Tuberculosis (TB) control is based on early detection and complete treatment of infectious cases. Consequently, it is important that TB suspects and patients can readily access medical care. This qualitative study investigated determinants of access to DOTS services as identified by patients, health providers and community members in four districts in Tajikistan.Focus group discussions were conducted in order to investigate access to TB services. A conceptual framework for access to care guided the analysis. Thirteen focus group discussions involving a total of 97 informants were conducted. Content analysis of discussions and a rating to quantify the relative importance of discussed factors were carried out. The conceptual framework identifies five main components of access to which factors can be assigned: availability, adequacy, acceptability, accessibility and affordability.Financial factors were considered the most important determinants of access to diagnosis and treatment of tuberculosis. Expenditure for drugs and consultations, for transport, and for special foods as well as lost income were identified as major barriers to treatment. Stigma, doubts about curability and low perceived quality of care were not seen to be significant determinants of access to care for tuberculosis. Community members were well aware of symptoms of tuberculosis and of medical services. These findings were consistent between different respondent groups . They were also highly consistent between the open discussion and the confidential rating.Illness-costs to households were identified as the main barrier to tuberculosis diagnosis and treatment. To improve access and ultimately adherence to tuberculosis treatment, effective mitigation strategies, e.g. changes in case management, food contributions or financial stimuli, need to be explored and implemented. Tuberculosis (TB) cases often delay seeking care even when chemotherapy is free of charge,2 and deIn many contexts, TB is linked to stigma and/or perceived to be incurable-10. For Tajikistan has seen the breakdown of the previously comprehensive health system. Health care workers are badly paid and poorly motivated. Often patients have to pay for health services that are stipulated to be free of charge. Tajikistan adopted the DOTS strategy in 2002 and reported 79% DOTS coverage, 33% case detection and 84% treatment success in 2006,17. A stThe objective of this study was to identify the factors with the strongest influence on access to tuberculosis services - from the point of view of community members, TB patients and health services providers.The present study received ethical approval from the Ministry of Health of Tajikistan. It was conducted in the four pilot districts of Project Sino, which supported the integration of TB services into primary care, funded by the Swiss Agency for Development and Cooperation. DOTS implementation in these districts started in 2004 (Danghara and Varzob) and 2005 (Shahrinaw and Tursunzoda). TB laboratory services and treatment are available at DOTS-centres in each district centre. Primary care facilities are allowed to diagnose TB but virtually always refer suspects to the DOTS-centres for diagnosis. PrimaryWe used a previously described analytical framework of access to care in contexts of livelihood insecurity. Our anaThirteen focus group discussions (FGDs) were conducted in 2006 to investigate factors influencing access to care for tuberculosis. Five FGDs were conducted with community members, four with TB patients and four with health services providers to cover experiences of stakeholders involved in TB treatment. Stratification along different criteria was used to obtain more valid results (Table The FGDs covered the following topics: (i) symptoms and causes of TB, (ii) perceived appropriateness of treatment, (iii) factors determining the communities' ability to receive diagnosis and (iv) to complete treatment for TB. At the beginning of the FGDs with community members no hint to TB was given. Participants were asked about diseases causing cough; subsequently introducing other symptoms like sputum production, fatigue, weight loss, and night sweats. After the discussion on diseases causing the named symptoms, the focus on TB was disclosed to the participants. In FGDs with patients and providers, the focus on TB was known from the beginning.After the discussion, participants of community and patient FGDs were asked to rank the factors preventing "people from receiving full medical treatment" by importance in a participatory approach ('rating'), using chickpeas to rank the perceived importance of different factors. No rating was conducted among providers, because it interfered with local concepts of professionalism. For the rating, all factors named during the discussion on access to care were listed. The researchers suggested the following potential factors whenever they were not spontaneously mentioned: attitude of providers, insufficient confidentiality of medical services, stigma of TB, attitude of other community members towards TB patients and lost income. Each participant was asked to confidentially allocate six, three and one chickpea to the three most important factors.FGDs were conducted in Tajik. Translation to the minority languages Uzbek and Russian were provided by the moderator and an observer as needed. All FGDs were recorded on audiotape and transcribed to English. The accuracy of the transcriptions was checked by the main researcher who is fluent in Tajik and English. Where needed, the whole team re-checked the transcription by listening to the audiotape and by checking their own notes taken during the FGDs. The main researcher read the transcriptions repeatedly, categorised the statements using the analytical framework described above and added codes in TAMS Analyzer .Fourty-three community members participated in the community FGDs, 21 women and 22 men with a mean age of 42 years. Among providers, 15 doctors, nine nurses and seven TB specialists participated (mean age 45 years). Of 23 patients, eight were women and 15 were men. Participants were mainly from rural areas with about one fourth coming from semi-urban areas.First the results from the discussion on characteristics of TB and on barriers to treatment are presented and then the relative importance of identified factors from the rating. The topics that came up in the discussion on access to diagnosis and on access to treatment were very much the same. Participants also explicitly stated that the same factors were important at both times. Consequently the results are presented jointly.Upon presentation of symptoms of TB, community members mentioned a number of respiratory diseases, most prominently asthma, influenza and bronchitis. Community members also mentioned TB soon in all FGDs. Overall, knowledge of symptoms was accurate. Community members were able to identify medical facilities providing TB treatment in their surroundings.Knowledge about causes of TB was limited. In particular the belief that TB was inherited and normally incurable was found commonly among community members and also expressed by one patient and one provider. These beliefs were closely linked to the stigmatisation of the illness. The stigma was magnified by the fact that TB services are offered in separate facilities.Despite the misunderstandings on causes of TB and prospects of care, all respondent groups deemed medical treatment necessary and community members stated that they would seek medical care in case of illness. Community members showed themselves well aware of the availability of TB services at the DOTS centres. Overall it was revealed that due to the difficulties associated with accessing medical care, patients tended to delay presenting until their health status had become severe - despite community members being aware of better prospects of cure at earlier presentation to care.Respondents in all FGDs agreed that financial factors were the strongest determinants of access to care and the patient's ability to take the full treatment, i.e. adherence. On the question, why people with TB do not get treatment, a woman  from Varzob town said: "No money, no treatment - money plays a great role." A general practitioner (40 years) from Danghara answered: "First, because of the financial situation, because of the funds." Other possible reasons were not perceived to be equally important. Although stigma of TB was acknowledged, most participants emphasized it would not prevent patients from visiting medical facilities. Side-effects of treatment were experienced by some participating patients, but were not mentioned very often and were considered important by a small minority only.The perceived higher importance of economic factors relative to acceptability and accessibility of services was also reflected in the number of statements among all respondent groups Figure . FactorsCommunity members allocated 12%, 62% and 20% of chickpeas to the categories 'missed opportunities', 'medical expenditure' and 'non-medical expenditure' respectively (Figure Costs mentioned in the FGDs can be grouped into six categories: diagnosis, drugs and consultation, hospitalisation, transport, increased expenditure for food and lost income. Diagnostic expenditure was seen to be less important with the exception of radiography, which was considered expensive by patients and community members. Cost of drugs and consultation were identified as important barriers by patients and especially by community members Figure . Three pWhile several studies showed that patients face substantial costs even where TB drugs are stipulated to be free of charge,21-24, fThe main limitation of this study is possible reporting bias. Reporting bias, however, should be reduced in the confidential participatory approach. The high consistency between the open discussion and the participatory approach lead us to believe that reporting bias was limited. At the time of study implementation, DOTS was relatively new to two of the study districts. Further improvements may have happened since then.The predominance of financial factors corresponds well to the results of the small number of previous studies investigating the importance of financial and a wide range of other factors,12. The Enabling patients to obtain prompt diagnosis and full treatment and thus interrupting the cycle of infection is crucial. The results of this study suggest that doing so requires a reduction of the costs faced by patients and their households.When designing strategies to reduce costs to patients, it should be kept in mind, that components of access to care are interrelated. For example, improvements in the quality and reliability of food provided at the hospital would reduce the need for patients' relatives to travel on a daily basis to bring meals to hospitalised patients. Case management factors, like the provision of additional treatment besides the TB-medication, have been found to cause substantial expenditures for TB patients in Tajikistan. ReviewiConcluding, it is difficult to increase TB case detection and treatment adherence as long as patients' immediate concerns are not addressed. For TB control to be successful in Tajikistan and many other countries, programs need to reduce financial barriers to TB treatment. Possible ways to ease the financial hardship of TB for affected households include among others changes in case management, financial stimuli and food supplements.The authors declare that they have no competing interests.RA was the main responsible researcher for all parts of the study. KW contributed to designing the study and to writing the manuscript. HA and SS participated in design of the study and data collection. All authors read and approved the final manuscript.


