However, H2SO4, HCl, and SOCl2 showed similar spatial distributions in the pH-EC curves and were difficult to identify. The results of this study provide information for chemical detection and identification using alternative sensors that permit easy and rapid field measurements in the event of a chemical spill and could be used as preliminary data for rapidly responding to accidents.Chemical accidents in rivers may be triggered by natural or anthropogenic causes and refer to the flow of large quantities of hazardous chemicals into rivers. In South Korea, domestic water is sourced from large rivers, such as the Nakdong River. However, owing to rapid industrialization, industrial facilities have become heavily concentrated in the middle and upper reaches of the Nakdong River. Therefore, severe problems could arise if harmful chemicals are leaked from industrial facilities into the river, and this contaminated river water is supplied to cities. Quantitative evaluation based on instrumental analysis during chemical accidents and prediction research based on modeling is actively being conducted however, research on the initial response is insufficient. Therefore, in this study, the variations in pH and EC were analyzed according to their chemical concentrations for seven chemicals. These seven chemicals are designated accident-preparedness substances that frequently cause chemical spills in South Korea. Additionally, we evaluated the possibility of identifying unknown substances by comparing the variations in pH and EC and statistics while diluting unknown substances. Thus, the potential of pH and EC as alternative indicators for detecting and identifying chemicals was evaluated in this study. NaF, NH Chemical accidents in rivers can occur either naturally or anthropogenically and refer to the discharge of large quantities of chemicals into rivers from factories or spills during transport or handling. Chemical accidents adversely affect ecosystems and humans through physical and chemical reactions; particularly, the unnatural quantities of chemicals entering the water system can alter the water environment . SeveralThe water intake rate for rivers in Korea is approximately 40%, which is high among the Organization for Economic Co-operation and Development (OECD) countries. Most of Gyeongsangbuk-do province relies on the Nakdong River for raw water , and theThe leakage of hazardous chemicals other than oil pollutants is analyzed through prediction models and the collection of samples for laboratory analysis. Prediction research involving modeling utilizes mathematical models that entail a predictive function for leakage . During However, the above analytical procedure has limitations in terms of the speed of detecting and identifying chemicals in the event of an accident, making its application difficult for formulating an initial response. For a rapid response in the event of a chemical accident, the pollutant should be easy to measure. In addition, pH and electrical conductivity (EC) can be utilized as alternative indicators for the detection and identification of chemical substances if a high concentration of a chemical substance flows into the river and changes the pH and EC of the water in a unique pattern. Therefore, in this study, we selected accident preparedness substances that are frequently released because of chemical spill accidents in South Korea and analyzed the variations in pH and EC according to their concentrations. In addition, these results were used to identify other diluted unknown substances by comparing the variations in pH and EC. Finally, the possibility of using pH and EC as alternative indicators for chemical detection and identification was evaluated.The Chemical Control Act of South Korea has described and is regulating 97 accident preparedness substances. In South Korea, most industries handling chemicals are located near large rivers. In this study, we selected seven chemicals among the accident preparedness substances that are frequently released because of chemical accidents and are handled in most factories .The ability of alternative indicators to detect the organic matter among the accident preparedness substances presents certain limitations owing to its extremely low-dissociation rate in water.Furthermore, when substances, such as oil or phenol enter the river, their detection is easy as they are visible to the naked eye. South Korea has already developed suitable response plans for oil and phenol. Therefore, this study only considered inorganic chemicals that are difficult to detect with the naked eye.Sensors for measuring the changes in pH and EC were selected according to the concentrations of the analyzed chemicals. The pH was measured using a Professional pH meter PP-50 . The measurement range is −2 to 20, and the accuracy is ±0.002 . EC was Conducting field experiments to measure the concentration changes over time by introducing hazardous chemicals into natural rivers is not realistic. Therefore, solvents were selected to dilute the chemicals assuming that their concentration after entering the rivers was diluted over time at specific points. Furthermore, since the baseline pH and EC differ in each river, changes in these values may vary depending on the river into which the chemicals flow. Therefore, we selected solvents by considering the characteristics of river water and the conditions that may produce different baseline concentrations in the same river (ordinary season and flood season) .The Joman River (JM), located in Juchon-myeon, Gimhae-si, Gyeongsangnam-do, has agricultural and industrial areas that are located around the water-sampling point. The Sineo Stream (SS) is a waterfront river in Gimhae-si, Gyeongsangnam-do that flows through a residential area. The West Nakdong River (WNR) is a lake-type river, wherein floodgates cause the water body to stagnate, and the flow rate is controlled by the Noksan Floodgate in the estuary and the Daejeo Floodgate in the upstream section. The Gam Stream (GS), which is located in the midwestern part of Gumi-si, Gyeongsangbuk-do, accommodates several factories that handle chemicals in the Gam Stream Basin. Furthermore, large-scale chemical accidents have previously occurred around the Gam Stream.The concentration range for this study was selected considering high to low concentrations that are representative of chemical accidents, assuming a case of chemical flow into the river .A 0.5 M stock solution of the selected chemicals were prepared to improve the accuracy of low-concentration solutions. The samples were prepared by transferring 200 mL of river water into 30 measuring cylinders for each chemical and adding the stock solutions prepared at the concentrations stated in To conduct experiments at different baseline concentrations for each chemical, six solvents were prepared using JM, SS, and WNR water samples collected during ordinary and flood water seasons .The pH and EC were measured in samples with concentrations of 0–3000 mg/L of each chemical in different solvents. The pH and EC measurements were combined for each chemical depending on the concentration of the six solvents.Subsequently, experiments were performed using the combined results to verify whether the substances can be identified when the selected chemicals flow into another river. In this experiment, high-concentration samples were produced assuming that each chemical is an unknown substance . The pH The pH and EC were measured according to the concentrations of chemicals in samples produced using six solvents. Each of the seven chemicals under the conditions described in 2SO4, HCl, and SOCl2  was used for statistical comparisons and was calculated according to Equation (1):4OH showed distinctly lower MAPEs for both pH and EC than those of other substances. However, NaCN and NH4OH were still considered identifiable because their MAPE values for EC distinctly differed from each other, except for the low MAPEs at pH < 2. The unknown substances identified based on the statistical results matched the seven unknown substances listed in The experimental results for the seven chemicals at six different concentrations were designated as the actual values. The results of experiments on unknown chemicals were designated as the forecast values. The abovementioned results confirm that each chemical flowing into the river exhibited a unique pH and EC variation pattern according to its concentration. Therefore, the pH and EC have the potential to be considered alternative indicators for identifying unknown substances in the event of chemical accidents.However, when chemicals enter a river and alternative indicators are measured at a specific point, the total concentrations of these chemicals cannot be determined. Therefore, the variations in the alternative indicators measured in this study according to the chemical concentrations were combined and represented as pH-EC relation curves . We atte2SO4, HCl, and SOCl2, had very similar distributions in the pH-EC relation curve. Conversely, the remaining substances  had distinct distributions.However, the substances with pH < 2 at high concentrations, namely H4HF2, NaCN, and NH4OH could be clearly classified by comparing the distributions of unknown substances in the pH-EC relation curve. However, as H2SO4, HCl, and SOCl2 showed similar spatial distributions in the pH-EC relation curve, identifying them in natural rivers using the alternative indicators was difficult.This study is a basic research stage on chemical accidents, and research was conducted using an accident preparedness substance designated in Korea. For the detection and identification of chemicals, pH and EC were used as alternative indicators, and the possibility of use was confirmed when the two indicators were linked. In (1)The measurement results for pH and EC according to the concentration of the seven chemicals showed very similar patterns, even when solvents with different base concentrations were used. This confirmed that the variations in pH and EC according to the concentrations of chemicals had low sensitivity to the base concentration of the solvent and that each chemical has a distinct effect on these parameters.(2)For each chemical, the average variations in pH and EC in six solvents according to the chemical concentrations were numerically compared with the variations in pH and EC according to the concentrations of unknown substances. The unknown substances were identified by assuming that the MAPEs of pH and EC would be the lowest when comparing the unknown substance with the correct chemical. Consequently, all seven unknown substances could be identified through the MAPEs, demonstrating the possibility of using pH and EC to identify chemicals.(3)4HF2, NaCN, and NH4OH could be clearly classified by comparing their distributions in a pH-EC relation curve. However, H2SO4, HCl, and SOCl2 showed similar distributions in the pH-EC relation curve. Therefore, there are limitations in classifying these three substances using pH and EC in natural rivers.The actual concentrations of chemicals cannot be obtained by measuring pH and EC in the event of chemical accidents in rivers. Therefore, the measurement results according to the concentrations of the seven chemicals were combined and represented as pH-EC relation curves. NaF, NHAn experimental study on the variations in pH and EC according to the concentrations of chemicals was conducted assuming the inflow of hazardous chemicals into a river. Since field experiments in rivers using hazardous chemicals are not realistic, the experimental conditions were designed assuming that the concentrations of chemicals will be diluted over time as they enter and flow in the river. Considering that each river has different base concentrations, river water samples were collected during the ordinary and flood seasons at three points and used as solvents for the chemicals, and a sufficiently high concentration range was selected to represent chemical accidents. Furthermore, the possibility of identifying unknown substances was evaluated through statistical analysis of the measurement results and unknown substances. The results demonstrated the possibility of using pH and EC as alternative indicators for chemical detection and identification. The findings of this study can be summarized as follows:This study shows that chemicals can be detected and identified in the field using alternative sensors with easy and fast measurements in the event of chemical spills. However, there were limitations in identifying specific chemicals using these indicators, and the quantitative evaluation of chemicals was impossible. It is expected that faster chemical detection and identification may be possible by combining the results of this study with data-based research techniques, such as deep learning if the information on the pH-EC relation curves of accident preparedness substances can be produced in advance. Furthermore, the findings of this study could be used as basic data to develop the initial response plan for chemical accidents.


