The Danish OPUS I trial randomized 547 patients with first-episode psychosis to a two-year early-specialised assertive treatment programme (OPUS) versus standard treatment. The two years OPUS treatment had significant positive effects on psychotic and negative symptoms, secondary substance abuse, treatment adherence, lower dosage of antipsychotic medication, and a higher treatment satisfaction. However, three years after end of the OPUS treatment, the positive clinical effects were not sustained, except that OPUS-treated patients were significantly less likely to be institutionalised compared with standard-treated patients. The major objective of the OPUS II trial is to evaluate the effects of five years of OPUS treatment versus two years of OPUS treatment.The OPUS II trial is designed as a randomized, open label, parallel group trial with blinded outcome assessment. Based on our sample size estimation, 400 patients treated in OPUS for two years will be randomized to further three years of OPUS treatment versus standard treatment. The specialized assertive OPUS treatment consists of three core elements: assertive community treatment, psycho-educational family treatment, and social skills training.It has been hypothesized that there is a critical period from onset up to five years, which represents a window of opportunity where a long-term course can be influenced. Extending the specialized assertive OPUS treatment up to five years may allow the beneficial effects to continue beyond the high-risk period, through consolidation of improved social and functional outcome.NCT00914238Clinical Trial.gov  The yearly incidence of patients aged 18 to 35 years with schizophrenia in Denmark in 2008 was approximately 800. The yearly incidence for patients of the same age with other disorders in the schizophrenia spectrum  consisting of a multimodal phase-specific treatment of first episode psychosis versus standard treatment. The resIt has been hypothesised that there is a critical period up to five years after onset of psychotic illness, which represents a window of opportunity where the long-term course can be influenced. The objThe study is designed as a randomized, open label, parallel-group trial with blinded outcome assessment Figure . Given tAll patients treated within the Danish mental health services for at least 11/2 year by the six OPUS teams will be approached for eligibility. Patients must fulfil the ICD 10 diagnostic criteria for schizophrenia or schizophrenia-like psychosis (F2)[patients aged 18-37 years with first episode psychosis in schizophrenia spectrum, who in the inclusion period of the trials are treated for at least 11/2 year by one of the six OPUS teams will be asked to give signed informed consent to participate in the trial.patients whose diagnosis was evaluated retrospectively and found not to fulfil the criteria for first-episode psychosis in the F2-spectrum (ICD 10) at any time during the first 11/2 year of OPUS treatment, and patients who do not give signed informed consent to participate in the trial. Drug and alcohol misuse will not lead to exclusion. Patients who are mentally retarded in moderate to severe degree are not treated in OPUS teams and are therefore not a part of the inclusions and exclusions criteria.Randomization will take place approximately six months prior to the termination of the original two-year OPUS treatment. This will allow a gentle transfer to other treatment services for the control group, and allow proper time to plan the future course of treatment for the experimental group. Expected duration of participating in the trial is therefore 3 1/2 year from entry interview to follow-up interview.Randomisation will be centralised and computerised with concealed randomisation sequence carried out by the Copenhagen Trial Unit (CTU). Block size will be unknown to the investigators and clinicians. Randomisation will be stratified for treatment site (six sites) and severity of global score on the four of the five domains in SANS, anhedonia, avolition, alogia and affective blunting, with distinction between at least one of the global score measured less than 3 compared to 3 or more. Signed informed consent will be obtained prior to patients being randomized. The allocations concealment is ensured by the investigators call to the randomisation unit, CTU, after completing the collection of baseline data and data needed for the randomisation.The trial is pragmatic, comparing five years versus two years of specialised, assertive intervention programme (OPUS) defined by a set of protocols.The integrated OPUS-treatment consists of three core elements: assertive community treatment, psycho educational family treatment, and social skills training. In addition, the patients receive group intervention to facilitate recovery, cognitive behaviour therapy when indicated, and crisis intervention. All patients are designated a primary staff member, who are responsible for maintaining the contact and to coordinate the treatment within the team, but also coordinate across social services and other institutions involved in the treatment. The pharmacological treatments are guided by official Danish guidelines. The teaThe OPUS staff consists of a multidisciplinary team, including a psychiatrist, psychologists, nurses, social workers, physiotherapist, and vocational therapist. All team members, except the psychiatrist, function as primary team member for the patients. The patient to staff member ratio is 10:1. All members of the OPUS staff are well educated, and have obtained great experience in first episode psychosis, and are continually trained and supervised in the core elements of the OPUS treatment to provide the specialised assertive intervention.The aim is to continue the original patients - primary team member relation in the extension period, if possible. Patient to staff member ratio is 15:1. Patients will still be offered treatment tailored to meet their individual needs. As a minimum the patients will receive at least one face-to-face contact each month with their primary team member, and at least one other contact . Families can in the extension period still join the psycho-educational family treatment due to their needs, and will at minimum be invited to booster sessions of a survival skills workshop. Patients can participate in all group programmes available in OPUS. Within the resources of the team, there is no upper limit for the amount of treatment the individual patient may obtain.The intensity of intervention will be registered. Interventions intensity will be extracted from the Danish Psychiatric Case Register. In case of doubt, data will be cross-validated with data extracted from the patient's medical record. Cost of intervention will be assessed with help from the economists in regional health authorities.Patients, who after 11/2 years of OPUS treatment, are randomized to further half a year of the specialised assertive intervention, will be transferred to standard treatment after a total of two years OPUS treatment. Standard treatment can be either affiliation to a community mental health centre, assertive community treatment, or primary care, depending on the patient's needs. The most common will be referral to community mental health care centres, which usually offer the patient treatment in which home visits are possible but office visits are the general rule. The patient to staff member ratio varies between 20:1 and 30:1.The transition from the OPUS treatment to standard treatment will be carried out gradually and as gentle as possible.Monitoring the fidelity of the intervention to OPUS treatment will be carried out by an independent investigator interviewing the six OPUS team leaders, using the index of fidelity to Assertive Community Treatment (IFACT). AssertiThe primary outcome measure is: negative symptoms measured with schedule for assessment of negative symptoms in schizophrenia (SANS). InvestThe secondary outcome measures are: simultaneously remission of both negative and psychotic symptoms, measured with SANS and schedule for assessment of positive symptoms in schizophrenia (SAPS), psychoTo be able to evaluate the external validity of the trial, we will furthermore register sex, age, diagnosis, medical treatment, substance abuse, and treatment adherence for the patients who do not participate in the trial.vital status, cause of death , use of participants can withdraw his/hers informed consent from the trial at any time without any explanation. We have obtained permission from the Danish Data Protection Agency  for register-based information for all randomized patients, and in analyses of this information, we will include data from all patients.In the OPUS I trial we found that the patients treated in OPUS had a mean score of 1.42 in negative dimension and patients treated in standard treatment had a mean score of 1.84 in negative dimension with standard deviation of 1.2,12. In tThe primary outcome measure, negative symptoms, will, as other continuous outcome measures, be subjected to analysis using a mixed-model analysis with a repeated measurements model with unstructured variance matrix, using the mixed-model command in SPSS. This approach assumes that the distribution of missing data can be estimated from the information from previous interviews and from information about other patients in the database. The condition for using this method is the assumption that data are missing at random or missing completely at random when taking into consideration the information extracted from baseline interviews and information about the other patients in the database. In this model, baseline values of the scales are included. Variables included as covariates will be site (six different teams), sex, co-morbid substance abuse, baseline values of the remission variable, and the baseline values of variables that differ significantly in drop-out analyses. Besides the above-mentioned variables, compliance with medication, level of school education, and whether or not a family member is involved in treatment will be included in analyses of differences between patients that are lost to follow-up and those who remain in the trial. If significant, these variables will be included as covariates.For evaluation of the dichotomous secondary outcome measure (simultaneously remission of psychotic and negative symptoms or not), we will use multiple multivariate imputations, using all other covariates to impute a distribution of missing values. The dichotomous outcomes will be analysed with logistic regression analyses. Variables included as covariates will be the same as those included in analyses of continuous measures. Similar to the repeated measurement, the condition for using multiple imputations is that data are missing at random or missing completely at random, when taking into consideration the information extracted from