HomeStudy findings also make an important contribution to our understanding of the intertwining nature of spread and sustainability processes in home care. Data collected at the second interviews demonstrated that following the internal spread phase, resources such as release time for the project lead and for the staff to attend educational sessions related to the innovation were greatly scaled back, putting sustainability in jeopardy. Sustainability of the innovation was not considered as a part of the planning for spread process. Literature suggests that some of the facilitators of spread found in this study may be similar to those that facilitate sustainability of innovations ,55-58.Finally, this study makes a valuable contribution to our understanding of how contextual factors at multiple levels influenced the spread process in home care settings. Research has shown that health care reforms to shift the focus of care from costly acute care institutions to home care settings have resulted in heavier workloads, job insecurity, job stress, and decreased job satisfaction for home care workers . The homStudy findings reflect all three forms of data analysis described by Strauss and Corbin  as buildThere are a number of considerations for practice, policy, and research arising from the study findings. In relation to practice considerations, almost all participants spoke about the value of implementing the innovation on a small scale before moving it to the rest of the organization. They described the value of ensuring it was feasible and applicable and that frontline staff had opportunities to try it out, give feedback, and build buy-in. Another practice implication involves explicitly planning for both spread and sustainability at the start of the change process. It is clear that we cannot afford to invest time and resources in spreading innovations that are not sustained or evaluated and revised over time. While commitment and passion were consistent behaviors among leaders spreading best practices, evidence shows that leadership can be developed and acquired and is not an innate trait ,61. ReseStudy findings call attention to policy considerations for spread in home care settings, in particular strategies that address the contextual barriers to spread. Increased investment in the home care sector is key, given the increasing number of older home care clients, limited resources, and escalating costs associated with increased client acuity ,23. InveFindings also highlight the need to ensure the necessary resources for stakeholders to ‘see the benefits’ of spread. Efficient audit and feedback mechanisms allow providers to see the immediate and beneficial effects of practice change on client outcomes. Home care organizations and funders need to invest in electronic health records and feedback systems that facilitate communication both within and across home care agencies.Further research is needed to test this spread model in other home care settings to confirm its applicability. Inclusion of additional innovations, home care settings, and interviews over a longer term might result in revisions to the model. Research is also needed to explore how external spread happens in and beyond the home care sector, as external spread was not evident in this study. Further research is required to explore the intertwining nature of sustainability and spread and to identify approaches that will ensure both spread and sustainability of effective innovations. Study findings indicate that there was a significant investment of resources in the spread process . However, we do not know the impact of spread on the costs of programs or what factors affect costs of spreading innovations . This isThe theoretical model provides a new conceptual rendering of the process of the spread of best practices within home care settings. This understanding of the spread process has the potential to facilitate more effective and efficient spread of best practices to improve outcomes for frail older adults, the highest users of home care services. The key concepts of the theoretical model provide a useful guide to inform spread of innovations and may be relevant beyond home care settings.Some of the qualitative data set supporting the results of this article are included within the article. A longer report with more details is available from the lead author.We defined spread (or success) as “the process through which new working methods developed in one setting are adopted, perhaps with appropriate modifications, in other organizational contexts” . We cons


The research on aging and age-related diseases, especially the neurodegenerative diseases, is on the fast track. However, the results have so far not been translated to actual benefit for the patients in terms of treatment or diagnosis of age-related degenerative diseases including those of the CNS. As far as the prevention of the cognitive decline during non-pathological aging is concerned, there is nothing much to offer other than calorie restriction and physical exercise. Needless to say, the benefits are not up to our expectations. However, over the years at the experimental level it has been possible to identify several cellular and molecular mechanisms that are intricately associated with aging in general and neurodegenerative diseases in particular. These include oxidative stress and altered redox-signaling, mitochondrial dysfunction, inflammation, proteotoxicity and altered gene expressions. These inter-dependent pathways mediate cellular senescence