Epidemiology is often a challenging course that is not well appreciated by many students learning veterinary medicine. The curriculum for this topic can sometimes be dry, difficult for students to contextualize, and heavy with statistics and mathematical concepts. We incorporated the concepts of epidemiology that are most important for practicing veterinarians and combined these with evidence-based veterinary medicine principles to create a practical course for second-year undergraduate veterinary students. We share the structure of our course and the different learning components, which also included incorporating graduate student mentors for journal clubs and an assignment that culminated in some students publishing their review findings. Anecdotal responses from students suggest they enjoyed the course and learned skills they felt would be useful in veterinary practice to help them make evidence-based clinical decisions. Veterinary education is evolving. In the last 20 years, many schools have shifted their focus to competency-based professional education , 2. AchiIn addition to addressing the teaching strategies used to promote competency-based education, assessments need to be considered. Practical skills and rational problem-solving skills should be incorporated in the assessment process. However, assessing multi-level cognitive competencies is more complicated than basic knowledge assessments. To further compound the difficulty, since 2020, many teaching and assessment activities in veterinary schools around the world have been conducted fully or at least partially online due to the COVID-19 pandemic , 8.Some courses are more conducive to problem-based learning and other active learning exercises than others. For example, physiology or medicine courses can use case-based teaching relatively easily . In the At the new college of veterinary medicine at City University of Hong Kong, we delivered a second- year course in EBVM as part of the undergraduate veterinary medicine curriculum. The overarching goal of this course is to teach students how to make evidence-based decisions in clinical practice and to foster deep learning and critical thinking skills. This course combined the basic principles of epidemiology such as sensitivity and specificity of diagnostic tests, how to interpret clinical presentations and diagnostic tests to make clinical decisions, how to search for literature to answer clinical questions, and how to interpret and how to weigh the value of study results based on types of studies conducted, outcomes measured, and potential biases. In this paper, we describe how we created different levels of active learning experiences for our second-year veterinary students engaging them in activities despite COVID- 19 restrictions limiting face-to-face classes.In January 2020, we developed a course in Evidence-Based Veterinary Medicine (EBVM) for the second-year students in a 6-year Bachelor of Veterinary Medicine program (BVM) at City University of Hong Kong. Prior to designing the course, we reviewed the underlying pedagogy for teaching veterinary medicine and EBVM using an outcome-based approach and active learning , 12, whiThe students had 1 year of general undergraduate sciences completed, which included a basic statistics course when they enrolled in our EBVM course. We had in-depth knowledge of their biostatistics background, so we were able to link concepts from this course and build on student's prior knowledge. We also understood which of the foundational concepts required further coverage within the EBVM course. Additionally, students were signposted at various points in both courses as to where the knowledge would be useful within the 6-year programme (for example the 5th and 6th year research projects). Finally, the learning outcomes in this course were reviewed to determine their alignment with the expected “Day One Competencies” of City University of Hong Kong's veterinary graduates.The EBVM course was originally supposed to be delivered face-to-face, but due to the COVID 19 situation in Hong Kong in February 2020, it had to be delivered using online teaching within 3 weeks of the commencement of the first class. The second year of this course, which started in January 2021 (referred to as the second cohort) was completed face-to-face. We report the issues and modifications used for the two delivery methods when relevant.The intended learning outcomes for this course included the following: (1) Describe the principles of evidence-based veterinary medicine; (2) Demonstrate critical appraisal of clinical research, including evaluating external and internal validity of studies, diagnostic test interpretation, measures of association, and bias analysis; and (3) Answer a clinical question in PICO format   using evThe course used several strategies to achieve these objectives , includiThe course also used a variety of assessment methods . We had The course was structured in two parts. First, we taught general principles of epidemiology and evidence-based veterinary medicine, which covered topics such as how to formulate an answerable clinical question, conduct a systematic literature search, how to read peer-reviewed papers, how to analyze the strength, magnitude, and validity of the findings from different types of study designs . The initial epidemiological concepts were taught in a didactic manner on zoom for both cohorts due to COVID restrictions. We had interactive questions during the lectures, but that was the limit of active learning for the initial component of the course. Students were assessed on these fundamental principles using a summative exam on the 6th and 8th week of the course for the first and second cohorts, respectively. The second part of the course consisted of the active learning through journal clubs and a group based knowledge summary activity.https://veterinaryevidence.org/index.php/ve/guidelines-for-authors) with the aim of publishing the reviews at the end of the course in their journal, Veterinary Evidence. This assignment enabled students to practice systematic search and critical appraisal of relevant literature to answer a clinically relevant question, and make a conclusion based on the information they had acquired. This knowledge summary exercise also helped them work as a team, and communicate their findings in written form, both of which are critical skills for veterinarians and are recognized as an essential part of a veterinarian's employability  Knowledge . The role of the supervisor was to ensure the student group discussion stayed on track and that all questions in the guide were discussed. If the students did not understand a specific topic, it was the role of the supervisors to probe the group with questions to help students discover the learning objectives. If this did not work after a few questions, the supervisor intervened and reviewed the concept with the group.The first cohort of students consisted of 29 students, and the second cohort had 23 students.The topics covered in this course included: introduction to evidence-based veterinary medicine, causation verses associations, measures of clinical outcomes, clinical decision making and the role of economics, sampling, study design, measuring effect and statistical significance, diagnostic test evaluation, bias in clinical research, and systematic review of the literature. The average score on the written exam for the first and second cohort of students was 86.5 and 88.3%, respectively. We increased the didactic lectures in the second year from 15 to 21 h to address the contents in more depth.We reviewed 16 papers in the first year and reduced this to five in the second year to ensure that the students had sufficient time to read and understand the literature. There has been research suggesting that students who feel their workload is too high are more likely to adopt a surface learning approach , where tStudents commented on their evaluations that they found this exercise difficult, especially at the beginning of the course, but eventually improved in their critical assessment of research studies. We believe our study question sheet helped guide them through the papers in a systematic manner, which helped train them over time. Graduate students also seemed to improve in their ability to identify key points in papers as the course progressed. Journal clubs or literature review sessions in professional medical schools have been reported to help student knowledge . These ahttps://veterinaryevidence.org/index.php/ve/clinical-queries) or developed by locally based clinicians to address a practice-based knowledge gap specific to the region. This proved very onerous to grade, so for the second cohort, we limited the number of questions to two (one per faculty), and we assigned each question to three groups of students. At the end of the second cohort, we compiled the results of all the groups addressing the same PICO and submitted the results for publication to Veterinary Evidence. One paper has been published (Twelve different PICO knowledge summaries were conducted the first year this course was offered as each group of students had to answer their own clinical question. These questions were selected from the Veterinary Evidence website (ublished , and theStudents provide annual feedback on taught courses via a questionnaire consisting of 10 questions marked on a seven point scale see . The oveThe PICO exercise provided an interactive style of learning, which has been shown to enable students to develop active learning skills, encourage deep learning through engagement, and develop students as lifelong learners , 24. GroThere are several other examples of active learning activities for EBVM courses , 26–28. The original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the Local Legislation and Institutional requirements. Written informed consent for participation was not required for this study in accordance with the National Legislation and the Institutional requirements.SR and SS-H designed and implemented the initial course. SS-H and ON developed new materials, improved, and refined the format of the course. ON is the current course leader. SR, ON, RP, and SS-H reviewed pedagogical approaches associated with active learning and EBVM. SS-H wrote the first draft of the manuscript. SR, ON, and RP edited the document. All authors contributed to the article and approved the submitted version.SR was employed by Ag Research Limited.