baseline interviews and information about the other patients in the database.Analysis will be based on the intention-to-treat principle. Data from all patients will be included in the group to which random assignment is made, regardless of intervention received.We plan to recruit 400 patients for the trial from 2009 to 2011. This is realistic as each of the six OPUS teams discharges approximately 40 to 50 patients per year.The result of this trial can be of great importance for future health-care planning to benefit people with a first-episode psychosis. The extended treatment period will, as mentioned earlier, be tailored to meet the patient's individual needs, witch means monitoring the treatment intensity up and down to support the patient's empowerment and recovery process. The design of the trial does not put participants at any unacceptable level of risk and the trial design uses the best form of standard care as the control group intervention.http://www.cvk.sum.dkAll potential participants considered for this trial will be provided with written and oral information on this trial so that they can make an informed decision about their participation. The participants must sign this consent form before being randomized. This protocol was submitted the Regional Ethics Committees for The Capital Region for review . The Committee assessed the protocol to be exempt from formal approval with the reason that the trial is a non-biomedical trial. For further detail information please contact: The participants will be offered written information about the findings and the results after analysing the OPUS II trial. The information is offered in form of a standard letter and will be posted to those who sign up for this opportunity.The OPUS II trial has permission from the Danish Data Protecting Agency: J. no. 2009-41-3314 and is publicly registered .The strengths of the OPUS II trial is the high internal and external validity. The useThe publication of the current design article and registration of the trial at 'clinical.trials.gov' are intended to prevent selective outcome reporting. The risk of spurious findings, random error, is reduced, in case the pre-specified sample size is reached.The fact that we are not able to blind the participants and personnel in the extension period of OPUS treatment might increase the risk of performance bias. Due to the novelty and excitement of participating in a research project it could be argued, that both participants and staff conducting the experimental intervention would be more enthusiastic and keen to perform well and thereby offer a higher level of OPUS treatment than the actual intervention itself.All potential patients in the catchments area are approached and offered OPUS II treatment and together with few exclusion criteria it provides a high level of external validity. However, the educational requirements for OPUS staff are a potential limitation to less developed health-care services.Negative symptoms as measured with SANS are the primary outcome measure for this trial. Negative symptoms are associated to the patients experience of quality of life and the level of social functions,25, and A further strength of our trial is our aim to monitor program fidelity and to address the presence or absence of critical components in the OPUS treatment. Currently, no single accepted validated standard to measure the program fidelity of first episode psychosocial treatment exists, and we hope to be able to contribute to the establishment of such a standard.ACT: Assertive Community Treatment; CTU: Copenhagen Trial Unit; CSQ: Client Satisfaction Questionnaire; DUP: Duration of Untreated Psychosis; GAF: Global Assessment of Functioning; ICC: Interclass Correlation Coefficient; IFAC T: Index of Fidelity of Assertive Community Treatment; OPUS: is not an abbreviations, OPUS is a name borrowed from the world of music; PSP: Personal and Social Performance scale; QOL: Quality Of Life; SANS: Schedule for Assessment of Negative symptoms in Schizophrenia; SAPS: Schedule for Assessment of Positive symptoms in Schizophrenia; SCAN: Schedules for Clinical Assessment in Neuropsychiatry; UKU: Side effect rating scale; WAI: Working Alliance Inventory;The OPUS II research group has a close collaboration with Professor Ashok Malla, Douglas Hospital Research Centre (McGill University), Principal Investigator of the trial 'A randomized controlled evaluation of extended specialized early intervention service vs. regular care for management of early psychosis over five year critical period'. We will ensure that the OPUS II trial and the Canadian trial are comparable regarding intervention, assessments tools, and other methodological questions ensuring that the results can be meaningfully meta-analysed.The authors declare that they have no competing interests.M.Sc. Marianne Melau, Dr. Gertrud Krarup, and Prof. Merete Nordentoft are responsible for inclusion of patients and research interview. Dr. Anne Thorup, Dr. Lone Petersen, Dr Pia Jeppesen, Psychologist, Dr Mette Bertelsen, and Dr. Christian Gluud were involved in planning of the trial, critical comments to the manuscript, and approval of the final version of the manuscript.


This paper reviews the development of early Soviet drug treatment approaches by focusing on the struggle for disciplinary power between leading social and mental hygienists and clinical psychiatrists as a defining moment for Soviet drug treatment speciality that became known as "narcology." From this vantage point, I engage in the examination of the rise and fall of various treatment methods and conceptualizations of addiction in Russian metropolitan centres and look at how they were imported (or not) to other Soviet republics. As clinical psychiatrists appeared as undisputed victors from the battle with social and mental hygienists, the entire narcological arsenal was subdued in order to serve the needs of mainstream psychiatry. However, what that 'mainstream' would be, was not entirely clear. When, in 1934, Aleksandr Rapoport insisted on the need for re-working narcological knowledge in line with the Marxist approach, he could only raise questions and recognise that there were almost no "dialectically illuminated scientific data" to address these questions. The maintenance treatment of opiate users, which emerged as the most effective one based on the results of a six-year study published in 1936, was definitely not attuned to the political and ideological environment of the late 1930s. Maintenance was rather considered as a temporary solution, in the absence of radical therapeutic measures to free Soviet society from "narkomania." As the Great Terror swept across the Soviet Union, Stalin's regime achieved its objective of eliminating drug addiction from the surface of public life by driving opiate users deep underground and incarcerating many of them in prisons and the Gulag camps. In the final section, I briefly discuss the changing perceptions of drug use during the World War II and outline subsequent transformations in Soviet responses to the post-war opiate addiction [Additional file  When in 1922 a prominent Central Asian psychiatrist, Leonid Antsyferov, presented his paper on "hashishism in Turkestan" at the First Scientific Congress of Physicians of Turkestan, he called for the Soviet government to take a number of urgent measures aimed at rooting out this 'evil' or, if such an objective would prove unrealistic in a short term, then at least at reducing it to its smallest possible extent. He argued that repressive measures alone would be insufficient and that the struggle against drug addiction should be conducted by different means, namely enlightenment and treatment. In his view, physicians were to be placed at the head of this struggle because the task of making the masses healthier was particularly close to their mandate .  Medizin . Among tpsikhiatriia prizreniia") and supporting "active psychiatry" .narkodispanser that he advocated as the best tool for prevention and treatment of social diseases. An enlightenment project in its essence, narkodispanser would "enter the life of narkoman" as a "caring friend" and "authoritative counselor" and "illuminate, with such a bright light, both the entire everyday life [byt] of the patient and the source of his disease..." [[Sholomovich continued his crusade against traditional psychiatry in two other essays published on the pages of the same volume. In one of these papers he argued that "one could not eliminate the consequence [narkotism] without doing away with the causes," which were social and economic in their nature. It was not a psychiatric hospital but rather ase..." , massive everyday life narkotism," which included alcohol use and in his view affected as much as 70 to 80 percent of the adult male population. The psychiatrist, with his "therapeutic spoon" would never be able to deplete this ocean of "social pathology" and, therefore,He finished by openly declaring "the break-off with traditional psychiatry" and admitting that this had been the most difficult task facing the Moscow-based Narkosection - "the first and so far the only Soviet squad to fight narkotism." How did he explain this 'separation' of narcology from psychiatry? Narkomans with psychiatric co-morbidity , having grown up, detaches itself from the maternal soil and enters...a new, independent pathway...[[thway...