Results of blood test are essential and often guiding for the diagnostic work. In emergency departments (EDs) a competent and rapid treatment therefore requires an efficient process for ordering blood tests, informing clinicians that samples have been taken, for communicating test results, and for physicians acknowledging having assessed results.The ED in Slagelse Sygehus has implemented icons on their electronic whiteboard that visualize the progress of the blood-test process.The aim of our study was to evaluate the impact of the icons on the workflow.The study was designed as a qualitative study using the methods of observations and informal interviews.The observations amounted to 19 hours in total and consisted of shadowing 6 physicians and 2 nurses for a couple of hours at a time. Informal individual interviews were held with all observed professionals and with another two nurses, two laboratory technicians, a coordination nurse, a triage nurse, and a secretary.The nurses frequently attended to the icons on the whiteboard. The arrival of new test results was seen as an opportunity to make the physicians aware of patients that could be discharged or transferred to other departments. The icons thereby supported the nurses in maintaining flow of patients.The physicians did not attend to the icons for maintaining flow, but used the icons at two daily timeouts, when they collectively assessed patients. Overall they considered test results as input to the clinical evaluation of individual patients.Our study indicates that the blood-test process can contribute to the steering of which patient the physicians should see next. Presently, this steering is mediated by nurses, who keep an eye out for the icons reflecting the blood-test process.The physicians did not attend the icons themselves, hence the blood-test process did not steer physicians directly. If the blood-test process should steer physicians’ actions directly, bypassing the nurses, the information of blood tests should be mediated by other means, for example by smartphones carried by the physicians. This calls for further studies.


Because classical music has greatly affected our life and culture in its long history, it has attracted extensive attention from researchers to understand laws behind it. Based on statistical physics, here we use a different method to investigate classical music, namely, by analyzing cumulative distribution functions (CDFs) and autocorrelation functions of pitch fluctuations in compositions. We analyze 1,876 compositions of five representative classical music composers across 164 years from Bach, to Mozart, to Beethoven, to Mendelsohn, and to Chopin. We report that the biggest pitch fluctuations of a composer gradually increase as time evolves from Bach time to Mendelsohn/Chopin time. In particular, for the compositions of a composer, the positive and negative tails of a CDF of pitch fluctuations are distributed not only in power laws , but also in symmetry . The power-law exponent decreases as time elapses. Further, we also calculate the autocorrelation function of the pitch fluctuation. The autocorrelation function shows a power-law distribution for each composer. Especially, the power-law exponents vary with the composers, indicating their different levels of long-range correlation of notes. This work not only suggests a way to understand and develop music from a viewpoint of statistical physics, but also enriches the realm of traditional statistical physics by analyzing music. Because music has well accompanied human beings for thousands of years, abundant scientific researches have been done to understand the fascinating power of it. For example, a research group used positron emission tomography to study neural mechanisms underlying intensely pleasant emotional responses to music In this work, we attempt to understand music from a statistical physics point of view. Traditional statistical physics mainly concerns about natural systems, whose structural units are usually molecules or atoms. Those units are not adaptive to the environment because they have no mental faculties. From the 1990s, people gradually applied the methods originating from traditional statistical physics to investigate the intelligent and adaptive human systems. For example, Mantegna and Stanley discovered a scaling behaviour of probability distribution for a particular economic index in 1995 We analyze 1,876 compositions of five classical music composers across 164 years All pieces of music in our work were downloaded from kern humdrum music data base Let us denote the pitch of time The reason why we focus on two adjacent notes may be two-folded. Firstly, if we focus on the pitch change between two notes with First, let us take a glimpse at the data of pitches of the five composers, by calculating the mean value of pitches as we can see in Next, let us move on to statistical analysis of pitch fluctuations, After the statistical analysis of pitches and pitch changes, we are now in a position to investigate the CDFs.CDF (cumulative distribution function), The CDF of pitch fluctuations for each composition is calculated at first, and then it is classified in accordance with musicians, as shown in Next we examine the time evolution of this scaling property  of a composer gradually increases as time evolves from Bach to Mendelsohn/Chopin. In particular, the positive and negative tails of a CDF (cumulative distribution function) for the compositions of a composer are distributed not only in power laws , but also in symmetry . Particularly, the power-law exponent decreases as time elapses. Furthermore, we have also calculated the autocorrelation function of the pitch fluctuations. The autocorrelation function shows a general power-law distribution for each composer. Especially, the power-law exponents vary with the musicians, indicating their different levels of long-range correlation of pitch fluctuations. Compared with the previous works on analyzing music, we focus on pitch fluctuations and study the time evolution and development of the classical music. In particular, all of our statistic results are based on MIDI files. We choose only those five composers due to the limitation of database. However, in the preparation of MIDI files different temperaments, tunings and transpositions in the music were neglected. Works playing with different instruments may correspond to different notes and even form different styles. Thus the statistical results remain to be improved in these aspects. Further, although we study the overall statistical properties of each composer, we should mention that each composer still has various styles in his career and we just have a rough style comparison between composers. This work may be of value not only for suggesting a way to understand and develop music from a statistical physics point of view, but also for enriching the realm of traditional statistical physics by including music.