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Alloplastic materials can be used together with tissue and structure to close nasal septal perforation.to test cellulose use in the closure of septal perforation in rabbits and to compare fibrosis, inflammation, vascular congestion and graft integrity.Fifteen rabbits. The rabbits were divided into two groups: Control: Five rabbits and Bionext® and fibrin glue Tissucol®: Ten rabbits. Septal perforations were done in all of them. In the Bionext® group the closure was performed with the placement of cellulose.Two rabbits died in the first week. Cellulose group: 2 closures without the cellulose in between the septum membrane and in 4 cases the graft stood in the middle of the perforation locked in place by the edges. No closure in the control group.There was no closure of the perforation of the nasal septum with the graft between the septum membranes. There was no statistically significant difference concerning acute inflammation, vascular congestion and fibrosis between the 2 groups. In cases in which the graft remained in place, there was no change in its integrity. It may be used as a substructure for reepithelization of the perforation edges. Nasal septum perforation is a disorder of easy diagnosis through the use of a nasal speculum or nasal endoscopy in the office. It can have numerous causes, from very benign ones, to local manifestations of systemic diseases. Moreover, nasal septum perforation varies broadly depending on location, size and symptoms; in consequence, many are the treatment options, including conservative treatment and numerous surgical techniques. Treatment must be customized for each patient.,The main cause of septal perforation is iatrogenic - as a complication of nasal surgery,,Among the diseases associated with nasal perforation, we list: cutaneous mucosal leishmaniasis; nasal abscess; syphilis; tuberculosis; typhoid fever; diphtheria; Wegener granulomatosis; lupus erythematous and sarcoidosis. Neoplasia and carcinomas also can cause nasal septum perforationInhaling irritating products can also cause nasal septum perforation, such as in cases of nasal aspiration of cocaine, which causes ischemia by vasoconstrictionOften times, the perforation happens before other systemic disease symptoms, and clinical investigation is necessary for those cases without clear etiological diagnosisNasal septum perforation can be range from asymptomatic to those causing severe epistaxis, nasal cosmetic deformities, crust forming and nasal obstructionThe surgeries proposed to close perforations use flaps and grafts. The latter can be autologous (removed from the same being), homologous (from another being of the same species), heterologous (from another being of another species) and alloplastic . Autologous grafts have the main disadvantage of causing trauma to the donor areas; and homologous and heterologous grafts bear risk of contamination for the individual receiving tissue from another beingAn inert material which could provide structure to the healing would be very useful in the treatment arsenal of this disorder. The cellulose film formed by the fermentation from Acetobacter xillinum bacteria is inert, resistant and insoluble, permeable to liquid and gas and resistant to stretching and traction. It is sterile, non-toxic and non-pyrogenicStudies in rabbits, replacing the septal cartilage for cellulose showed a partial absorption of the cellulose film after four weeksWe propose an experimental study to close a nasal perforation in rabbits using the cellulose film together with fibrin glue used for fixation, and analyze the tissue response, graft properties and whether or not the perforation would be closed.Using the LILACS and Pubmed databases and the Internet, we searched the existing literature in relation to the cellulose produced by the Acetobacter xillinum bacteria, its development and use; surgical techniques used to close nasal septum perforation and the different materials used for this task.Nasal septum perforation closure surgery in humans In 1935, Imperatori et al.The techniques used to close septal perforation can be grouped in: those in which we use flaps from the nasal septum itself to close it with or without grafts, and the techniques which use neighboring flaps.The papers which suggest flap rotation are unanimous as to the need for a second surgical procedure to resect the vascular pedicle.Among the techniques using septal mucosa flaps, we find the description of fascia and perichondrium grafting in between the septal mucosa leaflets, by Wright et al.McColloughFairbanksSuggestions concerning the use of artificial material or implants associated with closure techniques were given by Gyeney and KerenyiOther materials such as gold, ivory, cobalt and cork have also been usedStoor et al.The Bionext® cellulose film arises from the fermenting of Acetobacter xylinum bacteria, done through the experiment carried out by microbiologist Luís Fernando Xavier Farah (1984) from Curitiba (PN).,,The cellulose produced by the bacteria can be in the form of a flexible, semitransparent and yellowish membrane, or as a solid, dense, malleable mantle, of firm and jelly-like consistency, of about 0.5cm thick . The filIt is efficient for pain relief and to reduce healing time in dermoabrasion lesions, skin donor areas, or in large burns. This composite has been successfully used as bandage in skin sores, burns and skin donor areas. It was also used as substitute for meninges.34It is seen as a material of numerous possibilities, from paper to protect documents to bullet proof vests1To test the use of cellulose produced by Acetobacter xylinum bacteria -Bionext® together with the Tissucol® biological fibrin glue in the closing of septal perforation surgically inflicted in rabbits.2To histologically compare the degree of fibrosis, vascular congestion in the animals, graft integrity and whether or not the septal perforation was closed.For this study we used fifteen adult New Zealand rabbits weighing approximately 3kg, cellulose mantle (Bionext®) and fibrin biological glue (Tissucol®).Sample size and selectionThe rabbits were randomly assigned (coin flip) into two groups: Control Group made up of five rabbits; and the Bionext® group associated with the fibrin glue Tissucol®, made up of 10 rabbits.One rabbit from each group died in the immediate post-op. the rabbits were slaughtered fifty days after the experiment.The surgical procedures were carried out following the ethical principles of experimentation with animals, set forth by the Brazilian Code of Animal Experimentation (COBEA). Protocol 09/07 ICAO.12.2% lidocaine and noradrenaline soaked cotton in the concentration of 1:50,000 in both nasal cavities.2Bilateral subperichondrial septum injection of the same solution.3Upper left-side anterior septal incision followed by ipsilateral subperichondrial detachment.4Square-shaped incision and removal of approximately 7mm measured with a surgical caliper, on each side of the septal mucosa and septal cartilage.The surgical procedures were done with the rabbits under general anesthesia, using Zoletil® (Tiletamine associated with Zolazepan) and Nilperidol® (Fentanyl associated with Droperidol) and kept under spontaneous ventilation, in dorsal decubitus. They were submitted to nasal septum perforation as per described below:The experimental group was submitted to the placement of the Bionext® graft in the same procedure when the perforation was made; anchored in between the remaining septal mucosa, which were previously detached and not removed .Figure 2The rabbits were kept under the same daily care conditions as they were prior to treatment, for 50 days, when they were slaughtered for observation of the nasal septum perforation and underwent histopathology analysis of the surgical specimen.For the slaughter at the end of the follow up period, the rabbits were again anesthetized and received IV sodium thiopental (dose 40mg/kg). After the slaughter, the facial mesostructure was removed en bloc for histopathology purposes.The rabbits were evaluated by clinical parameters which could indirectly assess tolerability issues, such as general and breathing discomfort. The parameters evaluated were: amount of food ingested, rabbit weight variation, temperature, respiratory rate and the presence of nasal bleeding. All the rabbits were weighed before the procedure and on a daily basis until their slaughter. The amount of food ingested was controlled daily in grams. Ear temperature, in Celsius was measured twice a day. Respiratory rate was checked twice-a-day. Bleeding was seen daily.The animals' facial mesostructures were dissected and fixed in a 10% formaldehyde solution.The animals' facial mesostructures remained for 6 days in a 5% nitric acid solution for decalcification. Once decalcified, the nose and skull were sliced in 5mm cross-sections. The slices were then dehydrated, clarified and included in paraffin. After inclusion in the paraffin blocs, the specimens were cut in the microtome at an average thickness of 5μm. Figure 3PThe slices were then dyed with hematoxylin-eosin and the tissue response patterns were histologically assessed. We analyzed: whether or not there was an inflammatory process; Bionext® (ibt) integrity; fibrosis; congestion and whether or not the septum perforation had been closed . The sliWe compared the results from the Control and Bionext® groups by means of the F test of independent samples with non-paired comparisons between the groups as a whole. For parameters with discontinuing categorical values, such as the degree of inflammation, we used the Wilcoxon non-parametric test.Two rabbits died in the first week of the experiment, one from the Bionext® group and one from the Control Group.On On ,Because of the need for a framework for fibroblasts to grow - supporting growth at the margins of the mucosa, one towards the other through a simple border suturingBecause the perforation and repair surgery were carried out in the same procedure and with the film already in place since the onset of the healing process, we did not have atrophic margins and we had very little vascularization, which is common in the clinical practice and does not foster closureKnowing of the ease in intraoperative handling, although of little adhesiveness, we added biological glue to the margins of the perforation with the aim of fixing the film. Thus, the experiment would be similar to the one from Kridel et al., who in 1998, who suggested the use of biosynthetic substitute  fixed with suture points to one of the sides and the other one is closed with mucosa flap rotation; nonetheless, in our case we used cellulose film and biological glue without closing the mucosa in any of the sides of the perforation.The film incorporation and absorption were more significant after four weeks in the studies by OliveiraAll the studies carried out evaluating the cellulose film had it in contact with some tissue, we found it interesting to assess its behavior when it is attached only to the borders of the perforation.The perforation closure with the cartilage replacement for the cellulose did not happen. In the cases in which the perforation closed, either the cellulose film was kept attached to the perforation's epithelized borders like a “cork” , or it wThe graft shifting may have happened because of the smooth surface of the cellulose film, and due to the lack of efficacy of the fibrin glue in contact with the cellulose or by the mechanical force of sneezes. Postoperative packing for a long period of time, such as the 12 days proposed by Kratz in 1973The lack of statistically significant difference as far as acute inflammation, vascular congestion and fibrosis are concerned, prove that the implant is inert and well accepted by the nasal mucosa.The weight gain of the group submitted to the graft shows it is well tolerated by the animals and also shows little suffering with the experiment.a)There was no statistically significant difference concerning acute inflammation, vascular congestion and fibrosis between the two groups.b)In the cases in which the graft was kept positioned, there was no change to its integrity.c)It can be useful in the therapeutic weaponry as a basis for reepithelization of the perforation borders.