and often culminate in programmed cell death like apoptosis and autophagy, and in the context of brain these changes are manifested clinically as cognitive decline and pathologically as neurodegeneration. This special issue provides the readers with glimpses of this complex scenario from different angles primarily in the context of brain and also attempts to identify the potential drug targets against neurodegenerative diseases. The eight articles in this special issue appear a bit disparate at the first sight, but the common theme is easily discernible on scrutiny. All the articles are related to causes, consequences, models and mechanisms of aging and age-related diseases in general and neurodegeneration and neuroprotection in particular. The importance of the topic cannot be too emphasized in a world where the percentage of aged population is on the rise continuously causing a huge burden on every nation in terms of finances and health care support. For majority of the articles in this series, the main context is the brain aging or Alzheimer's disease or other kinds of brain damage, but a few articles have addressed the process of aging and age-related diseases on a larger canvas. Several of these reviews were presented and discussed in an international conference (NEUROCON 2015) held last year at Haldia, India [APP, PS 1 and PS2 genes have given a big boost to the hypothesis of proteotoxic mechanism mediated by the oligomers of amyloid beta peptide, often called the Amyloid Cascade Hypothesis, in explaining the neurodegeneration of the sporadic AD. Thus, the experimental AD research has produced a surfeit of mechanistic pathways triggered by amyloid beta peptide oligomers that culminate in the apoptotic or autophagic death of neurons [The manifest common end point of brain aging and AD is the impairment of memory and cognition, and at the molecular and cellular level the similarity is very striking between these two conditions. For example, mitochondrial dysfunction, oxidative stress, inflammatory response and proteotoxicity are common themes in AD and brain aging ,3,4,5. H neurons , 8. Desp2+ activated K+ channels could be linked to altered electrophysiology of neurons with clear implications in brain aging and AD [Mitochondrial dysfunction and oxidative stress as mentioned already are central mechanisms involved in brain aging and AD pathogenesis, and two articles in this issue deal with these aspects. As far as the oxidative stress is concerned, Sesti has emphasized in his review that instead of studying the generalized oxidative damage markers, the identification of specific oxidative alterations in ion channels in the brain would be more revealing . Thus, rg and AD . Onyangog and AD . This hag and AD . In thisg and AD . The autg and AD . This aug and AD . Neverthg and AD . Anotherg and AD . In thisg and AD . It is ig and AD . It is tg and AD . The autg and AD . The autg and AD .Hypoxia induced changes in gene transcription through activation of the transcription factor HIF-1α and subsequent activation of a set of histone lysine demethylases causing epigenetic changes in chromatin have been analyzed in great details in the review article by Salminen et al. . While a


Nepal and Alberta are literally a world apart. Yet they share a common problem of restricted access to health services in remote and rural areas. In Nepal, urban-rural disparities were one of the main issues in the recent civil war, which ended in 2006. In response to the need for improved health equity in Nepal a dedicated group of Nepali physicians began planning the Patan Academy of Health Sciences (PAHS), a new health sciences university dedicated to the education of rural health providers in the early 2000s.Beginning with a medical school the Patan Academy of Health Sciences uses international help to plan, deliver and assess its curriculum. PAHS developed an International Advisory Board (IAB) attracting international help using a model of broad, intentional recruitment and then on individuals’ natural attraction to a clear mission of peace-making through health equity. Such a model provides for flexible recruitment of globally diverse experts, though it risks a lack of coordination. Until recently, the PAHS IAB has not enjoyed significant or formal support from any single international institution.However, an increasing number of the international consultants recruited by PAHS to its International Advisory Board are from the University of Alberta in Edmonton, Alberta, Canada (UAlberta). The number of UAlberta Faculty of Medicine and Dentistry members involved in the project has risen to fifteen, providing a critical mass for a coordinated effort to leverage institutional support for this partnership. This paper describes the organic growth of the UAlberta group supporting PAHS, and the ways in which it supports a sister institution in a developing nation. Sharing knowledge and experiences for the betterment of medical education in developing countries is one of the key benefits of global health education endeavors. In this paper we describe a program that is being developed as a joint venture between a group at a Canadian university and their colleagues at a new health sciences university, the Patan Academy of Health Sciences (PAHS) in Nepal. The intention of this collaboration is to build educational programs that increase health services for rural populations in Nepal. This paper focuses on the rapid, yet effective evolution of a PAHS support group at the University of Alberta (UAlberta) and