To stimulate discussion around the topic of ‘carbohydrates’ and health, the Brazilian branch of the International Life Sciences Institute held the 11th International Functional Foods Workshop (1–2 December 2011) in which consolidated knowledge and recent scientific advances specific to the relationship between carbohydrates and health were presented. As part of this meeting, several key points related to dietary fiber, glycemic response, fructose, and impacts on satiety, cognition, mood, and gut microbiota were realized: 1) there is a need for global harmonization of a science-based fiber definition; 2) low-glycemic index foods can be used to modulate the postprandial glycemic response and may affect diabetes and cardiovascular outcomes; 3) carbohydrate type may influence satiety and satiation; glycemic load and glycemic index show links to memory, mood, and concentration; 4) validated biomarkers are needed to demonstrate the known prebiotic effect of carbohydrates; 5) negative effects of fructose are not evident when human data are systematically reviewed; 6) new research indicates that diet strongly influences the microbiome; and 7) there is mounting evidence that the intestinal microbiota has the ability to impact the gut–brain axis. Overall, there is much promise for development of functional foods that impact the microbiome and other factors relevant to health, including glycemic response (glycemic index/glycemic load), satiety, mood, cognition, and weight management. Carbohydrates are one of the three macronutrients, which contribute to energy intake. While broadly composed of carbon, hydrogen, and oxygen, they occur in a wide variety of forms that may be classified by chemical structure or physiological effect. These effects are wide- ranging, from impacts on blood glucose levels to alteration of the microbiome. The 11th ILSI Brazil International Workshop on Functional Foods held in São Paulo, Brazil, on 1–2 December 2011, ‘Carbohydrates, Microbiome and Health,’ focused on several types and effects of dietary carbohydrate. The theme ‘carbohydrates’ often stimulates controversial discussion because of conflicting evidence and varying scientific views on their health impacts. The goal of the event was to present consolidated knowledge and scientific advances in recent research on the relationship between carbohydrates and health. The topics of fiber, fructose, glycemic index, mood, satiety, and gut microbiota were covered. This marked the first workshop in the series since the adoption of a definition for dietary fiber by the Codex Alimentarius Commission in 2009 and, as such, presented an opportunity for issues surrounding the implementation of the Codex definition and health benefits of fiber to be discussed by a body of scientific and regulatory experts who are preeminent in the field. Representatives from academia, industry, and regulatory agencies attended the event, and experts from Brazil, Switzerland, Canada, Argentina, the United States, and the United Kingdom presented the state of the science. The workshop was facilitated by professors Antonio Herbert Lancha Junior and Elizabete Wenzel de Menezes, and it was coordinated by Professor Franco Lajolo, all from the University of São Paulo, São Paulo, Brazil.Dietary fibers are carbohydrates that are not digested within the upper gastrointestinal tract and pass to the lower gastrointestinal tract (large intestine), where they are available for fermentation. Dietary fiber, and its relationship with health and disease, has been the subject of much research and discussion throughout the 20th century. In addition, fiber-rich foods have been recognized for centuries for their association with intestinal health. For example, in the 4th century BC, Hippocrates championed the benefits of wheat with bran to help keep the large intestine healthy. Since the 1970s, a number of important developments have occurred in the field of fiber, spanning disease/health association, definition, measurement, ingredient design, material characterization, mechanisms for physiological effects, and development of nutritional recommendations.Dietary fibers represent a large family of components. Collectively, these components are carbohydrates, are neither digested nor absorbed in the upper gastrointestinal tract, and show some physiological effect. As a broad family of components, many differences exist among them, including structure  and physical and chemical properties ; thus, they can have very different physiological effects and metabolic consequences. Because of the wide variety of materials/ingredients that can be considered as dietary fibers, there is a clear need for a common understanding of dietary fibers supported by an authoritative global definition.A number of authoritative statements/definitions are available relating to dietary fiber. In 1997, the Food and Agriculture Organization of the United Nations recommended to classify carbohydrates according to their DP , not according to origin (i.e. whether they are intrinsic or extrinsic) or solubility , and theEven though Codex made a step forward in attempting to establish a global definition on dietary fibers, it is clear that much remains to be done at both the global and national levels. Indeed, support should be provided to guide national authorities to correctly implement the Codex dietary fiber definition regarding the aspects on DP 3–9 and physiologic effects. A harmonized global definition is fundamental to help further research, method development, and regulation.Dietary fiber is the carbohydrate that is resistant to digestion and absorption in the upper digestive tract. Although fiber was traditionally considered inert, it is now appreciated that fiber has links to health promotion and disease prevention. Originally, effects were thought to be related to solubility, but recent findings indicate that fermentability, viscosity, and other properties may be important .The Institute of Medicine recommends a dietary fiber intake of 14 g/1,000 kcal . InterprThe recommendation for fiber is based on evidence for reduced cardiovascular disease (CVD) risk and lower body weights in prospective cohort studies , 13. TheFiber intakes are generally below recommended levels, with American consumption of fiber about half the recommended 25 g/day for females or 38 g/day for males based on 14 g/1,000 kcal. Fiber intakes for children and the elderly are particularly poor in comparison with the guidelines. For these reasons, the 2010 Dietary Guidelines for Americans list fiber as a ‘nutrient of concern’  and 12.5Because most food sources are not particularly high in dietary fiber, fibers are often added to popular foods, including cereals, breads, dairy products, and beverages. Added fibers have a number of demonstrated benefits but vary greatly in their physiologic effects . Public Dietary interventions that lower the glycemic index (GI) and/or the glycemic load (GL) of the diet are known to improve fasting blood glucose in individuals with impaired blood glucose control, such as those with diabetes . There iDietary carbohydrates represent a wide variety of ingredients that do not provide the same blood glucose response. Some may be quickly digested and released in the bloodstream (e.g. sugars and starches), some may be slowly digested but available for a longer period of time in the blood, and finally others are non-available carbohydrates that can be fermented further down in the colon. The blood glucose response therefore depends on the type of carbohydrates ingested, and this response to a specific ingredient can be measured and compared with glucose or a standard food (such as bread): this is called the GI of a tested ingredient. To correctly measure the GI of a food, the 50 g of available carbohydrates is compared with 50 g of glucose or available carbohydrate in a standard food, meaning that it is not a comparison of the same amount of food .There are some additional confounders inducing a variability of the results, such as baseline blood glucose, person-to-person variation, and a variation across time for the same person. The GI of a food can also depend on the way it is cooked (e.g. warm vs. cool potatoes), the degree of maturity (e.g. green vs. mature banana), or the type of the ingredient (e.g. fine flour vs. coarse flour) . Some otThe GL is another measure of the glycemic response of a food, which takes into account the amount of available carbohydrate in a portion of food eaten and how frequently it is eaten. The glycemic glucose equivalent (GGE) may be the most usable unit for the consumer. Indeed, the GGE gives the theoretical amount of glucose that would give that glycemic response of a specific amount of a specific ingredient .per se, which provokes an effect on satiety. Concerning any impact on body weight, there is some evidence that a lower GI is associated with a reduction of body weight, as presented in the Diogenes study  that particularly contribute to that effect.The association of a low GI or GL diet with a variety of health endpoints has been postulated; it has been particularly shown to improve fasting blood glucose in people with impaired blood glucose control, and to improve insulin sensitivity in non-diabetic as well as overweight, obese, and subjects with type 2 diabetes . Lowerines study . HoweverThe degree of the association between the glycemic response and these health indicators varies among studies and is influenced by different factors such as body mass index, gender, or baseline blood glucose levels. It could be interesting to see whether there is any possible association with the microbiome.Overall, it seems to be quite difficult to inform consumers of this concept because it may not work in mixed meals and is dependent of confounding factors such as previous meal effects, and