The current English teaching mode focuses on the traditional offline teaching and online teaching. In order to solve the problems that some students are inefficient and cannot teach students according to their aptitude in the teaching process, this paper uses the big data analysis strategy based on a neural network algorithm. This paper studies the discrete dynamic modeling method of learner behavior analysis in English teaching. Firstly, it summarizes the current situation of English teaching and the research status of the hybrid application of discrete dynamic modeling technology. Secondly, combined with English teaching content and teaching objectives, through the analysis of various data of students' learning behavior, this paper evaluates students' English teaching quality from five aspects that affect the students' English teaching quality and puts forward a personalized English teaching quality evaluation model based on discrete dynamic modeling technology and learners' behavior analysis. Finally, through the practical teaching application in a university, the feasibility of the discrete dynamic English teaching model is verified. The results show that compared with the current innovative English teaching methods based on a dynamic iterative decision algorithm, the personalized discrete dynamic English teaching model based on learner behavior analysis significantly improves the quality of English teaching and students' academic performance. The mainstream English teaching still focuses on the traditional offline face-to-face teaching, supplemented by online network teaching, so the teaching mode is relatively single . Since tCompared with the current innovative English teaching methods with dynamic iterative decision-making algorithms as the mainstream, the innovation of this paper is to improve the efficiency of English teaching by combining discrete dynamic modeling technology and neural network algorithm. On this basis, it can make full use of each student's learning behavior, learning data, and test scores in the English classroom through real-time dynamic tracking. It can realize customized analysis, quantitatively describe the similarity and coincidence degree of each learning behavior and teaching strategy with behavior analysis factors, complete the influence ranking of English classroom teaching indicators with quantitative indicators, and effectively conduct multivariate analysis.Aiming at the problems of low teaching efficiency and poor intelligence in English teaching, this paper studies the construction of a discrete dynamic modeling method for learner behavior analysis in English teaching. China has developed slowly in the mode of innovation and quality evaluation of English teaching, while some foreign developed countries have good basic and phased innovative achievements in the field of English Teaching . It is vBased on this model, the strategy of a discrete dynamic system for learners' behavior analysis in English teaching is put forward, and the sufficient conditions for the asymptotic stability of the closed-loop system for learners' behavior analysis are analyzed. The designed strategy can ensure that each state of the actual discrete dynamic system tracks the desired state, and the simulation results verify the effectiveness of the discrete dynamic modeling strategy proposed in this paper . The estDynamic iterative decision-making algorithms are mainly differentiated teaching methods, and rarely make effective analyses by combining learners' behavior habits . It doesIn this paper, the discrete dynamic modeling is studied under the analysis of English teaching learners' behavior. Teachers' intuitive judgments in the classroom of English teaching learners' behavior analysis are sometimes wrong . BecauseThe teaching behavior in line with the theory of “the essence of learning is trial and error” involved in sanddike's connection theory in the learning view of behavior school runs throughout the whole English teaching activities, especially in the oral training of students. English teachers often have to face the mistakes of students in language learning. This makes students inevitably make mistakes in practice. The usual practice is that no matter what mistakes students make in their expression, they will not interrupt directly, but write down the questions first. When summing up, all students are required to analyze mistakes together and constantly encourage students to speak out first, which is the first step to success. For those students who are unwilling and unable to participate in classroom activities, teachers should create more opportunities for them to express themselves, but this opportunity is selective, that is, the tasks they are competent for. Modeling is actually an iterative process, which cannot be achieved overnight. The following figure describes the important process of modeling. There are several steps in the figure, which reflect that modeling is a spiral process, and its importance is obvious. Therefore, special attention should be paid to the implementation of these steps. That is, the layer-by-layer decomposition of the system and the use of reusable components. The data analysis process is shown in Firstly, through image sensing equipment, the current English learning behavior of different types of professional students can be recorded online. It is used in computer language processing and converts it to multi-channel binary numbers. Then the teaching system is used to store students' learning data information in a multidimensional way. Vectorization analysis and feature extraction can be carried out for the first time. In this process, simulation analysis can be carried out on the data collected by different types of learners' behaviors. The results are shown in As can be seen from As can be seen from xi= and xj= be the observed values of English learning behavior of different students, then the similarity measure function R(x) and correlation function Q(x) between them can be characterized asIt can be seen from the changes of statistical data in W(x) correlation function T(x) areThe corresponding dispersion function and P(x) and European iterative function Y(x) areThe corresponding Fourier definite function s2 isThe corresponding square sum difference In order to support the application of modeling in different fields, the concept of learner behavior analysis in English teaching is proposed. To a certain extent, this language library is similar to the professional language. The domain model library contains reusable components such as predefined system definition, mathematical function definition, and typical type definition. The use of these reusable components produces a high-level specification description of a discrete dynamic modeling system, that is, the specification and complexity of learner behavior analysis in English teaching description are reduced. Reusability is also a way to improve the efficiency of the modeling process. It can describe a discrete dynamic modeling system in less time. A discrete dynamic modeling system, which is different from a continuous dynamic system, has a large number of practical problems in the real world. The solution to such events is far from the maturity of the theory of a continuous dynamic system, which requires the further development of relevant theories. Another way is to modify the existing components in the discrete dynamic modeling system. In order to modify the existing components, users need to know the internal behavior of the components. The process of a discrete dynamic modeling system is complex and cumbersome, and sometimes it has to go through many steps of derivation. For the data of 8 learning behavior types (A-H), after 12 groups of simulation analysis are carried out on the discrete dynamic model, the data analysis and processing process are shown in As can be seen from R corresponding to the three functions isThe information threshold Based on the informal description of learner behavior analysis in English teaching, we distinguish the discrete dynamic modeling system entities involved, such as suppliers, customers, and transporters of the logistics system. We decompose the logistics system into subsystems until each subsystem is a basic material system, a basic information system, a control system, or a component. It has been widely used in many fields because of its strong ability for function distribution and function description. It is a powerful tool for modeling and performance analysis of asynchronous, discrete, and concurrent event dynamic systems. The simulation analysis is carried out, and the data processing process is shown in In order to verify the practicability of the English teaching model constructed in this study, this study carries out practical teaching experiments combined with the actual English curriculum content, teaching process, and students' learning behavior data characteristics in Colleges and universities, and makes quantitative analysis according to students' classroom performance behavior. These external and controllable factors are attributed to the very few external and controllable factors. It shows that students' attribution tendency to their success in learning English has high stability. In foreign language learning, they generally work hard and can control their learning behavior. They believe that they can accept academic challenges. Even if they have unsuccessful experiences, they will not attribute their failure to their ability. This positive attribution will encourage students to actively summarize the experience, stimulate