[: p72].As Sholomovich believed, the above process of "natural evolution" was common in science.narkodispanser announcing the independence of 'daughter-narcology' from its 'mother-psychiatry' and the marriage between narcologists and social hygienists, it should not be surprising that narkodispanser came to be viewed by many as one of the strongholds of social hygiene.The timing of Sholomovich's attack on psychiatry could not be more fortunate for a cohort of leading Soviet social hygienists, who were also entering the battle with psychiatrists for the hegemony over habitual alcoholism research and treatment. On 11 September 1926, with reports of apparently rising alcoholism appearing in the press, the Council of People's Commissars (Sovnarkom) issued a decree on immediate measures in the field of the struggle against alcoholism and charged Narkomzdrav with "strengthening systematic research" on alcoholism and the prophylactic fight against it. In February 1927, Narkomzdrav, headed by Semashko, issued a circular passing the responsibility for the systematic study of alcoholism as a social disease to the State Institute for Social Hygiene ,22-24. Wnarkordispanser to narkotism? Firstly, the strong emphasis on causes rather than consequences clearly implied that prevention would be given higher priority over treatment. According to Sholomovich, once poverty, the absence of human rights and economic exploitation common to capitalism were addressed, people's reliance on 'narcosis' and consumption of all kinds of 'narcotic poisons' in order to achieve harmony was eventually to be replaced with "physiological cultural narcosis." Under the new rule of the Bolsheviks, Soviet citizens would be "inebriated by culture, science, the beauty and harmony of life and labour" . Hf advice . Leadingchopaths'. By 1928narkodispanser project, challenges related to the treatment of 'narkotists'  also need to be put in the context of social hygienists' research on alcoholism that appeared after 1926.However, in order to have a more complete account on the sustainability of the bytovoi) alcoholism and was widely replicated in different surveys on the local level, covering no less than 40,000 respondents . narkodispansers - were stripped of their independence status and had to 'rejoin' their 'mother-psychiatry'. In 1932, they were no longer called 'narkodispansers' and became part of neuro-psychiatric dispensaries ot every person becomes a morphinist," he emphasised, since in order for that to happen, an individual needs to have a certain predisposition, whereas if a "normal person" gets exposed to morphia for some medical reason, this only results in some unpleasant feelings such as nausea and drowsiness, but they "all go away" after some time and "[t]his is the end of the business" .appear"  complaints about non-acute headaches and not quite good sleep, nurses, without knowledge of physician, offer morphine to the patient, while other fellow patients advice that he accepts the offer and provide a syringe for this purpose. The same officer, who gave up morphinization after one year, is mobilised again [and] ends up in a regiment, [where] he meets an old fellow-morphinist, and once again fails to resist the temptation.Morphine is offered to the Party worker in a Soviet by his comrade, as a remedy for overcoming fatigue and for reducing a strain on the nerves, which had resulted from work[load] during Iudenich's advance on the city of Petrograd.In a ration detachment, heading down to Ural for provisions, nine [servicemen] turn out to be morphinists, who then seduce the tenth [into morphine use], and on their way back this tenth [person] is already willing to give away everything in order to obtain morphine.While working in the accident and emergency department...I had an opportunity to observe morphinism among prostitutes and other frequenters and visitors of various cafés and similar establishments. There, honestly speaking, morphine [use] was more often combined with other drugs [use], especially alcohol and cocaine [[cocaine [: p47].chekists (and people with apparent connection to the organs of power) relied on their 'authoritative profession' to support an already existing addiction and rarely, if ever, ended up as drug patients . Ykuknar as a 'traditional' native intoxicant, for example, has been widely reported by numerous commentators in pre-Soviet and Soviet Central Asia , would consent to [consume] kuknar" .ded too [: p1339]. shira" [: p4]. Surmically ,49. Althte users ,44,68.But, as far as the treatment of 'narkomania' was concerned, with the usual length of patient's stay in the drug treatment institutions in Russia and in other republics ranging between one to two months, and in some places like Ashkhabad narcological unit constituting on average 22 days, Soviet psychiatrists' appeals for the intensive use of labour therapy rarely materialized and often remained wishful thinking. Although in 1928 Gorovoi-Shaltan argued that the 'curing' of morphinism, rather than the withdrawal of morphine from the patient, represented the major challenge for the psychiatrist, the debates and discussions on the management and different methods of withdrawing opiates from patients in a clinical setting, in fact, became central to the development of narcology from the late 1920s and onwards . As descreduce the number of days both patients and staff had to suffer. In the Leningrad-based clinic where she worked, they initially withdrew opiates from their in-patients by gradually reducing the dose over the course of three to four weeks. While this was the case until 1925, the patient and his doctor were 'fighting' with each other every time the dose had to be reduced. Psychologically, this method appeared to be even more painful for the patient than an abrupt one, according to Golant, and it obviously caused serious inconvenience for the staff members who had to be able to obdurately refuse patients' pleas for the injection of an extra dose of morphine. The situation changed once the decision was made not to provide any opiates to the patients after they were admitted to the clinic. Although the patient's reaction to the abrupt withdrawal was quite 'stormy' ("burnaia"), Golant suggested that it normally lasted only for a very short period of three to six days and was followed by tangible improvements .pritony) and their 'vicious inhabitants', the prevalence of drug use has decreased, according to one source, "only from the mid-1930s", down from 90 cases per 10 000 people in 1932 to 9 cases per 10 000 people in 1940 [While unwilling to look back at their own professional past some post-Soviet psychiatrists and narcologists are still searching for the magic bullet against narkomania (and remain content with the Russian government's oppressive prohibition of opioid substitution therapy), Stalin's regime had found it already in 1937. In Moscow, where repressive measures were particularly focused on 'dens' , which supposedly had disappeared due to the Soviet rule's concern for the culture, education and medical care of the Soviet people . In factNarodnyi komissariat zdravookhraneniia, People's Commissariat of Public Health; NKVD-Narodnyi komissariat vnytrennikh del, People's Commissariat of Internal Affairs; Sovnarkom-Sovet narodnykh komissarov, the Council of People's Commissar.The following abbreviations are used within the manuscript text: Narkomzdrav-The author declares that they have no competing interests.a While many leading Russian psychiatrists were fluent in foreign languages, it seems that Erlenmeyer's (and Sollier's) work on the treatment of morphine addiction first became available in its Russian version only in 1899. Burkart's monograph on the chronic morphine poisoning (khronicheskoe otravlenie morphiem) was published in Russian in 1882 [ in 1882 ,46;b Many papers from the first volume of Voprosy Narkologii were initially presented and discussed at the First Scientific Conference on the Questions of Narkotizm that was organized in Moscow, in December 1923, following the All-Russian Conference on the Questions of Psychiatry and Neurology;c As presented by Sholomovich in different papers, these numbers of new patients contain discrepancies [epancies ,25;d It is worth mentioning here that in post-Soviet Russia there seems to be a continued interest in the use of oxygen for the treatment of drug and alcohol dependence [pendence ;e In 1931, for example, speaking primarily about neuro-psychiatric dispensaries, Prozorov wrote that the number of repeat visits was particularly low in those dispensaries, which did not have their own equipment for physiotherapy and could not refer their patients to such services  [rapies') ;f The paper was first presented in January 1924 at the Second All-Russian Congress on Psychoneurology in Leningrad;g For example, in the early 1930s, Kamaev was one of the authors who continued to stress the need for the organization of compulsory treatment of narkomans, placing this under the rubric of 'the struggle against narkomania on the administrative-legislative front' [e front' ;h There is a growing number of journal and newspaper articles being written on the history of gravidan therapy and its use in Soviet narcology [gravidan was first reported 1936 by B. Smirnov, who was writing from the narcological unit of a psychiatric hospital in Ashkhabad, Turkmenistan. According to Smirnov, the use of gravidan did not make much difference on the patients' reaction to withdrawal of opiates. The feedback from the patients was often negative as they complained that gravidan did not help to alleviate khumar , with injections causing only more pain [arcology -81, alonarcology ,42,49,69Abstract. The Soviet doctor and the treatment of drug addiction: "A difficult and most ungracious task". A Russian translation of an abstract of this article.Click here for fileN. V. Kantorovich. Dispensary observations over morphine users. An article on the results of opiate maintenance treatment study in Leningrad, USSR, 1930-1936.Click here for file


India is known to be endemic to numerous infectious diseases. The infectious disease profile of India is changing due to increased human environmental interactions, urbanisation and climate change. There are also predictions of explosive growth in infectious and zoonotic diseases. The Integrated Disease Surveillance Project (IDSP) was implemented in Gujarat in 2004.We analysed IDSP data on seven laboratory confirmed infectious diseases from 2005–2011 on temporal and spatial trends and compared this to the National Health Profile (NHP) data for the same period and with other literature. We chose laboratory cases data for Enteric fever, Cholera, Hepatitis, Dengue, Chikungunya, Measles and Diphtheria in the state since well designed vertical programs do not exist for these diseases. Statistical and GIS analysis was done using appropriate software.Our analysis shows that the existing surveillance system in the state is predominantly reporting urban cases. There are wide variations among reported cases within the state with reports of Enteric fever and Measles being less than half of the national average, while Cholera, Viral Hepatitis and Dengue being nearly double.We found some limitations in the IDSP system with regard to the number of reporting units and cases in the background of a mixed health system with multiplicity of treatment providers and payment mechanisms. Despite these limitations, IDSP can be strengthened into a comprehensive surveillance system capable of tackling the challenge of reversing the endemicity of these diseases and preventing the emergence of others. India is known to be endemic to a number of infectious diseases ranging from age-old scourges like cholera to relatively recent ones like dengue –3. In orAs per the 2011-census figures, the population of Gujarat is 60 million. It has increased by 9.7 million  over the last census figure. Interestingly this growth is not uniform; the urban growth rate at 35.8% is higher than its rural counterpart at 9.2%. The urban expansion is taking place in the form of unplanned and haphazard growth in the outskirts of existing towns and cities with the appearance of new urban clusters , acute respiratory infection (ARI)/influenza like illness (ILI), pneumonia, leptospirosis, acute flaccid paralysis, dog bite and snake bite since 2005. These diseases are reported to the IDSP through