the same foods can have different GIs depending on cooking time. However, despite the controversies, it may still be a good dietary tool for individuals with diabetes to guide them in their food choice.It was traditionally believed that postprandial blood glucose responses were determined by whether simple or complex carbohydrates were consumed. Over time, increasing experimental evidence has questioned this classification and given rise to the concept of the GI. The GI concept suggests, as an extension of the dietary fiber hypothesis first proposed by Burkitt and Trowell , that ceIndeed, in clinical trials, low GI foods have been shown to have beneficial effects on blood glucose control , 34 and Regardless of the large body of evidence that low GI diets may have health benefits in chronic disease risk reduction, numerous controversies around the GI concept have restricted the use of the GI at the population level and in nutrition counseling. One issue is the variability observed between GI values for the same foods between different laboratories, which can be resolved by using the standard method of GI testing and calculations . GIs derIn light of the growing obesity epidemic, many health conscious consumers are looking for foods and snacks that help keep hunger away and control overconsumption. One approach to help consumers better control their food intake may be to increase satiation, the factors that bring a meal to an end. Another approach is to enhance satiety, the feelings of fullness, and decreased hunger after a meal that suppresses the urge to eat.ad libitum intake of a meal.There are several potential physiological mechanisms involved in satiation and satiety, each of which provides potential targets for products with these benefits . The actCarbohydrates contribute a high proportion of calories in the diet, so understanding the effects that different carbohydrates have on satiety is of potential interest in helping consumers meet their needs. Overall, carbohydrates are considered to be intermediates between proteins and fats in promoting satiety, with proteins considered the most satiating of the macronutrients. Although the amount of total carbohydrate does not seem to relate to satiety , the typThe ultimate objective for understanding the effects of different carbohydrates on satiation, satiety, and food intake is to help consumers make informed choices about what and how they eat. The EFSA has to date evaluated and rejected satiety claims for six types of fiber . AlthougThe brain is the most metabolically active organ in the body. Although it uses glucose as its major source of energy, it requires a continuous supply because its reserves are limited. The brains of children use glucose at a greater rate than that of adults. The adult brain accounts for 2% of body weight but 20% of the basal metabolic rate. As the carbohydrate in a meal delivers glucose into the blood stream, there has been an interest in the impact of this macronutrient on the brain, specifically on mood and cognition.Although there is a popular belief that a sugar-containing drink in the short term results in a ‘rush,’ a feeling of energy, there is no experimental support for this idea. In the first hour after consumption of a sugar-containing drink, there are reports of small increases in subjective energy. However, the effects are small and not easily demonstrated . After sThe impact of sugar on the behavior of children became of interest in the consumer and scientific sectors in the early 1990s. In 1995, Wolraich et al. published a review of the impact of sucrose on behavior in children and found that irrespective of the test used or the behavior observed, there was no evidence of an adverse effect . The uniThere is increasing interest in the interaction between individual differences in the ability to control blood glucose levels (glucose tolerance) and the carbohydrate content of the meals. There is consistent evidence that those with poorer glucose tolerance have poorer memories . In chilOverall, the current data indicate that reactions to a meal depend upon the individual differences in glucose tolerance. The advantages for both mood and cognition can be seen with low amounts of carbohydrate or carbohydrates with a lower GI. Although there is some evidence that attention can be influenced, memory appears to be more susceptible to the carbohydrate content of meals.Probiotics and prebiotics are two functional food concepts claiming to benefit or support gastrointestinal health through different mechanisms. Both concepts complement each other since a prebiotic is, in essence, a fermentation substrate used by probiotics. Formally a prebiotic has been defined as a non-viable food component, which confers a health benefit on the host associated with modulation of the microbiota . In turnin vitro growth and metabolism in characteristic human probiotics  is thought to be the principal mechanism underpinning the adverse effects of fructose. Classical biochemistry teaching is that fructose bypasses the control step of phosphofructokinase acting as an unregulated substrate for DNL . While iDespite the uncertainties in the existing data, nutrition guidelines have taken a harm reduction approach to fructose. The American Heart Association recently put forth guidelines recommending restriction of added fructose for mitigation of chronic disease . The AmeContrary to the concerns expressed, the CIHR series of systematic reviews and meta-analyses have shown that there is a moderate body of consistent evidence drawn from more than 40 controlled feeding trials that fructose in isocaloric exchange for other sources of carbohydrate at low-to-moderate doses  does not harm serum lipids , blood pHarm under certain conditions, however, remains an important consideration. An emerging body of consistent evidence shows that fructose consumed at high doses, such as >100 g/day across all groups  or >60 gThere remains a need for larger, longer-term, and higher quality ‘real-world’ feeding trials to disentangle the role of fructose from that of energy in cardiometabolic disease.The European Branch of the International Life Sciences Institute (ILSI Europe) operates on the premise that global health promotion and disease prevention can only be achieved through evidence-based nutrition, founded on accurate data. The Functional Foods Task Force of ILSI Europe has contributed to the approach on how to substantiate health claims on foods. Both the FUFOSE   and PASSNumerous other initiatives addressed the question of providing guidance for marker selection, such as the Biomarkers Definitions Working Group  and the Nutrition research is facing some challenges such as how to show that specific foods may have an impact on maintaining or improving specific health functions, whereas currently, nutrition effects are assessed via clinical endpoints linked to disease state. How much do markers used in a study reflect the clinical endpoint? How meaningful are these markers, mostly coming from the medical field, in assessing maintenance of normal body function?All of these aspects should be considered when studying nutrition and health. Many articles or guidelines have highlighted that markers should be validated. However, no clear and practical framework has been proposed thus far for validation in the nutrition research field.To stimulate research, innovation, and competitiveness, it is now time, in the European food industry, to provide nutrition scientists with clear guidance from public agencies on the specific type of marker information needed to scientifically substantiate an impact on health.In 2011, ILSI Europe initiated an activity with the purpose of identifying consensus criteria for the evaluation of markers to use in nutrition research and to develop guidelines for the adequate use of these criteria. A scientific panel has been identifying the evidence-based validation criteria for markers based on a literature review. In parallel, a series of expert groups from various task forces of ILSI Europe have identified the criteria for marker validation based upon the markers broadly used in their expertise field of nutrition research. Data collected by the different groups will be reviewed and discussed with relevant experts, stakeholders, and representatives of other global initiatives to draw conclusions.Understanding how and why markers can be considered as valid is a common concern. By creating a list of agreed-upon criteria, guidelines will be offered to the nutrition research field to harmonize marker selection and provide recommendations for the development of future markers. A list of validated markers will improve the ability to compare data across studies and ensure the highest quality of science-based nutrition information.13/g feces) and the immune cells associated with the mucosa responsible for the mucosal immune response. Many factors impact the gut microbiota, including nutrition, bacterial interactions, and presence of disease, pharmaceuticals, bacterial metabolites, antibodies, pH, age, and bile acids  and it is difficult to modify its behavior by foods. However, functional food can influence not only the microbiota, favoring the growth of beneficial microorganisms, but also the mucosal immune system associated to the gut. These functional foods by definition can exert a beneficial effect in addition to their nutritional properties. They usually contain live microorganisms with probiotic characteristics as defined by the FAO . We haveresponse –125. L. in vivo, ex vivo, and in vitro assays comparatively with a non-probiotic strain. We established, by in vitro assay, that species specificity is not a necessary condition for the selection for the probiotic strain to be used in a functional food. The most predictive biomarkers for a beneficial