motivation, maintain motivation level, and help them succeed in subsequent learning activities. The simulation analysis results before the experiment are shown in It can be seen from Figures The data analysis times and completion degree of discrete dynamic model based on neural network algorithm increase, and the data operation rate of discrete dynamic model decreases and then increases. These are external controllable factors, which are caused by a very small number of external controllable factors.Great changes have taken place in its internal relevance, and its changing laws are also different. The difference between the experimental process and the simulation process lies in the difference in minimum value. This is because different simulation data sets have different comprehensive solutions and correlation analyses.This experimental study adopts different questionnaire contents. The questionnaire includes the following aspects: English learning habits, oral practice time, English reading habits, classroom student participation, types of homework completion, and English listening status. In the overall process of the experiment, 88.3% of the people have obvious effects, of which 62% are girls and 26% are boys. The error analysis results of the experimental results are shown in It can be seen from This paper analyzes learners' behavior in English teaching. In the discrete dynamic model of students' English classroom teaching, students' behavior is constantly changing, and the causes of problem behavior are also different. Based on the analysis of English learners' behavior, a discrete dynamic model suitable for a general hybrid simulation system is established. Firstly, this paper analyzes and expounds on the current research status of English teaching. The application of dynamic modeling technology is analyzed. Secondly, combined with the English teaching content and teaching objectives, through various data analyses of students' learning behavior, this paper evaluates students' English teaching quality from five aspects that affect students' English teaching quality and puts forward a customized English teaching quality evaluation model based on discrete dynamic modeling technology and learners' behavior analysis. Finally, through the practical teaching application in a university, the feasibility of the discrete dynamic English teaching model is verified. The results show that compared with the current innovative English teaching methods dominated by dynamic iterative decision-making algorithms, the customized discrete dynamic English teaching model based on learner behavior analysis has significantly improved the quality of English teaching and the improvement of students' performance. In English teaching, they should also learn and understand the theories and research results of educational psychology, which can help teachers understand “problem-finding and problem-solving behaviors” from different aspects, fundamentally improve students' interest and enthusiasm, and truly improve the efficiency and quality of behavior analysis of English teaching learners. However, this paper does not consider the personalized teaching model according to the actual situation of different students. Therefore, the model in this paper may deviate from the actual simulation. This requires further discussion in the future.


An effective disease surveillance system is critical for early detection and response to disease epidemics. This study aimed to assess the capacity to manage and utilize disease surveillance data and implement an intervention to improve data analysis and use at the district level in Tanzania. Mapping, in-depth interview and desk review were employed for data collection in Ilala and Kinondoni districts in Tanzania. Interviews were conducted with members of the council health management teams (CHMT) to assess attitudes, motivation and practices related to surveillance data analysis and use. Based on identified gaps, an intervention package was developed on basic data analysis, interpretation and use. The effectiveness of the intervention package was assessed using pre-and post-intervention tests. Individual interviews involved 21 CHMT members  with an overall median age of 44.5 years . Over half of the participants regarded their data analytical capacities and skills as excellent. Analytical capacity was higher in Kinondoni (61%) than Ilala (52%). Agreement on the availability of the opportunities to enhance capacity and skills was reported by 68% and 91% of the participants from Ilala and Kinondoni, respectively. Reported challenges in disease surveillance included data incompleteness and difficulties in storage and accessibility. Training related to enhancement of data management was reported to be infrequently done. In terms of data interpretation and use, despite reporting of incidence of viral haemorrhagic fevers for five years, no actions were taken to either investigate or mitigate, indicating poor use of surveillance data in monitoring disease occurrence. The overall percentage increase on surveillance knowledge between pre-and post-training was 37.6% for Ilala and 20.4% for Kinondoni indicating a positive impact on of the training. Most of CHMT members had limited skills and practices on data analysis, interpretation and use. The training in data analysis and interpretation significantly improved skills of the participants. Over the years, the integrated disease surveillance and response (IDSR) in Sub-Saharan Africa has relied heavily on the data generated from the routine health management information system (HMIS) implemented at the facility and district levels of the health systems . The HMILike elsewhere in Sub-Saharan Africa, studies in Tanzania have found that routine analysis of surveillance data at the health facility and district levels is not optimal, attributed mainly to lack of adequate analytical capacity and skills among the healthcare providers and managers ,16–18. AThe Tanzanian health management system is decentralised, i.e. most the decisions on disease surveillance are made at the district level. It is critical to have skilled workforce at this level that can manipulate, analyse, and interpret surveillance data generated within their level to support decision making. However, the perception on data quality and usefulness, lack of skills, complex information systems, and the volume, velocity, variety, veracity and value hinder these practices ,20. It i2. According to the 2012 national census, the city had a population of 4,364,541, with an annual growth rate of 5.6% [This study was conducted in Ilala and Kinondoni districts in Dar es Salaam City, Tanzania. Dar es Salaam is the largest commercial city in Tanzania with an area of 1,339 km of 5.6% . At the In Tanzania, each district has a council health management team (CHMT) responsible for overseeing implementation of health activities under the supervision of the regional health management team (RHMT). The routine health management information system (HMIS) is the primary source of data for IDSR and monitors large number of other indicators . StructuThe entire period for implementing this study was approximately 14 months, from September 2019 to December 2020. The implementation process, the timeline and activities involved are illustrated in The mapping exercise was done for each district separately. Briefly, information on the performance of IDSR looking at all its components were gathered. This included the structures, human resource availability, roles and responsibility, capacities, readiness of the system to detect, prevent and control diseases with respect to staff and resources, infrastructure, and analytical skills. This exercise involved consultative workshops and discussions with the key members of CHMTs and RHMT.Based on the gaps identified during the mapping exercise, an intervention package in the form of training modules was developed. The training modules focused on improving the understanding of key statistical concepts used to present epidemiological data, increasing skills in basic data analysis, interpretation, and use of the information for action. The practical exercises during the training were designed to assess the capacity of participants on extraction of set of data on priority diseases from DHIS2, analyse, visualize and interpret, identify alerts or important thresholds and suggests needed response to disease outbreaks in accordance to the Tanzania IDSR Technical Guidelines, 2011 . The modAfyaData app [Prior to the development of an intervention package, an individual-level in-depth interview was carried out with the participants to identify skills gaps on surveillance data analysis and use, which included attitudes, motivation, practices and analytical capabilities. A pre-designed semi-structured interview guide was converted to a questionnaire then installed in smartphones with Data app  to captuA training workshop was preceded by a pre-test that asked questions on knowledge related to disease surveillance, key steps in data management, importance of public health surveillance, and participants understanding on data analysis, epidemic/action thresholds, its importance, measures used in summarization, and ways to present/communicate epidemiological data. The same questions were administered as a post-test after the training intervention.Two hands-on practical exercises on utilizing data extracted from DHIS2 were embedded during the training, one led by the facilitators and the other by the participants teaming up in their respective districts. Prior to these practical exercises, the participants and facilitators discussed and agreed on one epidemic-prone disease category (referred here as Category A) and one disease of public health importance (Category B), as exemplar tracers. Viral Haemorrhagic fevers (VHF) and pneumonia were selected for Category A and Category B, respectively. Data for these diseases were extracted, analysed, interpreted and the experience of the practical exercise were discussed in plenary sessions.The surveillance data management components assessed were performance in extraction, visualization, presentation, interpretation, detection of the epidemic thresholds, action taken and suggested future actions. For Category A, deliberate exploration was made as to whether the reported incidence of VHF prompted any action from the districts. The team agreed to assess data covering at least the past 3–5 years. Details of the exercise including expected outcomes based on the IDSR guidelines are given in Data collected from the individual-level assessment was submitted to a server. Quality assessment was conducted by examining different fields of the questionnaires and their completeness. The pre-and post-tests data were analysed by comparing