how it has initiated a multifaceted collaboration at PAHS.Located in Kathmandu, The Patan Academy of Health Sciences admitted the first students to its medical school in 2010. Unique to Nepal, PAHS recruits and educates students to provide rural health care – a key step in reducing the rural-urban disparity that helped ignite a decade-long civil war in 1996. More than just a medical school, PAHS is a gateway to Nepal’s most needy communities, where global innovations in health education are taking root. While the Academy has started with a medical school, it is dedicated to the education of not only rural physicians, but also nurses, midwives, public health professionals and other health care providers. Having adopted best practices from around the globe, PAHS is actively engaged in solving the health care inequity in one of the world’s poorest nations .The group from the University of Alberta is made up of diverse members from within the Faculty of Medicine and Dentistry who share a common interest in Nepal, the betterment of its health care system and improvement of its people’s health. This Nepal group provides multifaceted support in areas where PAHS has identified needs, from fund development, to pedagogy, to program development and research.The UAlberta Nepal group is hoping to help PAHS become an example of innovative and sustainable medical training in the developing world, built upon a framework of competency-based medical education, community responsiveness and effective international collaboration.With a population of 27 million, and only 17% of its citizens urbanized, Nepal lives with a constant rural-urban disparity in health. A powerful caste system, limited possibilities for advanced education or travel, a strong economic divide, a recent decade of civil war and subsequent political instability mean the urban-rural health divide remains. While advances have been made in the last quarter century on the targets of the Millennium Development Goals, progress in bringing health equity to the Nepal’s 22 million rural residents remains slow. Average national life expectancy has risen to 66.5 years , but literacy is only 33% among women. Infant mortality (46/1000) and maternal mortality  are in the bottom 25% worldwide  [Nepal], 2012). A robust 5 hospital beds for every 1000 population does not reflect that those beds have few nurses and few doctors to tend to them. A reported rate of 1 physician per 5000 is an average that does not reflect the profound lack of rural medical care  practice. The result is an excess of under-resourced urban specialists with no unifying primary care system, and virtually no doctors for the rural majority in Nepal.At the turn of this century a dedicated core of Nepali physicians came together to create a new health sciences university, one that would help to remedy the health inequity of their nation. From the outset, the mission of the Patan Academy of Health Sciences was to sustain improvement of the health of the people of Nepal, especially those who are poor and living in rural areas, through innovation, equity, excellence and love in education, service and research. After years of national and international collaboration, and not without significant struggle, the founding faculty members succeeded. On August 20, 2007 the Government of Nepal endorsed the concept proposal and PAHS came into legal existence on February 6, 2008 with the Charter granted by the Parliament of Nepal.PAHS is unique in its inception, its vision and its support. It is the only medical school in Nepal designed to educate and retain rural physicians. Led by its then Vice Chancellor, Dr. Arjun Karki, and his team, PAHS adopted exemplary educational practices from around the globe. Together with an International Advisory Board, the leaders of PAHS have indigenized some of the most successful admissions, curricula and assessment in medical education. Spearheaded by a curriculum that integrates students into rural communities PAHS aims to create not just doctors, but medical leaders and agents of change. To do so they employ a unique admissions process that preferentially selects for capable students from poorer rural and remote districts.The Patan Academy of Health Sciences is housed at the Patan Hospital. Founded in 1956 by the United Missions to Nepal; its ethos of service to all patients regardless of ability to pay enshrined Patan Hospital as a top centre for healthcare in Nepal. In 2006, Patan Hospital was handed over to the government of Nepal, but the hospital’s mission remains unchanged: to provide a caring, effective and efficient hospital-based health service for any person in need who presents to the Hospital.Today Patan Hospital is one of the largest hospitals in Nepal. Using modern equipment it provides treatment for almost 320,000 outpatients and 20,000 inpatients, including 10,000 surgeries every year. The hospital has been operating with an annual revenue of around US $3.5 million, making great use of this limited resource.PAHS provides scholarships to 60% of its students , which puts a substantial financial burden on the institution, hence the importance of making best use of limited resources.While just starting out, the research programs at the PAHS and the Patan Hospital are already punching above their weight. Several areas of expertise are already developing. Patan is the current world leader in enteric fever research, and has produced top tier publications , which hInnovations in education  and healMajor challenges common to many medical