effect on the gut are chemokine expression and macrophage activation. IgA producing cells and cytokine release are not exclusive to probiotic bacteria and therefore would not be proper biomarkers even in an in vivo assay. Our study also showed that probiotic characteristics are not related to the L. acidophilus lipoteichoic acid (LTA) molecule. However, the possibility that LTA acts together with other molecules in the immunomodulatory capacity of probiotic bacteria is not excluded. The next phase of this work is to demonstrate efficacy of these markers in humans.One of the important questions is how to select a functional food that will improve the intestinal health. The best option would be to select a good probiotic strain; however, what biomarker should be selected to indicate an impact on intestinal health? Potential options include cytokines, epithelial interleukin-6, immune cell receptor expression, or increased macrophage activity. Taking into account the beneficial effect of some probiotic strains present in functional foods, we analyzed the effect of a probiotic strain by The intestinal microbiota, until recently considered a mere bystander, has been elevated almost to the status of an active organ, playing a role in a wide range of host physiological processes. Examples of these host–microorganism relationships are observed in the fermentation of indigestible carbohydrates, the synthesis of certain vitamins, the degradation of dietary oxalates, the development of the immune system, the protection of the epithelial tissue, and some angiogenesis stimulations . It is cPrevotella-dominated cluster. This confirms that diet can modulate the gut microbiota composition and therefore have an impact on human health; however, the mechanisms by which diet influences the gut microbiome remain to be fully understood.Although the microbiota is different from person-to-person, individuals within a human population can be grouped according to their gut microbiome , 135. InShort-term dietary interventions have shown to be capable of causing a measurable effect on the gut microbiome composition within 24 h, but are not enough to completely change the system from a pre-existing state into another. Whether long-term interventions can do so is still an open question, but dietary therapies have the potential to be used to manipulate the host's associated microbiome. Applications are evident on the treatment of certain inflammatory bowel diseases, such as Crohn's disease. This new knowledge could also open the door to personalized therapies, in which treatments would be designed according to the subjects’ intestinal microbiome composition.The idea that the vastly complex microbial ecosystem in the human colon has a profound impact on health is now gaining widespread acceptance in the scientific community and the food and healthcare industries. Recent research is illuminating the intricate interactions between microbes in the colon, their metabolites, and human metabolism, which will ultimately help to define ‘normal’ or ‘healthy’ gut microbiota.Consequent to this area of work, there is increasing interest in the development of functional food ingredients to modulate the colonic microbiota and its metabolic profile for the promotion of health. Traditionally, this has been achieved through the administration of live bacterial supplements, or probiotics. Although there is accumulating evidence that specific, carefully selected bacterial strains can have health benefits, it is not possible to bring about large changes in the colonic microbiota in this way. In 1995, the concept of prebiotics was introduced. Since that time, there have been several definitions of prebiotics, with the most recent one published in 2010 . EssentiAlthough there is a range of prebiotics on the market, we have a poor understanding of the structure-function relationships in these molecules. Recent studies at Reading have given new insights into the influence of structure on prebiotic activity and can inform the development of new ingredients –138. DepPectins and oligosaccharides derived from them have been studied for their selectivity of fermentation and the effect on microbial populations depends upon the type of pectin provided .Much of the early work in this area has focused on increasing the relative populations of bifidobacteria and lactobacilli. These are non-pathogenic species with a range of recognized health-positive attributes, including inhibition of intrinsic and extrinsic pathogens, modulation of immunity, and synthesis of vitamins. The health attributes of these organisms are still being explored in the laboratory and in human volunteer trials, and data are accumulating to support the use of prebiotics in a range of chronic and acute gut disorders. Recent thinking, however, has focused increasingly on the metabolites produced by the colonic microbiota and the impact of these metabolites on health is currently being studied. This widening of emphasis is stimulating debate over the definition of prebiotics.In vitro studies suggest that higher the degree of polymerization (DP) of GOS provided, the greater the inhibition of enteropathogenic Escherichia coli adhesion  in foods, then resistance to food-borne pathogens may be increased. adhesion . Pectic adhesion . This aradhesion , 142.The evolving view of prebiotic function, coupled with new insights into the structure-function relationships in prebiotic oligosaccharides, is providing opportunities or development of novel functional carbohydrates. Enzyme-based technologies are being brought to bear on the challenge of manufacturing enhanced forms of prebiotic food ingredients. Rational choice of synthetic catalyst and carbohydrates source can potentially allow the development of precisely targeted prebiotics with a higher degree of selectivity than the current generation. An increase in the number of bifidobacteria is considered a positive health effect by the EFSA. At the same time, there is still no known cause and effect as related to health outcomes in humans and much work is needed to understand the potential short- and long-term health benefits.A microbiome refers to a collection of microorganisms associated with an organ or tissue. Colonization of the intestine begins at birth and continues throughout childhood. To give some perspective on the size of the gut microbiome, humans are composed of approximately 10 trillion cells; the microbiome is composed of 100 trillion germs. Once established, the microbiome may be acutely altered by illnesses, medications, or other temporary changes. With chronic modifications, the effect may be permanent. Diet is known to have early and important effects on the character of the gut microbiome .The science around the gut microbiome and obesity has been under development for only a decade; therefore, much is yet to be uncovered about this relationship and the underlying mechanism(s) remain under investigation. Thus far, it has been documented that intestinal bacterial microbiota operate differently in the lean compared to the obese . For exaSeveral observations to date suggest that successful manipulations of the gut microbiota may assist with weight loss. While artificially modifying the gut microbiota  may result in a weight change, the microbiota remains resistant to change and seems to revert to the original profile. In animal models, after 3 weeks of such suppression, modifications of the intestinal microbiota cause weight loss –147.The study of microbes has added a new dimension to the vast and complex pathophysiology of obesity and diabetes. It seems that the microbial composition may impact glucose homeostasis and diabetes . InitialPrebiotics and probiotics show promise for impacting some of the mechanisms under exploration. For example, by impacting the levels of PYY, GLP-1 and proglucagon to overall inhibit appetite and optimize glucose homeostasis . AdditioThe intestinal microbiota is a diverse and dynamic ecosystem that affects the host's metabolism and shapes intestinal motility and permeability, producing effects beyond the gut. An association of microbiota with behavior and the central nervous system (CNS) may initially seem far-fetched. Clinicians, however, have long recognized the benefit of antibiotics in the treatment of hepatic encephalopathy. Behavioral problems such as anxiety and depression are common comorbidities in patients with gut disorders. For example, 54%–94% of patients with irritable bowel syndrome (IBS) meet the criteria for at least one primary psychiatric disorder . SimilarHelicobacter pylori leads to abnormal feeding behavior and upregulation of central pro-inflammatory cytokines, which persist even after successful bacterial eradication  agent etanercept or specific probiotic bacteria In relation to glycemic response (GI and GL), the following points were suggested , 52, 54:The presentations and discussions of the ‘Carbohydrates, Microbiome and Health’ event brought to the participants’ attention aspects of carbohydrates that are still rarely discussed in Brazil and also confirmed a few recommendations that were described above for dietary fiber and glycemic response.Multiple activities were developed in 2011 by the Functional Foods Task Force of ILSI Brazil, in collaboration with scientists, health professionals, government, and industry, as well as nutrition students. These activities, which were based on a review of evidence, allowed for a scientific debate on implementation of the current Codex dietary fiber definition and on the feasibility of using the GI, and also demonstrated a need to discuss carbohydrates under a wider spectrum. The main recommendations of these activities are as follows:It is clear that while there has been significant movement within Codex, efforts towards global harmonization