scores at the individual and district levels to assess knowledge and skills gained. The scores from the individual-level assessment, pre- and post-tests were triangulated to derive an understanding on the performance of the surveillance system in the districts and between the two districts. To perform the analysis, the questions from the individual assessment were used to create four surveillance-readiness dynamics: data and information value; analytical capacity and motivation; relations and feedback; and opportunity for enhancing capacity. Components and attributes included in each dynamic are shown in The questions with more than three Likert scales were collapsed into three categories to create levelling of the distribution of the scoring. To create meaningful total scores that are closely consistent with the participant’s interpretation another decoding was introduced to the scores by making values of agreement/ above average/ Frequent = 1, neutral/ average/rarely/ = 0 and disagreement/ below average/never = −1.Individual’s average score for each of the surveillance-readiness dynamics was calculated by dividing the score by the maximum value expected for that dynamic based on the number of questions included. For instance, if 10 questions were used to form a dynamic then the maximum expected total score is 10; if an individual scores is 5, the average score will be 50%. The overall scores by district were then calculated and used to assess performance.The questions from the tests were grouped into five surveillance-knowledge categories: general understanding of disease surveillance and its activities; the what’s, whys and how’s (WWHs) of epidemiology and public health surveillance; the WWHs of data analysis; common epidemiological measures ; and uncommon ones .Average scores for each of the categories were calculated and compared between districts. Percentage differences between the mean scores were calculated and used to measure variation between district, i.e. indicating how closer or spread the individual scores of the two districts lie. For the practical exercise on data analysis a detailed assessment comparing expected practices according to the IDSR guidelines on how to respond to the two diseases  was doneTwenty-seven key district officials were involved in the mapping of the surveillance system. Findings from the mapping exercise indicate that the two districts reported to perform well in terms of health facility completeness and timeliness in weekly and monthly surveillance reporting. The challenges in disease surveillance included both intrapersonal and interpersonal factors, lack of guidelines in case management, difficult language used in standard case definitions, inadequate laboratory capacity, lack of appropriate rapid response teams, inadequate knowledge on outbreak investigation and inadequate capacities in data management.It was reported that the surveillance officers were not skilled enough on data entry, manipulation, and analysis. Participants admitted on lack of feedback on data analysis. They complained about not been able compare current and previous data due to lack of consistency. There was no sharing of information, knowledge, skills and experience between the surveillance and HMIS officers on data analysis at district level. In addition, they reported the existence several health information systems for district to use. These included Health Management Information System, National System for Government Health Officials and the Government of Tanzania Hospital Management Information System. It was proposed by the participants that there should be integration of surveillance system data to HMIS. Inadequate periodic supportive supervision from higher levels was also expressed by the participants.Several guidelines and reports were available and accessed for review. These included the National Guidelines for Integrated Disease Surveillance and Response 2011, Guidelines on Data Analysis and Use, and Guidelines on Monitoring and Evaluation. However, none of the two districts had Health Information Systems Policy Guidelines. Records on disease surveillance available at the district office included: (i) Weekly summary reports from health facilities; (ii) Monthly summary reports from health facilities; (iii) Weekly summary reports submitted to regional and national levels; and (iv) Monthly summary reports submitted to the regional and national levels. Computers, including desktops and laptops were available and used for report writing, data entry and storage. Ilala district had more computers (33) than Kinondoni (18), though most of them  were owned by the staff themselves (15).The interview involved 21 participants . The overall median age of the participants was 44.5 years . Fourteen (66.7%) had attained university education  education while others had attained advanced diploma (3), ordinary diploma (3) and secondary school education (1). The overall median number of years of working experience was 5 . Two participants had less than seven months of working experience. The positions of the participants in their respective districts were the IDSR Focal Persons (3), Maternal and Child Health Officers (3), Health Research Coordinators (2), Laboratory Technologists (2), Health Management Information System Focal Persons (2), Environmental Health Officers (2), Malaria Focal Persons (2), Tuberculosis and Leprosy Coordinators (2), Immunization and Vaccine Development Coordinators (2), and Sanitation and Hygiene Coordinator (1).The participants from the two districts demonstrated similarity on how they perceived the level of availability and values of the data used for surveillance with an average agreement of about 60% (difference between the district score = 0.46%). In both districts, over half of the participants regarded their analytical capacities and skills as excellent. However, a good proportion of the participants placed themselves in the low capability category. Excellent skills reported included data manipulation, interpretation, and developing of graphs to assess temporal trends. Very few reported to have skills to produce maps. A slight difference (9.26%) was observed for the agreement on the presence of analytical capacity between the two districts with Kinondoni presenting higher average score (61%) than Ilala (52%) .Table 1.The major sources of data for IDSR in the two districts were reported to be routine weekly and monthly morbidity and mortality reports from health care facilities extracted from the HMIS. Among the challenges reported included data incompleteness, long time periods spent to find out the required data for timely decisions, difficulties in the way the data was stored which hinders access. Data were reported to be used for monitoring interventions; decision making; budget preparation; setting targets and goals; ordering of medical supply and drug management; planning, supervision, health promotion and assessing health facility performance. The software/programmes reported to be used for routine data analysis included Microsoft Excel and DHIS2.Overall, Kinondoni presented higher scores than Ilala in all dynamics. Although almost two-third of the respondents from Ilala and over 80% from Kinondoni reported to frequently interact with data producers/sources  and other users, conducted joint discussions on data and feedbacks regarding data analysis outputs, a significant difference was observed between the districts (difference of 19.7%) . Agreemeversus 73%). Interestingly, the overall percentage difference was similar in all categories, indicating a homogeneity in the overall performance of the districts.In general, participants performed better on diseases surveillance questions than on data analysis questions. The overall pre-training score for Ilala was 65.7% while it was 74.0% for Kinondoni. The question with lowest score (average 18% in both districts) was on the usefulness of descriptive images in public health surveillance. As regards to surveillance knowledge categories, Kinondoni indicated a slightly higher scores in almost all the categories than Ilala, with a significant low minimum score observed in the general understanding of surveillance in Ilala  and in the epidemiology and public health concepts  and disease of public health importance using pneumonia (category B). Data for VHF  were extThe VHF data triggered a discussion on whether or not these were the correct data submitted from the health facilities, and if so, what exactly were the actions taken by the district authorities.During discussion, it was observed that though the district team noted that the VHF cases were reported from healthcare facilities during the whole period under review (2013–2020), no analyses were ever done. Moreover, despite the reported VHF cases for over 5 years and with increasing trend over time, and the fact that a single case of VHF requires notification to the higher level and actions to be taken, the district teams acknowledged that none of the two actions (including outbreak investigation and response) were taken as required by the surveillance guidelines .Table 3.Data on severe pneumonia cases from 2016 t0 2020 were analysed the quarterly trend presented to the participants for interpretation exercise and discussion. Although one of the requirements of the IDSR Guidelines is to analyse disease incidence trend in space and time, the district teams admitted that this is not routinely done, and it was their first time to notice the pattern of pneumonia in the districts. Through discussion, it could not be established as to the reasons for the pattern of pneumonia in the two districts. These data triggered a discussion on the number of cases reported, long-term changes in disease event occurrence, reasons for changes in disease occurrence, and comparison on the number of cases reported for different slots of time in quarters, seasons or years. The results of this exercise and discussion allowed users to add knowledge and skills on data extraction, visualization, presentation, interpretation, detection of the thresholds, response actions .Table 4.Generally, in the two districts, the overall performance of the disease surveillance system in terms of detection, monitoring and response to disease outbreaks wa not satisfactory. There were inadequate skills and capacity in data management including data analysis, interpretation and use, despite the availability of the guidelines on surveillance data analysis and use in both districts. Previous studies that in low- and middle-income countries, including Tanzania, reported a limited or no evidence of routine data analysis at the sub-national levels mainly due to lack of clear guidelines on how and when to analyse data ,24–28.The absence of data analysis, interpretation