schools in developing countries include low levels of funding, shortages of academic staff, limited faculty development and a pressing need to continue and evolve clinical service delivery.The challenges at PAHS are similar to those of many developing world medical schools. In addition to the demands of creating competent physicians, a significant added challenge exists: students must develop identities as a rural physicians as they pursue a mixed urban-rural education .Under the leadership of its founding Vice Chancellor, Dr. Arjun Karki, PAHS developed a very powerful tool to combat these challenges in the form of an International Advisory Board (IAB) chaired by Prof. Cliff Tabin from Harvard Medical School. The IAB enjoyed a very organic growth, with members being invited to join, and then staying on as their passion, interests and skills were found to match the needs of PAHS. At the request of PAHS faculty, the IAB members have advised on feasibility, admissions, curriculum and assessment, filled gaps in pre-clinical teaching, and provided faculty development and fund raising. Guided by their natural attraction to the mission of the PAHS, new IAB members continue to join, outpacing the normal attrition of volunteer members. Nowhere is this growth more evident than with IAB members from the University of Alberta who have had a rapid evolution in their support of the medical school.Alberta’s medical humanitarian involvement in Nepal goes back to 1960 and the efforts of Dr. Helen Huston . As a maIn 2011 Dr. David Zakus came to the University of Alberta as the new director of the Office of Global Health in the Faculty of Medicine and Dentistry. His leadership has given much energy and organization to the project and has provided an academic home for it at the University of Alberta. In 2012 Dr. Dominic Allain was added as Deputy Director of the Office of Global Health.The University of Alberta faculty and staff who are actively supporting PAHS understand that they can only meet a handful of specific needs. However, the group has been able to provide support in a large number of areas. A number of faculty members sit on the International Advisory Board (IAB) and provide advice and consultation at the Annual Consultative Meeting. The IAB is very active providing volunteer international faculty and external review  of PAHS activities.On the ground, tremendous support is still needed to get the day-to-day teaching done. While PAHS has developed its own educational experts, the faculty is small, experts in all subjects are not locally available, and development of best practices in clinical teaching and feedback is in progress. Thus far UAlberta has provided undergraduate teachers for cardiovascular, pediatric and nephrology problem-based learning blocks.University of Alberta faculty members have provided numerous faculty development sessions in medical education over the past four years spanning the gamut from how to provide effective classroom presentations to how to accomplish workplace assessment.A larger project to coach faculty in the best practices of formative feedback, a keystone of competency-based education, is underway.An international group of rural family physicians are investigating ways to support new community teaching physicians in Nepal with appropriate faculty development. Led by a physician from McMaster University, the group has extensive expertise in international family medicine and rural family medicine in North America and includes a member from the University of Alberta group.In another case, UAlberta is exploring a mechanism to bring a PAHS/Patan Hospital faculty member over for fellowship education in nephrology – a current gap in the clinical service at Patan and teaching at PAHS.An additional future project is to start discussions on creating local faculty development programs such as mentorship and peer-review which encourages reflective teaching practice.One of the needs of PAHS is to eventually develop post-graduate programs for their graduates. Initially, PAHS students will graduate and enter rural practice. The goal is that some of them will return for post-graduate education, and the work to set up such programs has begun.PAHS offers preferential selection of students who have completed rural service to provide additional motivation for students to serve in rural Nepal.One of the UAlberta faculty members will soon be spending a 1-year sabbatical at PAHS to assist it for the planning and development of competency-based clinical postgraduate residency training programs in general and emergency medicine program in particular. This will coincide with his collaboration in the competency-based medical education model being evolved at PAHS.When Dr. David Cook, a renowned UAlberta medical educator and member of the PAHS IAB died in 2009, a legacy fund supporting medical education in Nepal was created. With the blessing of the University of Alberta Faculty of Medicine and Dentistry, and the assistance of a key fund developer, the David Cook Nepal Medical Education Fund serves as a mechanism for Canadians to make charitable contributions to support University of Alberta-PAHS initiatives, which still need funds to achieve their educational mission. UAlberta/FoMD fundraising staff are also keen to lend their expertise and advice to the PAHS International Advisory Board in an effort to build overall philanthropic support for PAHS.Aligning with current work at PAHS, small amounts of Canadian-sourced funding have been obtained to research and implement elements of competency-based assessment and the corresponding faculty development.Additionally, faculty members are part of a multi-centered research group on the effect international clinical rotations have on students and communities they visit. This Canadian project is in the planning phase. Last year the UAlberta sent its first medical students and residents to PAHS for an educational experience in global health.Educating University of Alberta students in international health at PAHS is a priority for the Office of Global Health. PAHS is a safe, supervised, robust environment for Canadian learners to engage directly in learning about developing nations and their health systems. 