of a science-based fiber definition are needed. This definition should account for the wide variety of physiological effects thus far demonstrated.While varying by geographical region, demographics and forms of fiber consumed, fiber intake is generally quite low and added fibers may be useful in moving populations towards recommended intake levels.Low GI foods can be used to modulate the postprandial glycemic response and may affect health outcomes. However, a number of variables can affect GI and there remains need for a good consumer use/communication tool.Carbohydrate type may influence satiety and satiation. There is a need for additional work on measuring satiety, increasing consumer understanding of the concept, and assessing the impact of whole foods compared to ingredients.Glycemic load and glycemic index, which can be influenced by the fiber content of a food, show links to memory, mood, and concentration in certain study populations although additional work is needed to show long-term effects.The prebiotic effect of carbohydrates has long been known, but new research is clarifying the mechanisms underlying potential benefits. Key to demonstrating these benefits is the identification of validated biomarkers.Beyond benefits of carbohydrates, sugars, particularly fructose, have drawn some negative attention. In this workshop, it was made clear that when human data are systematically compiled and reviewed, the effects observed in animal studies are not evident.New research indicates that diet strongly influences the microbiome, and this may have implications for both disease and optimized health.There is mounting evidence that the intestinal microbiota has the ability to impact the gut–brain axis. Understanding these relationships holds potential for managing both GI and psychiatric disorders.Overall, there is much promise for development of functional foods that impact the microbiome and other factors relevant to health including glycemic response (glycemic index/glycemic load), satiety, mood, cognition, and weight management.As one of three macronutrients, carbohydrates constitute a notable portion of energy intake; therefore, their impact on health is significant. This is made more complex by the variety of dietary carbohydrates available. In this workshop, the latest findings on various aspects of carbohydrates and health were reviewed. Key points are as follows:


A significant number of medical doctors in the Philippines shifted careers in order to seek work as nurses overseas. The obvious implications of such a trend require inquiry as to the reasons for it; hence, this cross-sectional study. The data in the study compared factors such as personal circumstances, job satisfaction/dissatisfaction, perceived benefits versus costs of the alternative job, and the role of social networks/linkages among doctors classified as career shifters and non-shifters. Cross-tabulation was carried out to highlight the differences between the two groups. Finally, the Wilcoxon-Mann-Whitney test was utilized to assess if these differences were significant.A combined qualitative and quantitative method was utilized in the study. Data gathered came from sixty medical doctors practicing in three major hospitals in Tacloban City, Philippines, and from a special nursing school also located in the same city. Respondents were chosen through a non-probability sampling, specifically through a chain referral sampling owing to the controversial nature of the research. A set of pre-set criteria was used to qualify doctors as Among the different factors investigated, results of the study indicated that the level of job satisfaction or dissatisfaction and certain socio-demographic factors such as age, length of medical practice, and having children to support, were significantly different among shifters and non-shifters at p ≤ 0.05. This suggested that such factors had a bearing on the intention to shift to a nursing career among physicians.Taken in the context of the medical profession, it was the level of job satisfaction/dissatisfaction that was the immediate antecedent in the intention to shift careers among medical doctors. Personal factors, specifically age, support of children, and the length of medical practice gained explanatory power when they were linked to job satisfaction or dissatisfaction. On the other hand, factors such as perceived benefits and costs of the alternative job and the impact of social networks did not differ between shifters and non-shifters. It would then indicate that efforts to address the issue of physician retention need to go beyond economic incentives and deal with other sources of satisfaction or dissatisfaction among practicing physicians. Since this was an exploratory study in a particular locale in central Philippines, similar studies in other parts of the country need to be done to gain better understanding of this phenomenon at a national level. The United Nations Millennium Declaration in 2000, articulated in terms of eight (8) development goals, sought to achieve a more equitable world order by 2015. However, many of its indicators, especially the attainment of health equity, are in danger of missing their target. For instance, in the Philippines, many health authorities have conceded that the goal of achieving improved maternal health through reduction in the maternal mortality ratio of 52 deaths per hundred thousand live births, is unattainable. The lack of access to health services and competent health workers largely contributes to the problem. This is further compounded by the continued emigration of medical personnel, thus, complicating efforts to achieve health equity in developing countries.Migration of Philippine health workers is not a new phenomenon. It began in 1950s and was initially considered a stopgap measure to diffuse tight local employment markets. But as the overseas demand for health workers increased markedly, it became institutionalized, in order to gain hard currency for the government through the inflow of remittances. The present policy is based on the premise that migration eases domestic unemployment, brings in substantial dollar remittances, and increases productivity by enabling skill transfer .The contribution of overseas workers in shoring up the Philippine economy is generally lauded to the point of considering them as modern-day heroes. In the past few years, however, public outcry and worries about the state of the Philippine health care system has been triggered by the phenomenon of doctors retraining to become nurses in the hope of securing employment overseas . At the The objective of this study was to explore the factors affecting the exit of physicians to seek work abroad as nurses. Specifically, doctors who were planning to work abroad as nurses were compared with doctors who planned to practice within the country, using the following criteria:1) socio-demographic and career profiles;2) level of job satisfaction;3) sources of job satisfaction and job dissatisfaction;4) perceived benefits and costs of alternative job; and5) social network/linkagesthis paper looks beyond the allure of financial reward and security and explores other factors at play when highly skilled doctors shift careers to become nurses abroad. Bringing these to light should help in some measure, in (1) understanding this career shift phenomenon; and (2) finding a durable solution to the problem of physician attrition in the country. Hopefully, then, it may lead to better retention strategies for our physician workforce and, perhaps, contribute to the attainment of the Millennium Declaration development goals.Central to this issue, then, is to understand what has pushed medical doctors to consider leaving their practice in lieu of other work opportunities. A review of the literature on job changing posits economic needs as the primary determinant of this move -9. HowevThis cross-sectional study used semi-structured questionnaires to gather information during the second quarter of 2007. Tacloban City was chosen as study site since there were undocumented reports that as many as half of all doctors practicing in the city and nearby localities were training as nurses with plans of going overseas. Tacloban City is the capital of Eastern Visayas, a region with one of the highest maternal mortality ratios in the Philippines.shifters, the researcher started with a doctor in one of the hospitals in Tacloban City, who was known to have finished a nursing degree after medical school and was willing to be part of the study. This respondent, in turn, gave names of other doctors she personally knew who had enrolled in nursing programs in order to work overseas. This led to the identification of respondents for inclusion in the research which, then, included consultants and resident physicians in three major hospitals in Tacloban City and doctors from various health facilities in nearby localities of Leyte enrolled in a special nursing program designed for physicians. As for the non-shifters, the researcher asked for doctors in the three major hospitals in Tacloban City and nearby health facilities who were also willing to be part of the study. Descriptive statistics were generated. Cross-tabulation was done to highlight the differences between shifters and non-shifters. The Wilcoxon-Mann-Whitney test was utilized to assess if these differences were significant.Due to the controversial nature of the research, respondents were chosen through non-probability sampling, specifically through chain referral sampling. A set of inclusion criteria was then used to identify thirty (30) respondents as "shifters" and another thirty (30) as "non-shifters". For the mean age and having or not having children to support. Shifters were relatively older (mean age of 42) compared to the non-shifters (mean