three mechanisms, namely syndromic, presumptive and laboratory confirmed, using S, P and L forms, respectively , 12. Of The National Health Profile (NHP) is an annual publication of the Central Bureau of Health Intelligence (CBHI), a national nodal institution for health intelligence in India . One segWe decided to analyse data on seven laboratory confirmed infectious diseases, namely enteric fever, cholera, hepatitis, dengue, chikungunya, measles and diphtheria collected and reported by Gujarat IDSP since 2005 and compare these rates to that in the literature from other parts of India. The rationale for this choice was that well-designed vertical programmes and infrastructure (including dedicated laboratories) already exist for diseases such as HIV , TB 15)15), poliWe collated district-wise and disease-wise disaggregated data from Gujarat IDSP's Annual Reports  from 200We validated these data through interviews of IDSP staff at the state level. We visited the IDSP reporting units at the district level to observe the disease reporting process. We met with Rapid Response Unit members who responded to these outbreaks. We also had discussions with the entomologist and the epidemiologists working for IDSP.We conducted an extensive literature search in Medline and Google Scholar databases for scientific papers and reports for prevalence and incidence studies on our selected diseases. The search queries used both free text and medical subject heading terms for names of our selected disease and epidemiological terms . The limits applied were that the work should have been in India and in the past decade. We excluded animal studies and case reports. We performed citation tracking of important papers to ensure that relevant (unindexed) papers were not missed in electronic searches. The case rates for the diseases in the literature were calculated from the cases reported in them in the same way as for IDSP and NHP data.To ensure that data entry and analysis were free from bias, an expert who was unaware of the disease profile in the state performed data entry. This analysis was scrutinised for errors by duplication and again peer reviewed by other experts who were not part of this study. Ethical clearance for this project was obtained through the Institutional Review Board of Public Health Foundation of India, New Delhi, by blinded external reviewers.A secondary analysis of the seven diseases, namely enteric fever, cholera, hepatitis (water-borne), dengue, chikungunya (vector-borne), measles and diphtheria (vaccine-preventable) reported by the state IDSP from 2005 to 2011 is depicted in During this 7-year period, for every 100,000 people in the state, approximately 186 have reportedly suffered from enteric fever, 173 from viral hepatitis, 17 from dengue, 11 from measles and 2 from diphtheria. The yearly average number of cases per 100,000 population is similar for enteric fever and hepatitis, 27 and 25, respectively.Interestingly, more than 70% of the cases of chikungunya, dengue, cholera and diphtheria were reported by urban reporting units, that is, by the office of the Medical Officer for Health in seven municipal corporations in the state. The same for enteric fever and measles was only around 35%. Also, the two diseases, cholera and dengue showed an unusually sharp decline in the number of cases during 2011, although the reported cases of both these diseases seem to have doubled between 2005 and 2009. Only diphtheria showed a steady decline in reported cases from 2005 to 2011, reducing to half in 2011. Although data for chikungunya is available only for 2010 and 2011, it also shows an increase in the number of cases in 2011.The spatial distribution of diseases in The annual reported cases in NHP of CBHI for Gujarat (Column 3, Comparative trend lines between all three sets of data show a good correlation only for dengue. For all other diseases, the national and state trends have been quite different from each other.Compared to average annual cases reported by IDSP Gujarat, the NHP for Gujarat reported half to one-third of this average for all the selected diseases .IDSP Gujarat, since it began in 2004, has been reporting an increasing trend of six of our seven selected diseases, excluding diphtheria. Thus, it appears that a state level monitoring system such as the IDSP holds more promise as a surveillance tool since it has shown a steady rise in reporting of cases. However, the NHP Gujarat has reported less than half the cases reported by the IDSP Gujarat. In an ideal data transmitting system, the two data sets would have shown similar case rates. Our comparative exercise has also revealed that two of the water-borne diseases, enteric fever and viral hepatitis cause the highest burden in Gujarat, while the vector-borne and vaccine-preventable groups exhibit much smaller numbers.Water-borne infections: Enteric fever, viral hepatitis and cholera show variable reporting characteristics. Enteric fever, as per Gujarat IDSP, is being detected in rural areas and causes the highest burden of cases compared to the other selected diseases. However, this rate is actually one-third the national average reported by the NHP, indicating that Gujarat is actually reporting much less number of cases of enteric fever than the rest of the country. In contrast, viral hepatitis rates indicate that the state is reporting double the national average. Cholera cases, though reported in very small numbers by Gujarat, are double the national average and also exhibit the highest urban proportion of all the diseases.This diversity of the case rates of these three water-borne diseases from the national average and their variable rural–urban characteristics is difficult to explain. The inconsistent data collecting and reporting efficiencies, private sector proportions, types and quality of water supply systems across the state and the country could be responsible for an immense range of contributory factors. That the IDSP is reporting increasing numbers of all these cases may be seen as a reassuring sign of improving surveillance for these diseases in the state.Comparison of national rates with academic literature for these three water-borne infections also reveals similar wide differences. Surveillance studies undertaken during 2003–2010 for the estimation of enteric fever and cholera have reported 6 and 10 times more lab-confirmed cases, respectively, than the national average reported by NHP between 2005 and 2011. According to IDSP Gujarat, the case rate for enteric fever in the state is only one-third of the national enteric fever rates, closer to the lower, more heartening rates in Chinese and Vietnamese endemic sites . NationaVector-borne infections: Dengue and chikungunya reporting also display diametric characteristics. While IDSP Gujarat reported double of the NHP national average for cases of dengue, it reported only one-tenth of the national average for cases of Chikungunya. The good correlation of the three data sets for dengue indicates that the reporting by NVBDCP Gujarat to the NHP agrees closely with that of IDSP Gujarat. Reporting for chikungunya exhibits an interesting feature—while IDSP Gujarat has reported extremely few cases in 2010–2011, the NVBDCP has been reporting cases to the NHP since 2005. Reporting by IDSP Gujarat seems to have begun after a seminal paper, which proposed that the chikungunya epidemic of August–September 2006 in Ahmedabad, the capital of Gujarat, was responsible for excess deaths in the city, was published . EstimatVaccine-preventable infections: Measles and diphtheria rates reported by IDSP Gujarat are higher than those reported by NHP Gujarat indicating a better capturing of these two diseases. The rates reported by NHP for India were slightly different than that reported by the WHO Observatory for the same time span. But since the reported cases of these diseases are very small, this difference is probably not noteworthy. India contributed 8.5% of the global number of measles cases and 71.3% of the global number of diphtheria cases in 2011, topping the list of contributing countries for diphtheria .The limitations of this study are first, IDSP estimates are conservative. The analysis presented above is based on data reported by the nascent IDSP system. Although the majority of providers currently do not report to it, more reporting units are being enrolled every year. Variations in laboratory-confirmed disease cases due to outbreaks have not been accounted for in our calculations. We also assumed a constant population over the study period for estimating the case rates. Second, in practice, larger hospitals and medical colleges generally undertake laboratory investigations of suspected cases of these diseases. Clinical diagnosis unsupported by laboratory investigations is routine in smaller and single healthcare provider practices and therefore information slips through the surveillance network. Private practitioners have significantly worse knowledge of correct diagnosis and treatment . Third, Despite these limitations, this work, to our knowledge, is the first to document case rates at a state-level in India and recognise the contribution of the IDSP system for epidemiological considerations. Our analysis shows that the existing surveillance system in the state is predominantly reporting urban cases. Reports of enteric fever and measles are less than half of the national average, while cholera, viral hepatitis and dengue are nearly double.The surveillance studies are focussed and conducted in endemic locations and therefore show high incidences of these diseases. Therefore, it is expected that their rates will be higher in the literature than the national average reported by the NHP of CBHI. However, for a large country such as India, such few and far between studies are not adequate in understanding the burden of these infectious diseases across the country.Although infectious diseases such as TB and HIV have higher burdens than enteric fever and hepatitis, there is a need to also begin addressing these latter diseases with a systems approach. Generating reliable data on these diseases is the obvious first step. The IDSP is ideally placed to take on this role. This could be vastly advanced by a more robust data access policy of IDSP data such as creating a central IDSP data repository for all the nine IDSP states across the country along the lines of the WHO Global Laboratory Directory for Cholera and Global Health Observatory for vaccine-preventable diseases. An open access policy to IDSP data would encourage involvement from interested stakeholders, especially private practitioners and researchers. This would contribute to a robust data collection and collation system. The IDSP can potentially be strengthened into a sound surveillance and response mechanism capable of taking on the challenge of reversing the endemicity of these diseases.