and utilization at the sub-national level was observed in the present study is in line with findings of studies in Ethiopia, Malawi and Nigeria . Skill gThe trained district personnel are key in the performance of the national IDSR, as district is the crucial link between data source  and decision/ policy makers (ministry level). Studies elsewhere have also reported that despite improvements in technological solutions and introduction of DHIS2, the actual use of data remains limited, especially at lower levels such as the facility and district in many countries ,32. In aThe findings from individual level assessment indicate that over a quarter of the participants from the two districts reported some difficulties in finding out the required data to make timely decisions. Although a good number of the participants regarded their technical skills in data management as excellent, they claimed to be less motivated on issues related to data management cycle. Despite all these, data in the two districts was described to be used for planning. The use of data in the identification of emerging epidemics was only mentioned in one district. Studies in Tanzania and elsewhere have reported that inadequate resources, lack of analytical and data use skills, refresher courses and review meetings, pressure of work, lack of incentives for data use are the most important systems-level management challenges in HMIS ,33.As regards to monitoring of disease occurrence in the district, only a few of the members were aware that their respective facilities reported notifiable epidemic diseases, including VHF during the past five years. Although all participants agreed that it is important to regularly examine the data submitted to the district level for any unusual event, none of them was prompted to take action in response to the VHF cases reported. The observations in the two districts emphasize the need for alert thresholds be applied to notifiable disease surveillance data to provide guidance for triggering further actions. The thresholds should be able provide an alert when the number of cases of a specific disease exceeds a pre-established threshold. However, this can only be done, if those responsible for routine analysis and interpretation of surveillance data do their job. During discussion, it was noted that the two districts actually experienced dengue epidemics during the reporting period, but since the variable in the DHIS2 system was VHF, the specific disease was not recorded. Tanzania, and particularly the City of Dar es Salaam has experienced dengue outbreaks during 2013–2015 and 2019 ,35. It iAccording to the National IDSR Guidelines, one single case of VHF is enough to initiate an investigation , yet nonFundamental challenges facing analysis and interpretation of surveillance data have been identified to include: understanding the purpose and context of the specific surveillance system; identifying a baseline rate of observations and to recognize deviations from that baseline; interpreting the meanings conveyed by these observations and to recognize the significance of these interpretations; properly discerning the degree of certainty that the available data can support regarding that interpretation; and timely communicating the observations with clarity to the desired actors that enables meaningful actions to be taken in response to the interpreted data . These fThe design and process of the training programme implementation provided an invaluable contribution to the responsibilities of the district teams. Firstly, the data analysis training brought together health workers of various disciplines and disease control programmes. This helped health workers who are primarily not involved in surveillance activities appreciate their indirect yet critical contribution to the surveillance programme and helped foster teamwork. Bringing together such a team aimed to ensure that competent health teams that can readily be mobilised and deployed for rapid outbreak investigation and response are available within the districts. Similar approaches have been reported to contribute to improvements in data use in Zanzibar and Cote d’Ivoire ,42. The One strength of this study is the involvement of the district health personnel in the data analysis exercises, suggesting that the findings have relevance throughout the health system in Tanzania. A potential limitation of this study was the small key informant sample. However, this part of the study was designed to prepare the background for the in-depth qualitative assessment rather than to yield statistically representative results. Moreover, since this study involved urban districts only, the findings cannot be used to generalize the situation in the rural district.The findings that epidemic-prone diseases were reported by the facilities and yet the districts did not take measures to analyse and investigate, demonstrate the need to strengthen the capacity of the district in the use of alert systems to identify the occurrence of notifiable diseases. The experiences from the two districts highlight the need to take conscious action to address knowledge and skill gaps of the human resource in order to improve performance in disease surveillance. Districts should introduce disease surveillance as an agenda in their routine meetings to examine reporting of unexpected disease and unusual trends observed over time. Like many complex health system interventions, success in the improvement of data management and use in decision-making should take a whole-stakeholder involvement approaches that involve the frontline health workers, district managers and policy-makers to realise the need and value of data. For surveillance to have an impact on health system performance, and hence improvement of the population health, it is important to address the district health workers culture and norms around data that will make the difference in the way they value data. Periodic refresher trainings are important and likely to make the surveillance system more user-friendly.


Background: The European Centre for Disease Prevention and Control describes the community pharmacist as the gatekeeper to the quality of antibiotic use. The pharmacist has the responsibility to guard safe and effective antibiotic use; however, little is known about how this is implemented in practice. Aims: To assess the feasibility of a method to audit the quality of antibiotic dispensing in community pharmacy practice and to explore antibiotic dispensing practices in Greece, Lithuania, Poland, and Spain. Methods: The Audit Project Odense methodology to audit antibiotic dispensing practice was adapted for use in community pharmacy practice. Community pharmacists registered antibiotic dispensing on a specifically developed registration chart and were asked to provide feedback on the registration method. Results: Altogether, twenty pharmacists were recruited in four countries. They registered a total of 409 dispenses of oral antibiotics. Generally, pharmacists were positive about the feasibility of implementing the registration chart in practice. The frequency of checking for allergies, contraindications and interactions differed largely between the four countries. Pharmacists provided little advice to patients. The pharmacists rarely contacted prescribers. Conclusion: This tool seems to make it possible to get a useful picture of antibiotic dispensing patterns in community pharmacies. Dispensing practice does not seem to correspond with EU guidelines according to these preliminary results. Community pharmacists are in a unique position to positively impact antibiotic use and reduce antimicrobial resistance ,2. The ECurrently, little is known about dispensing practices for antibiotics in community pharmacies and to what extent pharmacists fulfil the role as gatekeeper to antibiotic use in daily practice. In their systematic review on documenting dispensing practices , CerqueiTo assess the feasibility of registering antibiotic dispensing using the registration chart in the community pharmacy setting;To collect feedback from community pharmacists on the implementation of the APO method;To describe antibiotic dispensing practices in four European countries.One way to document healthcare practice is through self-registry by healthcare professionals. In general practice for example, the Audit Project Odense (APO) methodology was developed for quality improvement  and is un = 19) returned the questionnaire. The participation of pharmacy staff differed between the pharmacies. In 10 pharmacies, both pharmacists and pharmacist technicians participated in the pilot study. In four pharmacies, only one staff member participated; this could either be a pharmacist or a pharmacist technician. In three pharmacies, more than one staff member participated, although not the entire staff. In the remaining two pharmacies, only pharmacists participated. All pharmacies reported that registration of patients took less than one minute per dispensed antibiotic or between one and two minutes, except for one pharmacy that needed two to three minutes per registration. In all countries, pharmacy staff managed to register all patients with a prescription for an oral antibiotic or only missed a couple of dispenses during the study period. Reasons for not registering included high workload or forgetting. Most of the pharmacists found the registration chart, instruction form, and list of antibiotics clear and easy to use.In total, 20 pharmacies were recruited to participate in the pilot study, five in each of the four countries. One pharmacy in Greece dropped out of the study due to intense workload. All participants . The most frequently dispensed antibiotics were amoxicillin and amoxicillin/clavulanic acid, followed by macrolides or clindamycin and cephalosporines, although frequencies differed per country. In total, 77% of the dispenses were registered by pharmacists, 22% by other pharmacy staff, in 2% this was not reported. Nearly half of the dispensed antibiotics were prescribed for acute respiratory tract infections. The indication for the prescribed antibiotic was unknown to the pharmacy staff for 11% of the total number of dispenses. There was contact between the pharmacist and the prescriber for 14 (3%) of the dispenses, which led to changes to the prescription in nine (2%) cases. In Poland, there was no contact with prescribers at all, and in 12% of the dispenses this information was not reported .The frequency of checking for drug-drug interactions, contraindications, and allergies during the dispensing process differed largely between the countries. In total, in 49% of the dispenses none of the three safety checks were performed. However, in 70% of the cases in Lithuania none of the checks were performed, whereas