age of 33). While both shifters and non-shifters had an average of two (2) children, the majority of shifters had children (70%) compared to non-shifters (40%). The rest of the demographic variables were not significantly different. Table In terms of demographic parameters, a significant difference (at p ≤ 0.05) was noted between shifters and non-shifters only with regards to the number of years of medical practice and years since graduating from medical school were found to be significantly different. Generally, career shifters had graduated from medical school earlier than non-shifters. Thus the length of medical practice for shifters was more than twice (14 years on the average) than that of non-shifters (6 years on the average).Comparing shifters and non-shifters in terms of career profile, only In the majority of both shifters (57%) and non-shifters (67%), the preparatory course for Medicine (M.D.) was Bachelor of Science in Biology. The primary work setting for 77% of non-shifters and 50% of the shifters was in a private hospital. In both groups, 20% worked in a government hospital. Of the shifters, 13% came from Rural Health Units (RHUs) while only 3% of non-shifters worked in the RHUs.shifters in the study were either pursuing a Nursing degree or had already obtained it. From the data gathered, 47% of the shifters already had a Nursing degree while the rest expected to obtain it between the years 2007 to 2010. It can be noted, too, that almost all of the shifters (97%) already had an intention to leave the medical profession soon. In fact, 33% of the shifters intended to leave within the year of study, another 33% in the following 3 to 5 years, and 30% within 1 to 2 years, while only 3% of shifters had no specific timetable. Their target country of work was usually the United States of America (USA) (90%), while the rest identified the United Kingdom (7%) and Australia (3%). Some shifters had already sat for the licensure examinations for a foreign country. Specifically, 37% had undertaken the Commission on Graduates of Foreign Nursing Schools (CGFNS) examinations and 33% the National Council Licensure Examination (NCLEX) examination. In addition, 37% of the shifters had already applied for nursing employment abroad, either directly or through an agency.All motivation factors as sources of satisfaction and several extrinsic components that comprise the hygiene factors as sources of dissatisfaction [Literature on the subject has identified various intrinsic aspects of the medical profession that contribute to sfaction . These sRespondents also identified aspects of the medical profession that they perceived to be favorable. These are shown in Table non-shifters also perceived a sense of fulfillment/personal satisfaction in helping others and treating the sick as the most favorable aspect of their profession. Other favorable aspects for non-shifters included the social value and prestige of the medical profession, social recognition, as well as wider social contacts and interaction. Finally, the practice of specific knowledge/skills of the medical profession was also a source of satisfaction.Like the shifters, a majority of the The respondents also identified some aspects of their profession that they perceived to be unfavorable. A majority of the shifters perceived low salary/less work benefits as the most unfavorable aspect of their profession. Other unfavorable aspects included long working hours/excessive time commitment and a heavy/tiring work load. For many doctors medical practice was seen as a highly demanding profession that sometimes pushes one to neglect one's family. Moreover, the heavy burden of committing fatal mistakes also weighed heavily on the minds of many of the respondent physicians.On the other hand, for the majority of non-shifters, it was also the long working hours and the excessive time commitment that was perceived to be the most unfavorable aspect of their profession. Other unfavorable aspects ranked low salary/less work benefits, heavy/tiring workload, and stress/demands of the profession, among others  and hygiene factors at p = .05  between shifters and non-shifters.Statistical analysis was done using the Wilcoxon-Mann-Whitney test in order to test if the differences between the mean scores of the two groups, in terms sources of satisfaction and dissatisfaction were significant . A higher score in motivation factors signified greater satisfaction, while a higher score in hygiene factors signified less dissatisfaction. The results revealed that there were significant differences in the mean scores for motivation factors at motivation factors, shifters scored lower (mean score of 23.83) when compared to non-shifters (mean score of 26.77). Moreover, in terms of hygiene factors, shifters were more dissatisfied (means score of 22.20) than non-shifters (mean score of 24.53). When motivation and hygiene factors were combined, it also showed that a significant difference existed at p = .05 . This meant that when motivation and hygiene scores were taken together, non-shifters were generally more satisfied with their jobs than shifters as shown in Table In terms of satisfaction as measured by p = 0.05). Shifters were less satisfied than non-shifters with the following sources: opportunities to develop new skills, opportunities for advancement, growth of medical practice, and opportunities to acquire advance training.The statistical test results for each specific aspect of the medical profession revealed that a significant difference existed in terms of some enumerated motivation factors (p = 0.05). Shifters were more dissatisfied with these specific hygiene factors compared to non-shifters.In terms of sources of dissatisfaction, the test statistics also showed a significant difference between shifters and non-shifters in terms of the following: health policies/laws, overall job security, and resources available to support work  of the non-shifters did not even think of shifting to a nursing career.Both shifters and non-shifters had a wide array of other social relationships, which included people whom they consulted for career shift intentions. In fact, all but one shifter consulted other people about their intention to shift to a nursing career. Results showed that for shifters, the three (3) most influential people they consulted for the nursing career shift were their spouses (mean rank of 5.6), followed by their colleagues (5.0), and parents (4.7). Non-shifters on the other hand, identified their parents as having the most influence on their career decisions (mean rank of 8.9), followed by siblings, and colleagues. It can also be noted that the social networks of a majority of the shifters approved of their intention to shift careers and assisted the shifters in various ways. Specifically, these social networks offered words of support and encouragement, some provided helpful information about employment opportunities abroad, while others provided referrals to job placement agencies.Among the different factors investigated, the study indicates that age, having children to support, and length of medical practice were significantly different among the shifters and non-shifters. These variables played an important role in the physician's intention to shift to a nursing career. A study has shown that relationships are fundamental components of "physician job satisfaction" and that different aspects of the satisfaction have differing relevance to specific physician subgroups . In the et al. proposed that the level of satisfaction generally increased with the length of time spent in a job [It should be noted that this finding of shifters as being relatively older differs from previous studies -- that of an inverse relationship between age and job mobility ,14. Alsoin a job . Given tfirst, vocational ; and second, the maintenance of the personal-professional boundaries . The factors contributing to dissatisfaction was distaste for management and concern about professional isolation [Taking these results in the context of the medical profession, we see that these factors are interrelated. A British study made among young doctors to determine what was attractive in their careers found two aspects: solation . The facet al. proposed that the level of satisfaction generally increases with the length of time spent in a job [Also Stamps in a job . Given tSo how does shifting to a nursing career overseas then address issues on career advancement and growth among doctors, when the shift is actually a downward movement career-wise? Alderfer's Existence-Relatedness-Growth (ERG) theory, a modification of Maslow's hierarchy of needs provides a clue to understanding this paradox . The ERGexistential needs among medical doctors to career shift intentions? How did this regression to lower level needs lead to career shift intentions? Herzberg's Two-Factor theory allows us to look separately at factors that cause satisfaction as distinct from factors that cause dissatisfaction [intrinsic to the job while sources of dissatisfaction are drawn from factors extrinsic to the job. Factors that contribute to satisfaction are different from factors that cause dissatisfaction. It follows then that those who are both less satisfied and more dissatisfied with their jobs are more vulnerable to shift careers. Looking at the specific factors which contributed to the level of satisfaction and dissatisfaction, across the board in this study, shifters tended to be less satisfied in terms of motivation factors and more dissatisfied in terms of hygiene factors as compared to non-shifters.Can we relate this greater focus on sfaction ,17. HerzDoctors who were less satisfied with their jobs identified what is described by the ERG theory as "growth needs" as sources for lack of satisfaction. Specifically, the respondents