For many years, cardiovascular disease (CVD) was regarded as a lifestyle disease primarily affecting ageing, affluent populations. This is reflected in the virtual absence of global policies concerned with CVD control in poor and rich countries alike. However, CVD and other non-communicable diseases (NCDs), including cancer, chronic respiratory disease and diabetes, account for nearly two-thirds (63%) of global deaths, with the majority of deaths from NCDs (80%) occurring in low- and middle-income countries (LMICs).1This represents a public health emergency requiring an urgent worldwide response. Now with the World Health Organisation’s (WHO) adoption of a global target to prevent premature NCD mortality, the time has finally arrived for the global CVD community to join forces in reducing CVD suffering and death in all countries and among all populations.The World Heart Federation and its members and colleagues in the CVD community have been fighting the burden of diseases for years, while also advocating for governments to act. In the run up to the first-ever United Nations High-Level meeting on NCDs, which took place on 19 September 2011, the World Heart Federation worked with its 200 member organisations globally to lobby for CVD and the other NCDs to be recognised as a priority on the global health and development agendas.World leaders finally heeded our calls to action and they unanimously adopted a political declaration2 agreeing to address the prevention and control of NCDs worldwide, with an emphasis on developing countries. The declaration highlights NCDs as a major challenge for development in the 21st century, emphasising that NCDs undermine social and economic development, and threaten the achievement of global development and poverty-eradication goals.Just eight months later, governments agreed to take responsibility for responding to the challenge of NCDs. At the 65th World Health Assembly, all 194 member states agreed to adopt the first ever global NCD target: a 25% reduction in premature mortality from NCDs by 2025.3 The adoption of this bold global target is the result of commitment, hard work and a major lobbying effort from CVD activists. Most important to note, the overall mortality target and additional targets to be adopted later this year place CVD prevention and control at the heart of the NCD agenda, with risk management, low-cost treatment and care of CVD central to achieving the mortality and risk-factor targets.Many members of the African CVD community are to be congratulated for their efforts to make these achievements possible. In particular, Bongani Mayosi, chair of the World Heart Federation Rheumatic Heart Disease Working Group and, professor and head of the Department of Medicine at the University of Cape Town, participated in a civil society interactive hearing on NCDs at the United Nations in June 2011, to inform preparations for the UN meeting in September. At that High-Level meeting, Dr Kingsley Akinroye, then-president of the African Heart Network and board member of the World Heart Federation, spoke from the floor of the UN General Assembly about the importance of strengthening national policies and capacity to address the control of NCDs.But we cannot rest now. The target represents a rallying cry for further action by the CVD community. It automatically elevates CVD on the global health policy agenda, providing an ‘opportunity springboard’ from which we can accelerate action to reduce the global CVD burden. Because CVD is responsible for a higher proportion of NCD deaths than cancer, chronic respiratory diseases and diabetes combined (48 vs 36.5%),1 world leaders will look to us and our efforts to help reduce the CVD burden – and so our challenge is great.The next 13 years are crucial, and in order to mount a comprehensive response for achieving the target, the CVD community must forge innovative partnerships with policy makers, the private sector and healthcare professionals to create strategies that prevent CVD at local, regional and national levels. We need to look beyond the health sector and consider the many factors that influence heart health . We need to serve as the catalyst for renewed, global efforts to encourage heart-healthy behaviours. A concerted, global response is vital – we won’t curtail this global epidemic by continuing the same fragmented responses we have followed in the past. Everyone has a crucial role to play, and we must lead the charge and propel them to act.To achieve the target, policy makers urgently need to take action to help modify behavioural risk factors. Many CVD prevention strategies exist, however governments must do more to ensure that these are fully implemented and well-articulated in NCD plans, which the UN political declaration requires governments to complete by the end of 2013. As an example, one of the success stories in the fight against CVD is the WHO’s Framework Convention on Tobacco Control (FCTC), a treaty addressing issues around tobacco consumption, including restricting sales and advertising.National smoke-free legislation has been passed in Ghana, Mauritius, Niger, Kenya, Zambia and South Africa.4 However, according to the latest (2010) global progress report on implementation of the FCTC, only 50% of parties in the African region reported implementing a comprehensive ban on tobacco advertising, promotion and sponsorship.5 Our job therefore is to advocate for the full implementation of the FCTC, and at the same time push for more public-health campaigns to educate people on the links between tobacco consumption, CVD and premature death.Collaboration with the private sector is also imperative. Let us consider access to healthy food as an example. The factors that influence an individual’s ability to eat healthily are many, and are often beyond the control of that individual. In Africa, where many countries are increasingly experiencing a dual burden of obesity and malnutrition, strategies are required not just to affect an individual’s consumption of food but to modify food production processes.We can spearhead strategies to reformulate food products, to distribute healthy food options to those communities most in need, to promote and foster incentives for fruit and vegetable consumption, and to educate consumers to drive healthy food choices among those who have options available to them. We may face resistance from some corporate leaders, policy makers and even donors, so advocacy to stress the need for action is required alongside the development of new and creative partnerships that meet both health and corporate objectives wherever possible. We must also campaign for companion strategies for policies to change food production in the long term.We must work with healthcare providers to implement strategies that improve access to care and treatment. Consider blood pressure: in high-income countries, widespread screening, diagnosis and treatment have led to an impressive decrease in mean blood pressure,1,6 and correspondingly a drop in mortality from stroke and coronary heart disease is to be expected. Yet in Africa, more than one in three people (36.8%) are estimated to have raised blood pressure, and the prevalence is increasing.1,6Improving the availability of screening in primary care and treatment of high blood pressure with affordable essential drugs, including aspirin and statins, will prove vital to reducing premature CVD mortality in developing countries. More research is also needed to understand the burden of hypertension in the region in order to tailor approaches to addressing it. The distribution of penicillin to prevent rheumatic heart disease is a similar strategy that would cost little but have great impact. It is essential that we tackle these global inequalities in order to meet the target.Although we applaud the progress made at the World Health Assembly, the above examples show the complexity of CVD management. The global target is a landmark achievement that obliges action to deliver change for people with or at risk of NCDs and especially CVD. However, in isolation it is not enough – further targets are needed to shape a more complete framework and better guide collaborative, global action against CVD and its risk factors.We must keep the pressure on our governments to ensure the best possible outcomes for the millions of people suffering from CVDs and to avoid the 17.3 million deaths that occur each year. Specific targets are being considered for adoption around reducing the consumption of tobacco, salt/sodium, trans fats, and harmful levels of alcohol; reducing physical inactivity, elevated blood pressure, cholesterol and obesity; and ensuring access to affordable, quality-assured essential medicines, including multidrug therapy for people who have been identified at high risk of CVD.The window of opportunity to change the face of CVD forever is now and throughout the year, since the final targets will be agreed by member states in October 2012. We call on the CVD community to champion the additional targets, and push world leaders to agree on these promptly. Together we can avert deaths from CVD using proven interventions, and save lives around the world.


Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology has often been used by international or national health authorities, or scientific societies, for developing evidence-based treatment recommendations. However, the GRADE approach has never been used by practicing physicians who aim at harmonizing their prescribing behaviours paying due attention to the best available evidence. This paper describes the experience of a working group of psychiatrists who adopted the GRADE approach to develop clinical recommendations on the use of psychotropic drugs in specialist mental healthcare.In recent years the The project was conducted in the Department of Mental Health of Verona, Italy, a city located in the north of Italy. At the beginning of 2012, psychiatrists with a specific interest in the rational use of psychotropic drugs were identified and appointed as members of a Guideline Development Group (GDG). The first task of the GDG was the identification of controversial areas in the use of psychotropic drugs, the definition of scoping questions, and the identification of outcomes of interest. The GDG was supported by a scientific secretariat, who searched the evidence, identified one or more systematic reviews matching the scoping questions, and drafted GRADE tables.On the basis of efficacy, acceptability, tolerability and safety data, considering the risk of bias and confidence in estimates, and taking also into consideration preferences, values and practical aspects in favour and against the intervention under scrutiny, a draft recommendation with its strength was formulated and agreed by GDG members. Recommendations were submitted for consideration to all specialists of the Department, discussed in two plenary sessions open to the whole staff, and finally approved at the end of 2012.The present project of guideline development raised several challenging and innovating aspects, including a “bottom-up” approach, as it was motivated by reasons that found agreement among specialists, those who developed the recommendations were those who were supposed to follow them, and values, preferences and feasibility issues were considered paying due attention to local context variables. Clinical practice guidelines have progressively become a tool for supporting an evidence-based approach in health care. Guidelines are mostly seen as tools for making health practice more consistent and efficient and for narrowing the gap between what clinicians do and what scientific evidence supports -3.In recent years new methodological approaches for aggregating, synthesising and grading the quality of evidence have progressively been developed, in order to support a transparent and methodologically sound production of clinical practice guidelines. One of these tools is the GRADE methodology  -6. This However, the GRADE approach has never been used by practicing physicians who aim at harmonizing their prescribing behaviours paying due attention to the best available evidence. This paper describes the experience of a working group of psychiatrists who adopted the GRADE approach to develop clinical recommendations on the use of psychotropic drugs in specialist mental healthcare. Here we highlight how the GRADE approach was adapted to our local needs, and we raise for consideration some challenging features of the whole process.This project was conducted in the area of Verona, a city located in the north of Italy . In this area the main agency providing psychiatric care for the adult population is the Department of Mental Health (DMH) . The DMHAt the beginning of 2012 the DMH started a project aimed at producing evidence-based recommendations for the pharmacological treatment of complex clinical situations. Final goals were the implementation of a robust and shared methodology for choosing and managing pharmacological treatments, and the assessment of the impact of recommendations on prescribing behaviours.As initial step, psychiatrists with a specific interest in the rational use of psychotropic drugs were identified and appointed as members of a Guideline Development Group (GDG) Figure . The groThe first task of the GDG was the identification of controversial areas in the use of psychotropic drugs. A clinician’s perspective was chosen, and a list of controversial areas was initially developed by the GDG and subsequently circulated by email to all specialists of the Department, with a request of providing feedback by highlighting the three topics perceived as the most relevant and where guidance was needed. Specialists were also allowed to make suggestions by adding other topics that were not part of the initial list. On the basis of this consultation process, the GDG selected the six most relevant topics, as follows:1. Use of antipsychotics and benzodiazepines in patients with agitation and/or aggressive behaviour2. Use of antipsychotics, antidepressants, benzodiazepines and mood stabilizers in patients with borderline personality disorder3. Use of medicines in patients with unipolar depression:3a. treatment strategies in patients who do not benefit from initial treatment3a.  treatment strategies in patients with resistant depression3a. duration of antidepressant treatment4. Use of antipsychotics and antidepressants in elderly patients with:4a. behavioural abnormalities4a. depressive symptoms5. Use of medicines during pregnancy5a. antidepressants5a. antipsychotics5a. benzodiazepines5a. mood stabilizers6. Use of medicines in patients with medical comorbidities:6a. cardiovascular problems6a. Parkinson’s disease6a. epilepsyEach topic was reformulated using the PICO framework  into one or more scoping questions, in order to facilitate the process of searching and synthesizing the evidence. Finally, for each scoping question, the GDG discussed a number of possible outcomes of interest and, on the basis of relevance and clinical judgment, retained only those that were considered important or critical. These outcomes helped guide the subsequent phases of evidence retrieval, synthesis, and production of GRADE tables.For each scoping question a member of the scientific secretariat was appointed as focal point. Focal points searched the evidence and identified one or more systematic reviews answering the scoping questions. We did not include primary studies. Existing guidelines based on newly performed systematic reviews, such as for example NICE guidelines, were included. Medline, Embase, Psychinfo, CINAHL the Cochrane Library and BMJ Clinical Evidence were routinely scanned to help identify pertinent systematic reviews. For efficacy, only systematic reviews of randomized trials were considered; for tolerability and safety outcomes, systematic reviews of observational studies were considered and, in selected cases, individual observational studies were included. Pragmatically, only recent reviews (three years) were selected, and we gave priority to Cochrane reviews, assuming a higher methodological standard and considering that the standard of reporting the results of Cochrane reviews is particularly suitable for producing GRADE tables. We matched for each outcome one systematic review. If more than one systematic review was available, sometimes providing conflicting results, this was recorded using the footnote tool of GRADE tables. Focal points critically appraised the evidence and drafted GRADE tables using the software GRADEpro . As ratiFor each scoping question a scoping document including a PICO table, a list of included systematic reviews, GRADE tables and additional evidence that was not graded, was drafted and analytically discussed by the GDG. If the production of GRADE tables was not feasible, a narrative approach was followed. Figure The GDG critically appraised the evidence and suggested revisions to the GRADE tables and to the whole scoping documents. In addition, during GDG meetings, considerations on values and preferences, practical aspects such as drug labels, approved indications and safety warnings from regulatory agencies, feasibility issues and local aspects, were raised and extensively discussed. These considerations were incorporated into the scoping documents as key aspects to consider in addition to the background evidence when drafting a recommendation. Again, we followed the instructions used by WHO in the mhGAP project .On the basis of efficacy, acceptability, tolerability and safety data, and considering the risk of bias and confidence in estimates, and taking also into consideration preferences, values and practical aspects in favour and against the intervention under scrutiny, a draft recommendation with its strength was formulated, agreed by GDG members, and reported at the end of each scoping document. Following WHO methodology, recommendation strength was categorised into standard or strong. Only when the GDG was very certain that benefits outweighed risks and burdens a recommendation was rated as strong.Recommendations were submitted for consideration to all specialists of the DMH and discussed in two plenary sessions open to the whole staff. On the basis of feedback and suggestions obtained during these plenary sessions, final recommendations were drafted by the GDG. In addition, remarks and clinical considerations that were considered useful to contextualise the recommendations were added, although these were kept separated from the formally approved recommendations. The revised versions were circulated to all specialists for consensus and final approval.From each scoping document we extracted the PICO table, a summary table of efficacy and tolerability data, a summary table of additional considerations on values, preferences and feasibility issues, and the recommendation with its remarks. These extracts were included in an official document that was disseminated to all staff both in print and electronic format. A professional designer was involved in its production in order to maximise readability and usefulness.The project started in January 2012, and in January 2013 we were able to disseminate the recommendations  and in the social process (interpretation of the results of the systematic review) of guideline development. This approach provided doctors with an opportunity of training their ability to manage the evidence base, which is not straightforward for most doctors, and their attitude to explicitly draft recommendations on prescribing behaviours. The educational features of this project were formally acknowledged by local institutions which provided Continuing Medical Education (CME) credits to all participants.We still do not know if this “bottom-up” approach will enhance guideline uptake in practice . HoweverThe present project will be replicated in 2013, appointing different psychiatrists of the DMH as members of the GDG, and focusing on another set of controversial topics. The GDG will also regularly check the need of updating the existing guidelines. The scientific secretariat will be unchanged and will assure continuity in terms of methodology and overall process. Although we acknowledge the risk of guideline proliferation with an increasing issue of quality and potential conflicts of interest , we noteNot applicable.The authors declare that they have no competing interests.GO drafted the manuscript, IB co-led the drafting of the manuscript, CB provided input and edits and critically revised the manuscript. All authors participated in the project, and were members of the Guideline Development Group. All authors read and approved the final manuscript.


There is renewed interest in the role of the built environment in public health. Relatively little research to date investigates its impact on healthy ageing. Ageing in place has been adopted as a key strategy for coping with the challenges of longevity. What is needed is a better understanding of how individual characteristics of older people's residential environments (from front door to wider neighbourhood) contribute to their wellbeing, in order to provide the basis for evidence-based housing/urban design and development of interventions. This research aimed to develop a tool to objectively measure a large range of built environment characteristics, as the basis for a preliminary study of potential relationships with a number of 'place-related' functional, emotional and social wellbeing constructs.Through a review of urban design literature, design documents, and existing measures, a new tool, the NeDeCC (Neighbourhood Design Characteristics Checklist) was developed. It was piloted, refined, and its reliability validated through inter-rater tests. A range of place-related wellbeing constructs were identified and measured through interviews with 200 older people living in a wide variety of rural-urban environments and different types of housing in England. The NeDeCC was used to measure the residential environment of each participant, and significant bivariate relationships with wellbeing variables were identified.The NeDeCC was found to have convincing face and construct validity and good inter-rater and test/retest reliability, though it would benefit from use of digital data sources such as Google Earth to eliminate the need for on-site survey. The significant relationships found in the study suggest that there may be characteristics of residential environments of potential relevance for older people's lives that have been overlooked in research to date, and that it may be worthwhile to question some of the assumptions about where and how older people want to live (e.g. villages seem to be positive). They also point to the importance of considering non-linear relationships.The NeDeCC provides the basis for generation of evidence-based design guidance if it is used in prospective controlled studies or 'natural experiments' in the future. Ultimately, this will facilitate the creation of better places for ageing in place. With the recent shift in health provision away from a medical model to a focus on health promotion, increasing attention is being paid to the role of the built environment, particularly within residential areas -4. AccorThere are good reasons for investigating the role of the built environment in healthy ageing. As in clinical medicine it is recognised that people need to receive different medical treatments at different stages of life, so it can be argued that non-medical determinants of health will differ in their impacts over the life-course . LongeviFor ageing in place to work well, housing and neighbourhood environments need to facilitate older people's independence and wellbeing. According to Liu et al , recent There is a common view, now apparent in UK planning policies and elsewhere, that older people need higher-density homes  in urban locations. This is based on several assumptions: older households prefer less space and freedom from the burden of looking after a large house and garden ; being iWhat is lacking at the moment, in terms of both research and practice, is an integration of the health and built environment areas of expertise ,23. RecoFrom a built environment perspective, perhaps the most significant shortcoming in research to date is that it is often difficult to translate the findings into practice - i.e. to know how the built environment should be changed or designed differently to optimise wellbeing . This is• Often it is treated as a 'black box', despite comprising a huge number of individual elements: for example, a neighbourhood environment is unique in terms of its street layout, street design, amount of greenery, presence of street furniture, and the type and variety of buildings within it (to name but a few different elements). In order to know how best to intervene, built environment practitioners  need to know not just whether the built environment makes a difference but also which elements or characteristics are important .