in Greece no checks were performed in 18% of the cases. When looking at the individual safety checks, checking for contraindications was performed the least often (21%) and checking for allergies most often (36%). Only in Spain and Greece were there dispenses for which all three safety checks were performed, in 24% and 22% of registrations, respectively .Overall, in 66% of the dispenses, the pharmacy staff discussed treatment duration with patients. Other general advice that is deemed appropriate to give during dispensing of all antibiotics was given less frequently: information about side effects (21%), informing about risk of AMR (18%), seeking medical help if symptoms worsen (19%), and bringing back leftovers (4%). In 13% of the dispenses, the pharmacist did not provide the patient with any advice .Treatment duration was unknown for 7% of the dispensed antibiotics. In 70% of the dispenses, the pharmacy staff deemed the prescription appropriate for the specific situation on a clinical basis , in 3% the pharmacy staff did not agree, and in 26% the staff reported to not have sufficient information to make this judgement. This information was missing in 1%. In 31 cases, pharmacists judged a prescription as appropriate despite not knowing the indication and/or treatment duration, which was considered as inappropriate agreement . Four anMost feedback was about the domain of advice on the registration chart and instruction form. For example, for “discuss treatment duration” one Spanish pharmacist commented: ‘does this mean to explain and reinforce the importance of not stopping treatment until finishing it, or only explain the duration of treatment?’. Moreover, pharmacists reported they found some advice unnecessary to give while missing other information, although this feedback differed per pharmacy, within and between the countries. Several other topics were suggested to be added to the registration chart, including veterinarian use, probiotics, prophylaxis, injectable antibiotics, metronidazole, treatment preparation, and storage.Similarly, suggestions were provided for changes to other domains of the registration chart. Pharmacists in Greece described that it was difficult and uncommon to contact prescribers. In Lithuania, pharmacists reported that most of the time it was almost impossible to contact prescribers for clarification or changes to the prescription. Interestingly, the registrations during the pilot study show that in Greece there was contact with the prescriber in 5.5% of the cases and in Lithuania in 8.2% of the cases, whereas in Poland this was 0%. Additionally, some Lithuanian pharmacists mentioned that safety checks for contraindications and interactions were not performed in their pharmacies and patients were usually not informed about side effects from drug use. This aligns with the registered dispenses, as contraindications were only checked in 1.0% of cases, interactions, and allergies in 9.7% and 15.5%, respectively, and information about side effects was provided in 2.9% of the dispenses. Polish pharmacists reported that it was often not possible to give an assessment of the treatment as they did not know the indication for prescriptions and do not have access to patients’ medical history. Despite this, Polish pharmacists only reported an unknown location of infection in 10.8% of the dispenses. Finally, in Spain, the difference between pharmacists and other pharmacy staff was reported by multiple pharmacies. As only pharmacists are allowed to evaluate interactions and contraindications for new patients, it was suggested to exclude technicians from the study. Indeed, the registrations show a difference between pharmacists and non-pharmacists in Spain, as they checked for interactions in 44.0% and 10.5% of the dispenses, respectively, and comparably for contraindications (46.6% vs. 0%) and allergies (62.1% vs. 7.0%).Based on the written feedback that was provided by the participating pharmacy staff and the results obtained during registering the dispensing practice, several changes have been made to the registration chart . FirstlyAntibiotic dispensing in community pharmacies is complex and varying practices within countries and across borders exist. This study shows that a simple tool to measure the antibiotic dispensing process can be implemented in community pharmacy practice. When it comes to antibiotic dispensing in community pharmacies, practice does not seem to match EU guidelines. On the one hand, this could mean that proper guidelines should be based on a real-life setting involving practicing pharmacists in establishing such guidelines. On the other hand, registration of dispensing practices using the APO methodology reveals many possibilities for improvement, although the emphasis of such improvements should be dependent on contextual factors within and between countries.This is the first testing of the APO methodology in community pharmacy practice. The APO methodology has been proven to be effective in general practice over several decades ,8,10. DuThe complexity of the dispensing process makes it difficult to measure all topics related to it on a registration chart that can be completed within a few minutes. Within that framework, we attempted to include the most relevant parts of the antibiotic dispensing process but had to eliminate or simplify many topics from the registration chart. Several topics have been discussed and considered but not included in the final registration chart. These include registration of multiple other antibiotics and antibiotic classes, symptom assessment of patients without an antibiotic prescription, the patients’ perspective on the dispensing process, patient’s adherence to antibiotic therapy, the use of point-of-care tests, the use of “wait-and-see” prescriptions, and more specific details on safety checks and a wider range of possible appropriate advice. Through this method we developed a registration chart that takes little time to complete. Nevertheless, completing the chart during dispensing will take up additional time of pharmacists, which may mean that implementation might not be possible in all pharmacies for all antibiotic dispenses.Although it was estimated that the use of antibiotics without a prescription comprised about 7% of total antibiotic use in the EU , over-thThere is only limited literature available on documenting dispensing practice, even more so for antibiotics specifically. Cerqueira Santos et al.  reviewedThe ECDC has described a large role for the community pharmacist towards improving the quality of antibiotic use and therewith reducing antimicrobial resistance . NonetheThis pilot study is part of the Health Alliance for Prudent Prescription and Yield of Antibiotics in a Patient-centered Perspective (HAPPY PATIENT) project. This project aims to further implement the EU AMR guidelines on the prudent use of antimicrobials in humans . The proData collection was attempted in 25 community pharmacies, five pharmacies in five different countries with differences in scale and patterns of antibiotic use , and sprThe layout of the registration chart, with multiple variables categorized within overarching domains, was kept consistent with the original audit chart developed for GP practice as earlier published ,10. The The registration chart has been discussed during several meetings with expert groups: the developers of the original GP registration chart, local partners in the target countries, practicing community pharmacists and the complete HAPPY PATIENT project group. The list of antibiotics and antibiotic classes included in the registration chart was composed in collaboration with the local and clinical partners, for consistency throughout the project. The registration chart comprised nine domains with a total of 46 variables related to antibiotic dispensing, and two patient variables—age and sex ; it focu® SPSS® and Stata™ files by partners at the Research Unit for General Practice, Institute of Public Health of the University of Southern Denmark.The registration chart and an instruction document  were disTo assess the feasibility of implementing the registration chart in practice and to acquire feedback on the registration chart, the pharmacy’s staff was requested to complete a questionnaire following the pilot study . This quAll answers to the questionnaire were translated to English by the partners in the target countries. Due to the small number of participating pharmacies, the received feedback was discussed by the core research group in full. Any unclarities were solved, and suggestions towards increasing the ease of use of the documents or reducing the time needed to complete them were considered if these were relevant in all target countries. Similarly, the content of the registration chart was adjusted based on this questionnaire. To this extent, any topic suggested to include or remove was discussed within the core research group and compared to WHO and ECDC reports and SmPC texts. Topics mentioned by multiple pharmacists were given a higher priority. Any topic was only included if deemed relevant in all four countries and consistent with EU AMR guidelines. Additionally, the data collected with the registration chart was used to further improve its contents.The data collected with the registration chart were also used to illustrate community pharmacy practice regarding antibiotic dispensing using Stata/MP 16. Data were analyzed descriptively for pharmacies per country and for the countries together. Crosstabs of different combinations of domains were created to analyze combinations of dispensed antibiotics and provided advice. Appropriateness of advice was determined by comparing the collected data to SmPC information for the specific antibiotics. Safety checks of contraindications, interactions, and allergies were deemed to have to be performed for all dispensed antibiotics, as described as the role of the pharmacists in the EU AMR guidelines .The registration chart based on the APO methodology appears to be a feasible way to obtain detailed data on the antibiotic dispensing practices in community pharmacies. Pharmacists from different countries have been able to implement the registration chart in their daily practice. Although the complex process of antibiotic dispensing cannot be documented entirely within a few minutes, this tool does make it possible to obtain useful information about antibiotic dispensing. Nevertheless, the effectiveness of this tool is not solely based on its design; it will substantially depend on the implementation of interventions that result from using the tool in practice. This pilot study indicates the presence of considerable inconsistencies between the EU guidelines on dispensing and the everyday practices in the pharmacies.