pointed to unmet needs for career advancement, career growth, advance training, development of new skills, and personal accomplishment. With these unmet needs, the assertion of the ERG theory -- that unmet higher-level needs drive one to focus more on lower-level needs -- would explain why shifters prioritized needs such as higher compensation/income, availability of medical resources, better health policies/laws, and overall job security.This was in contrast to non-shifters who were more satisfied in terms of motivation factors and less dissatisfied in terms of hygiene factors as compared to shifters. Having practiced medicine for a shorter period than shifters, the non-shifters had not reached the point yet where they felt that their gratification of higher level needs (i.e. career growth and advancement) was stifled; regression to satisfy a lower level need was not that urgent or strong for them so as to shift careers. The findings that non-shifters tended to be younger and a greater number having no children, indicates that these factors had a bearing on the choice not to shift to another career offering greater returns in terms of material compensation and benefits.A closer look at the data suggests that taken in the context of the medical profession, it is the level of job satisfaction or dissatisfaction that is the immediate antecedent in the intention to shift careers among medical doctors. Additionally, socio-demographic factors, specifically age, having children to support, and length of medical practice gain explanatory power when they are linked to job satisfaction and dissatisfaction.The findings in the study suggest no difference in the perceived benefits and cost of shifting to a nursing career among both shifters and non-shifters. This suggests a lack of direct influence on career shift intentions. So the question as to why many doctors decide to shift careers at this point in time, suggests that there is more to the career shift phenomenon than just one's perceptions about the alternative job.Social networks and linkages do not appear to be different among career shifters and non-shifters. Both shifters and non-shifters alike were noted to have linkages with other doctors who shifted to a nursing career abroad. In the study, both groups were noted to have a network of people who played a major role in this important career decision. The central role of the family as an institution was evident in the data. A majority of the shifters indicated that their nuclear and extended families exerted a heavy influence on their intention to shift to a nursing career. Although collegial networks came in a close second in the degree of influence, the preponderance of their social linkages pointed to familial relationships and friendship ties. Although literature is abundant on the role of informal networks of colleagues facilitating and opening doors for career advancement, the ultimate arbiter of career shift decisions lies in the hands of the immediate family ,19. It iLooking at the specific phenomenon in the Philippines, the major destination country for the majority of our shifters is the United States which notably offers immigration opportunity for the whole family. It specifically targets health workers with strong family ties removing a potential hindrance for immigration. This condition, in fact, facilitates the decision to shift careers by including the family as a unit for recruitment.i.e. younger medical practitioners. What was surprising was that a greater proportion of non-shifters perceived their social network as supportive in the eventuality that they decided to change jobs. Although a majority of them would not consider shifting to a career in nursing in the near future, those who indicated that they might consider such a career move included economic and familial considerations as possible reasons.As with shifters, the non-shifters in this study, perceived their social networks not as a hindrance to career shift intentions but as supportive. Familial ties also played a major role in the career decisions. Parental influence was heavy among non-shifters reflective of the social status of many of the non-shifters, What then are we to make of this career shift phenomenon among medical doctors in Tacloban City? Data from the study indicates that medical doctors who have opted to shift careers to work overseas as nurses are not driven simply by economic motivations. Although financial consideration, admittedly, has played an important part in the career shift process it has not been the only influencing factor. Various other factors have influenced the decision to abandon their practice as medicine doctors -- albeit temporarily for some. Migration opportunities, career frustrations, poor working and socio-political environment are some of the other factors identified. On the other hand, those who have decided to remain in the medical profession have pointed to satisfaction with their present careers as their primary motivation. Other factors have included family unity and cost of retraining. It is apparent that for both shifters and non-shifters working as a nurse abroad is a tempting alternative to their present profession.What ties together the various factors that have made medical doctors shift careers? The desire to emigrate to the U.S.A. or other countries is not a new experience for Filipinos. Various political and economic studies have theorized about the role of our colonial history in the shaping of social consciousness and the perception of emigration as a symbol of success or its equivalent. Thus opportunities to migrate, especially to the United States are welcomed with open arms. In the past decades, the increased demand for health workers -- particularly nurses -- in the international labor market opened doors for medical professionals to enter the United States with immigrant visas. What has resonated in the study is the sense of frustration with their careers along with the failing healthcare system of the country. The interplay of these factors has pushed medical doctors out of their professions and pulled them into careers as nurses working abroad.What, then, differentiates shifters from non-shifters?The data analysis above has shown several important points.First, a career shift intention is influenced by one's satisfaction or dissatisfaction with the profession in that the less satisfied a person is with intrinsic aspects of the job and the more dissatisfied a person is with the extrinsic aspects of the job, the higher the tendency to shift to another career. In the context of the medical doctors, personal factors such as age, length of practice, and children to support, influence the level of job satisfaction or dissatisfaction in that the older one gets and the longer one stays in a job, the higher the level of dissatisfaction and lesser is the degree of satisfaction.Second, applying Alderfer's ERG theory and Herzberg's Two-Factor theory can provide a useful theoretical basis for understanding the career shift phenomenon among medical doctors. The ERG theory through its frustration-regression component explains why existence needs such as salary/compensation has become more important than higher level needs such as career growth and advancement, for the job shifters. The practical implications of Herzberg's theory provide a useful framework for analysis of the levels of job satisfaction and dissatisfaction.Third, data from the study also suggests that the perception about opportunity costs of shifting to an alternative career, was not a differential factor in career shift intentions among the doctors in the study. Though many doctors become nurses to enjoy the benefits of working abroad, the shift actually provides an avenue for getting out of a career that has become less satisfying over years of medical practice. It does not directly influence career shift intentions independently.Fourth, the role of social networks -- found to be present among both shifters and non-shifters -- did not prove to be a hindrance to career shift intentions. For both groups in the study, almost all their important relationships in terms of career decisions were supportive of intention to change jobs.Finally, two major issues were identified among medical doctors with intentions to shift careers -- the lack of opportunity for professional growth and the lack of adequate compensation and benefits for their work at home.The study suggests that for a local community like Tacloban City to retain medical doctors, it is not prudent to focus mainly on monetary compensation. As important is the need to address non-monetary factors that determine the physician's level of job satisfaction or dissatisfaction. These include, but are not limited to, creating more opportunities for professional growth, appropriate recognition for work, avenues to acquire advance training, increase the value of work done by physicians, improve health policies and laws, overall job security and increase resources available to support work. Since this is an exploratory study limited to a particular locale in the central region of the country, it is further recommended that similar studies be done in other parts of the Philippines to better understand this phenomenon at a national level.CGFNS: Commission on Graduates of Foreign Nursing Schools; NCLEX: National Council Licensure Examination; RHUs: Rural Health Units; USA/United States: United States of America; WHO: World Health Organization.The author declares that they have no competing interests.MPL started work on this research for her graduate degree program thesis and subsequently edited it for publication.Meredith del Pilar-Labarda is currently the Chair of the Medical Department, School of Health Sciences, University of the Philippines Manila, Palo, Leyte campus