• Measures are often subjective - i.e. ratings of quality by residents or researchers [e.g. ]. Subjec• Measures are often a combination of physical and social characteristics, including condition of buildings and streets and prevalence of vandalism, litter and graffiti (e.g. the REAT instrument ) 34,35],3534,35]• Measures are collected for a spatial unit, such as a 'lot' or block face, rather than for an individual  - as ClaThe ultimate goal in terms of investigating the impact of the residential environment on healthy ageing might be an experiment or trial involving the evaluation of an intervention, or a prospective controlled study investigating outcomes for older people moving into different settings. However, while there is some evidence that the built environment makes a difference in healthy ageing, there is little understanding of which individual design characteristics are important. The use of objective measures of the built environment has been growing in recent years, mainly through research on obesity . These mStudies of the built environment in relation to mental health, stress and social capital use some of the measures above but additional ones related to the more immediate home environment, for example dwelling form/type, storey height of housing, floor level of dwelling, characteristics of the street/home interface  -50. PurcThe purpose of the research reported here was to develop a tool which measures a wide range of urban design characteristics within an individual's residential environment, and to test this tool in a preliminary study, in order to identify potential predictors of older people's wellbeing that are worthy of investigation in future research.Using a sample of 200 older people living in a wide range of locations in the UK, various 'place-related' aspects of wellbeing were measured through in-depth interviews (guided by a questionnaire). Urban design characteristics of their neighbourhoods were measured objectively using a newly-designed and tested tool, the NeDeCC (Neighbourhood Design Characteristics Checklist).The NeDeCC develops previous work by one of the authors (EB) to measure or describe discrete housing areas using a Built Environment Site Survey Checklist (BESSC) . The new1. It comprises objective measures of the built environment, which could be termed 'descriptions' rather than evaluations;2. It attempts to measure a wide range of built environment characteristics within an individual's experiential residential environment, but only those that are modifiable in practice;3. The tool is designed to measure the residential environment of an individual rather than a predetermined spatial or geographical unit;4. The measures, though based around an individual residence, extend from their front door to the street on which they live and the wider neighbourhood beyond;5. The tool is applicable across the full range of residential environments on the rural-urban spectrum or whatever the cultural/international context;6. It is suitable for use by non-built environment researchers, being easy to apply without the need for specialist equipment or software.Reference was made to standard urban design texts and design guidance documents to ascertain the range of characteristics to be measured e.g. -60]. Res. Res60]]To measure an individual's residential environment using the NeDeCC, a map (e.g. Ordnance Survey in the UK) was obtained first, using their residential address or postcode as the reference point. A scale of about 1:1250 was found to be appropriate as this shows facilities, services, open space and trees. The extent of the individual's residential environment was defined and marked on the map as everything within a 300 m radius from their home that could be accessed on foot . Areas not accessible to pedestrians due to physical barriers (e.g. rivers and railway lines) were excluded from the survey. The 300 m radius was derived from an estimate of the average distance older people would be able to walk comfortably from their homes, based on 10 minutes' walking time and findings that older people walk more slowly than the average fit male adult . ObviousAs a measurement tool the NeDeCC has good face-value validity; each item is measuring a distinct, easily-identifiable objective physical quality . The construct validity of the NeDeCC, i.e. how far it adequately measures an individual's residential environment, was maximised by a) including only objective built environment measures  and b) including a broad range of items identified from focus groups and literature. This addressed weaknesses in previous measures of the built environment which included only single or ill-defined elements. None of these individual items were combined within a composite measure. A test of construct validity is how far the measures are associated with those you would expect them to be, from theory and previous research. For built environment measures, this is somewhat difficult to examine because of the paucity of research and evidence to date on individual elements of the environment. However, there is support for the construct validity of the NeDeCC because in general the associations found to be significant between individual built environment items and aspects of wellbeing were as theorised . For example, wellbeing was associated with the amount of greenery in the neighbourhood, supporting many other studies; and older people felt safest if they lived in villages, as found in previous work.The tool was piloted to test its usability. From this, the wording of items and their responses were refined for the purposes of clarity. Then, to check the inter-rater reliability of the tool, ratings were completed by two researchers for a number of individuals living in different neighbourhoods. The inter-rater reliability was found to be satisfactory for all the items . It was possible to ensure a level of test/retest reliability, even though this is less of an issue for a built environment measure . As the tool was used within a 300 m radius of each participant's home and participants were sometimes clustered within geographical areas, there was some overlapping of areas measured. The team found that overlapping areas were rated the same by researchers on the different occasions they collected the data.According to Masotti et al , a neighFunctional place-related wellbeing (6 items): amount of independence participants feel they have in life; perceptions of safety from traffic and non-motorised traffic ; incidence of falling outside; perceived noise problems; perceived air quality.Social place-related wellbeing (4 items): perceived community spirit; extent of social interaction; perceptions of safety from crime (before and after dark).Emotional place-related wellbeing (4 items): self-rated quality of life; satisfaction with the neighbourhood as a place to live; perceived attractiveness of the neighbourhood; enjoyment of trips in local neighbourhood.Wellbeing and neighbourhood characteristics were measured for a sample of 200 older people. This was considered the maximum sample size possible given the research timeframe and the need to conduct detailed surveys of each participant's residential environment. Older people were defined as those aged 65 and over, in line with previous studies.Older people were recruited from a wide range of location types, in Oxfordshire, Gloucestershire and Greater Manchester, including city/town centres, urban districts, suburbs/edges and villages, representing contrasting types of environment. Additionally, the sample was selected to provide a mix of older people living in age-specific housing (including sheltered housing and retirement homes) and 'ordinary' housing, and to provide a mix of social and private housing. Recruitment was carried out through two methods: for age-specific housing, the researchers approached housing associations and private developers, including those linked to the project as non-academic collaborators; people living in ordinary housing were recruited through older people's organisations . Ongoing recruitment was reviewed to identify gaps in terms of different social groups , urban-rural locations or housing types, and further recruitment was targeted accordingly. Characteristics of the sample are summarised in Tables The responses to each built environment measure arising from the NeDeCC were first investigated to determine the types of neighbourhoods that were present. Correlations between wellbeing variables were also examined to determine whether distinct constructs were being measured, or whether the potential existed to combine items into a smaller number of composite measures. Two sets of tests of independence were then performed. The first set compared housing type to responses to every other built environment measure; the second tested relationships between each of the 25 individual built environment characteristics and each of the 14 functional, social and emotional place-related wellbeing constructs. These analyses used a combination of Pearson chi-square tests where both variables were categorical and at least one was nominal in form; rank correlations where both variables were at least ordinal; and Kruskal Wallis tests where one variable was nominal and the other was of continuous or discrete type. A significance level of p < 0.05 was applied to all tests, adjusted for the number of tests being run by a Bonferroni correction to mitigate the risks of type I errors . As suchTable Furthermore, nearly all the built environment measures were significantly associated with housing type . This suggests that older people are living in very different types of environments depending on whether their home is sheltered accommodation or general housing, and/or whether it is private or social (i.e. rented from a housing association or not-for-profit developer). Moving between these types of housing could therefore have substantial implications for the character of environments older people inhabit.The second set of analyses tested relationships between the 14 wellbeing variables and 25 built environment variables. The analysis was hampered by a lack of spread for many of the wellbeing responses, particularly the emotional ones; for instance, self-rated quality of life, satisfaction with the neighbourhood, and enjoyment of trips in it. In general, the older people in the sample were very positive about all aspects of their wellbeing. However significant relationships with wellbeing variables were found for a number of different built environment characteristics. As the study is exploratory, the exact nature of these relationships is unclear, but they are summarised in tabular form in Additional file The table shows a spread of significant relationships among the variables. These should be interpreted with caution, particularly as the analyses did not control for background variables - i.e. it is likely that certain types of area are inhabited by certain types of people, so the relationships may simply reflect relationships between personal characteristics and wellbeing constructs. Further, the lack of sensitivity in the wellbeing measures may have masked differences for people in different environments. The dimensions of wellbeing with the greatest number of associations were: perceptions of safety from non-motorised traffic (bicycles and skateboards); perceptions of safety after and before dark; and self-rated quality of life. The built environment measures found to have the greatest number of significant associations were: type of housing; residential location on the urban-rural spectrum; built-up density; and number of junctions/intersections within 300 m radius. No associations were found for extent of 'eyes on the street' or motorised traffic level on particpant's street. Several measures were found to have only one significant association: age of housing; shape of street; size of block; and extent of natural surveillance within 300 m radius. However, this does not necessarily mean that these aspects of the built environment are unimportant for older people's wellbeing - if investigated further, they may be found to be strongly associated with wellbeing, even after controlling for background variables.Overall, the findings suggest that in future research it would be worthwhile investigating a wide range of different dimensions of urban design and residential environments, including those not commonly addressed , though not necessarily within one study. It is also worth investigating a wide range of pathways for the influence of the built environment. Though conclusions cannot be drawn from the superficial analysis in this study, it is notable that all the wellbeing constructs were found to be associated with at least one built environment measure. To delve a little deeper into the findings, some of the stronger associations were examined more carefully - the preliminary findings are reported below.Amount of greenery: older people living in more green areas reported greater satisfaction with their neighbourhood as a place to live; they were also more likely to perceive it as attractive - clearly, the two may be related.Density: older people living in higher-density areas tended to feel less safe from non-motorised traffic (cyclists and skaters) while those in moderate-density areas tended to feel less safe from motorised traffic ; in terms of social wellbeing constructs, older people in higher-density environments tended to feel less safe from crime, both before and after dark.Location: older people living in villages were most likely to rate their environment as very attractive, perhaps because they are greener; perceived safety before dark was found to be better in villages and small towns than cities and large towns, while perceived safety after dark was found to be best in villages and suburbs of large towns and worst in districts and centres of large and major towns/cities; perceived safety from non-motorised traffic was found to be worst among older people living in districts of major towns/cities and best among those living in villages and small towns.Street pattern: perceived safety from non-motorised traffic was found to be worst among older people living in distorted grid layouts and best in curvilinear (looped) layouts.Block size: in areas with very large blocks, older people were more likely to feel safe from non-motorised traffic, while those in areas with medium-sized blocks were likely to feel least safe.Setback of dwellings from the street: older people were more likely to report feeling safe from non-motorised traffic if they lived in areas where the buildings were set well back from the street, probably because this provides a buffer zone between the front door and cyclists or skaters on the pavement.Street topography: older people living on flat streets were less likely