2012 will see the first students and residents from the UAlberta institution visiting PAHS. Care is being taken to ensure rigorous oversight over the process to avoid disrupting the learning of the PAHS students, and to enhance the UAlberta’s partnership with them.This is not mere academic philanthropy. Faculty members take away tremendous inspiration, sense of value, collaborative projects and knowledge to apply back home. The value of this type of personal and professional development cannot be overstated.UAlberta faculty, students and staff engaged in the Nepal project understand many of the barriers to this style of international development work. Cultural barriers certainly exist; the largest of these are represented in the instability of the current political and funding system in Nepal, and a Canadian medical system that has moved away from the British-style medical hierarchy that exists in most Kathmandu teaching hospitals. And, of course, no UAlberta faculty have ever lived or practiced in the setting they are endeavoring to support.Yet the challenges faced within the supporting group of such a medical school cannot be ignored. Faculty members are naturally inclined to pursue their own interests, which can lead to gaps in support, or overdevelopment in some areas. Drifting from the core mission is easy, and in this case could happen if the focus of the group moved from developing a rural medical school, to developing the services at the urban hospital it is housed at. On the other hand, for the effective retention of its graduates in the rural areas, PAHS has publicly committed to provide preferential enrollment in its postgraduate training program for those who will fulfill their mandatory rural service obligation. However, in order for PAHS to be accredited for launching the postgraduate residency training programs, it has no option other than to upgrade the Patan Hospital. Hence there is a need to strike a balance between its rural health mission and clinical excellence of its teaching hospital, The addition of students and residents, while meeting needs at the UAlberta, adds the complexity of integrating them into a resource-poor setting while providing mutual benefit.The University of Alberta’s Faculty of Medicine and Dentistry has successfully evolved a functional support group that supports the mission of a novel medical school in a developing country. Much of the credit for success goes to the dedicated and visionary colleagues in Nepal, who have generously invited UAlberta into an effective collaboration. However, some of the success of the UAlberta group’s rapid evolution lies in its (at times inadvertent) use of several key principles:Have a clear mission. The mission of this project is to enhance peace in Nepal by supporting rural-urban health equity. Clarity of that high level goal has engendered natural support from our members. The connection of routine daily work to the higher mission is clear and motivating.Allow for organic growth. UAlberta has had a presence in Nepal, via Dr. Solez, for well over a decade. He knew the PAHS project was fertile ground for Canadian physicians, yet he and other Canadian leaders  let the project attract the right people at the right time. Word-of-mouth, rather than targeted recruitment, has led to the natural selection of collaborators who are attracted to the mission. Their passion is key; all have a myriad of skills that can be brought to bear for the benefit of PAHS.Leverage institutional support. But do not do so at the expense of the overall mission. In the span of four years, the group has expanded from the dedicated volunteerism of two faculty members to a recognized pillar of the Faculty of Medicine and Dentistry’s global health program involving fifteen faculty members. A yearly fundraiser has become a faculty-sponsored fund development project. Funding for research collaboration has been granted. UAlberta students and residents have been to PAHS, and an associate professor has been granted a one-year sabbatical to work with faculty at PAHS. Finally, as a marker of university-wide support, a memorandum of understanding has been drafted which will allow UAlberta faculty to engage in the project as faculty members, and not simply as volunteers. As support at the UAlberta was sought in all of these areas, none of it was felt to distract from the core mission – support rural health education in Nepal. The rewards for the University are those that come with effective global citizenship.Eventually, the establishment of a formal link between a the University of Alberta and PAHS may be considered a ‘twinning’ relationship, as this multifaceted support is increasingly formalized and maintained The University of Alberta Nepal Group has modeled a coordinated, synergistic effort that has resulted in a rapid evolution of effective support for PAHS.