to report safety from non-motorised traffic, perhaps because there are more cyclists and skaters in flat areas.The findings taken as a whole suggest that it is worth questioning some of the assumptions about how and where older people want to live - e.g. that they are better off in higher-density, urban areas. Further, it should be noted that the relationships between wellbeing and built environment characteristics may not be linear. Here, it was found that older people reported positive feedback in both high- and low-density neighbourhoods and negative feedback in moderate-density neighbourhoods (a curvilinear relationship). The potential for non-linear relationships should be taken account in future research - there may well be characteristics that are positive up to a point beyond which they become problematic. This is important information for designers and other providers of the built environment.Another key finding to draw from the research is the importance of meaningful calibration of measures. It is necessary not only to measure each relevant aspect of urban design within a residential environment but also to measure this well, using categories that allow adequate correlation with wellbeing outcomes.This study shows that it is possible to measure objectively a wide range of urban design characteristics, reflecting the nature of residential environments within which older people live. It has developed and tested a new tool, the NeDeCC, which can be used in further research. It can be used anywhere, in rural as well as urban locations, and in any part of the world, as the measures are independent of cultural context. The development of these measures provides a good basis for rigorous investigation of the role of the built environment in health and wellbeing from which it is possible to generate guidance for designers and providers of the built environment - architects, urban designers, housing developers, social housing providers and so on. There is scope for improving and developing the built environment tool. The authors are currently adapting it for completion through remote measurement, using digital maps and Google Earth Street View, eliminating the need for on-site survey. This saves time and resources and allows its use for large sample sizes. Other researchers have found these digital sources to be reliable alternatives to on-site survey ,67.Clearly, the potential of the tool would be maximised through its use in more sophisticated study designs: for example, recording changes to the built environment in 'natural experiments', prospective controlled studies or intervention trials, where background variables are controlled and account is taken of residential self-selection or drift. A major shortcoming of the research reported here was inadequacy of the wellbeing constructs that were used. The response was overwhelmingly positive, albeit partly because of the focus on older people; this degree of range restriction reduced statistical power, making it difficult to detect relationships with NeDeCC dimensions. More or different relationships may be found if better measures of wellbeing are used in future research. A validated scale such as WEMWBS , which provides a continuous measure based on a number of different parameters, would improve the power of the research.There is little doubt that one of the most important public health challenges today is the loss of wellbeing in society . IncreasThe authors declare that they have no competing interests.EJB was the principal investigator for the study - i.e. she developed the ideas and study design and methods and managed the research team collecting and analyzing the data. EJB also contributed to data analysis and drafted the manuscript. LM helped to develop the research design and NeDeCC tool and undertook most of the data acquisition and analysis. She also helped to draft the manuscript. CS provided the statistical expertise for the study - he was not involved in developing the NeDeCC tool and study design but undertook all aspects of analysis and helped prepare the manuscript. All authors read and approved the final manuscript.EJB (MA Cantab DipArch DipUD PhD) is Professor of Sustainable Building Design and Wellbeing and founder director of the WISE (Wellbeing in Sustainable Environments) research unit at the University of Warwick. Having qualified as an architect and urban designer, EJB took up a research career, with the aim of developing an evidence base for architectural practice. Her research investigates the social aspects of sustainability and how the built environment (architecture and urban design) influences people's wellbeing, quality of life and mental health. She has particular expertise in ageing research, including dementia-friendly design. She has also devised innovative tools and methods for obtaining objective measures of the built environment. EJB is now seeking to promote design for wellbeing in the built environment through the development of new cross-disciplinary courses.LM (BA Hons MPhil PhD) is co-founder of the WISE (Wellbeing in Sustainable Environments) research unit in the School of Health and Social Studies, University of Warwick. Her background is in social sciences, planning and inclusive urban design. Her research interests lie in how the design of the built environment, such as care settings, housing, urban form and streets, influences people's health and wellbeing and ability to lead independent, active lives. She has particular expertise in researching the design needs of older people and people with dementia.CBS is the statistician at the Institute of Work Psychology at the University of Sheffield. He has published across a wide range of social science disciplines, and is particularly interested in the use of statistical methods to support and add rigour to research in areas where advanced quantitative analysis would typically be considered an anathema.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/839/prepubNeighbourhood Design Characteristics Checklist (NeDeCC). Items and categorical responses included in the NeDeCC instrument.Click here for fileSignificant relationships between built environment and wellbeing variables. This table shows significant relationships between built environment and wellbeing variables.Click here for file


Many problems associated with the mixing process remain unsolved and result in poor mixing performance. The residence time distribution (RTD) and the mixing time are the most important parameters that determine the homogenisation that is achieved in the mixing vessel and are discussed in detail in this paper. In addition, this paper reviews the current problems associated with conventional tracers, mathematical models, and computational fluid dynamics simulations involved in radiotracer experiments and hybrid of radiotracer. Radiotracers are widely used for the measurement of the flow rate of liquids, gases, and solids in many industrial systems. Thus, in the enhancement of production efficiency and process optimisation, radioisotope-based technology continues to play a rapidly growing role in various industries, such as petrochemicals, oil, and gas, as well as wastewater treatment plants –3. An inRadiotracer technology also assists industries in satisfying the critical need for production efficiency through the identification of process malfunctions and anomalies, as well as mechanical damage in the plant. Although radioisotopes have been used to solve a number of industry problems for over 50 years, research and development of the technology continue unchallenged. The greatest benefit of radiotracer technology over the conventional methods is that the investigation can be carried out on-stream and without disrupting the operating process of the plant. Hence, any expensive downtime is avoided and the convenience of direct measurement results in substantial economic benefits and investigating costs. Nevertheless, although the technology is applicable across a broad industrial spectrum, Pant et al. , Hills , and FurThe measurement of homogeneous mixing efficiency is one of the main applications of radiotracers in the industry. Mixing involves the blending of two or more miscible fluids to obtain a predetermined degree of homogeneity. Stirred tanks are widely used in the process industries to perform many different operations, including the blending of miscible liquids into a single liquid phase, the suspension of solids, the promotion of heat and mass transfer, gas-liquid and liquid-liquid mass transfer, crystallisation, and chemical reactions , 9. SeveThe residence time distribution (RTD) is one of the important parameters that can provide information on the characteristics of the reactor, such as the flow pattern that occurs . The RTDStegowski and Furman  describeIn addition to the RTD, the mixing time is an important parameter that can be used to determine the homogenisation that occurs in a mixing vessel , 19. TheExtensive studies have been conducted to study the efficiency and flow characteristics of mixing vessels using a nonradiotracer approach. The techniques have been successfully implemented and published, but there are some discrepancies when these are compared with radiotracer techniques. Jafari and Mohammadzadeh  and WangThere is another drawback associated with the use of nonradioactive tracers. Delvigne et al.  used a tE(t), is a probability distribution function that describes the amount of time a fluid element spends inside a reactor. It helps in troubleshooting reactors and characterises the macromixing and flow within a reactor  and the corresponding times would be equal. The RTD curve became wider with decreasing liquid flow rates, which increased the mean residence time, as shown in Another factor that affects the RTD is stirring. Cao et al.  explainek-ε  model, which was successfully used by Shekhar and Jayanti [Numerical simulation is another technique that is used to calculate mixing time. CFD is currently widely used to verify experimental results. Osman and Varley  measured Jayanti  to simul Jayanti  who used Jayanti  who implk-ε model yielded better results with realisable and standard conditions, whereas Zadghaffari et al. [Yianneskis  reportedi et al.  discoveri et al.  used a fi et al.  and Zadgi et al.  agreed tThe use of CFD modelling in process industries has attracted a lot of attention since 1990. Modelling and numeric simulation have been used to validate a large amount of experimental data, especially in process industries. Rahimi and Parvareh  stated t99mTcO4 as the radioactive source for the investigation of the RTD in a laboratory jet mixer. They compared the experimental RTD derived from the radiotracer experiments with the simulations from three different CFD models: standard k-ε, RNG k-ε, and RSM. The authors found that the RNG k-ε, model best represents the radiotracer experiment curve. However, the authors did not describe the type of RTD mathematical model that they utilised. The authors also failed to highlight the anomalies in the laboratory jet mixer. Another hybrid investigation was conducted by Din et al. [k-ε, porous media, and pulse generation models. In their paper, the authors described the type of model used, as recommended by the IAEA. However, the results obtained from the CFD simulation were not acceptable because they deviated approximately 30% from the experimental measurements. It is possible that another type of model, such as the RNG or realisable standard k-ε models, might yield better results.Stegowski and Furman  used a sn et al.  who inteThe combination of radiotracer technology and computer modelling has increased the use of both of these technologies, which indicates its superiority among the conventional techniques that are used worldwide.In this review, the development of radiotracer technology has been described. The introduction described radiotracer technology in general, which was followed by a summary of the current problems that arise from the use of conventional tracers. A description of the mathematical models that are used in radiotracer applications was then presented, followed by a summary of computer simulations to analyse the RTD and mixing time and an introduction of a hybrid of radiotracer technology and computational fluid dynamics (CFD). The literature described in this review indicates the versatility and feasibility of radiotracer technology in numerous industrial and laboratory applications. Future research on radiotracer technology will fully utilise and validate its use with numerical solutions in the study of mixing vessels because radiotracer techniques are widely used for the identification of industrial malfunctions and measurement of process parameters, such as the mean residence time (MRT), residence time distribution (RTD), and flow rate. Radiotracer technology has many advantages over conventional tracers; these include its high detection sensitivity, physicochemical compatibility, in-situ detection, and limited memory effect. It is possible that radiotracer technology can be used in combination with an experimental design that implements the Taguchi Orthogonal Array Method, which is a robust design method that was developed to reduce cost and improve the quality of chemical process . The Tag