Little is known about factors associated with alcohol consumption and use of drugs with addiction potential in older adults. The aim of this study was to explore the association between socio-demographic variables, physical and mental health and the later (11 years) use of frequent drinking, prescribed drugs with addiction potential and the possible combination of frequent drinking and being prescribed drugs with addiction potential in older adults (≥ 65 years).In this longitudinal study, we used data from two surveys of the Nord-Trøndelag Health Study (HUNT2 1995–1997 and HUNT3 2006–2008), a population based study in Norway. We totally included 10,656 individuals (5683 women) aged 54 years and older when they participated in HUNT2. Frequent drinking was defined as drinking alcohol 4 days or more per week. Data on prescribed drugs with addiction potential were drawn from the Norwegian Prescription Database. Drugs with addiction potential were defined as at least one prescription of benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years between 2005 and 2009.The typical frequent drinker in HUNT3 was younger, more educated, lived in urban areas, and reported smoking and drinking frequently in HUNT2 compared to the non-frequent drinker in HUNT3. The typical user of prescribed drugs with addiction potential in HUNT3 was an older woman who smoked and was in poor health, suffered from anxiety, had been hospitalized in the last 5 years and used anxiety or sleep medication every week or more often in HUNT2. The typical individual in HUNT3 with the possible combination of frequent drinking and being prescribed drugs with addiction potential had more education, smoked, drank frequently and used anxiety or sleep medication in HUNT2.Individuals who were identified as frequent drinkers in HUNT2 were more likely to be frequent drinkers in HUNT3, and to have the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3. Health care professionals need to be aware of use of alcohol among older adults using drugs with addiction potential.The online version of this article (10.1186/s12877-019-1114-2) contains supplementary material, which is available to authorized users. Older adults often consume less alcohol than their younger peers , but alcA large number of studies have shown that alcohol consumption in older adults is associated with men , 17–22, With a few exceptions , 26, stuDrugs with addiction potential are used frequently among older adults in Western countries –31. This, higher levels of self-reported pain and stress [. In older adults, the use of opioids is more likely in older individuals [The use of addictive psychotropic drugs in older adults has been associated with higher age , 30, 35,d stress  and mored stress . In oldeividuals , among wividuals , 19, in ividuals , 18, 19,ividuals , 19 and ividuals , 39, 40,There is concern about the combined use of alcohol and drugs with addiction potential in older adults , 29, 38.Cross-sectional studies have identified older age , men 3838, pooreNevertheless, little is known about factors associated with frequent alcohol consumption and/or use of drugs with addiction potential in older adults in Norway , 43–46 oThe Nord-Trøndelag Health Study (HUNT)  is basedThree HUNT Surveys have been completed to date: HUNT1 in 1984–1986, HUNT2 in 1995–1997 and HUNT3 in 2006–2008 . All couWe used data from HUNT2 and HUNT3 in this study. Individuals who were invited to participate in HUNT2 were also invited to participate in HUNT3 roughly 11 years later. Table In our study, we included 10,656 participants aged 54 years and above from HUNT2 who had answered the first questionnaire in HUNT2 and the required question about alcohol consumption in HUNT3. Totally, 400 participants who responded to the alcohol frequency question in HUNT2, did not respond to this question in HUNT3, and thus excluded from the study. Very few participants who were 80 years or older in HUNT2 participated in HUNT3   of the NThe drinking frequency measures in HUNT2 and HUNT3 differed slightly. In HUNT2, participants were asked how many times a month they drank alcohol, while participants in HUNT3 were asked how often during the last 12 months they drank alcohol. The response options in HUNT3 were: 1 = 4–7 times a week, 2 = 2–3 times a week, 3 = about once a week, 4 = 2–3 times a month, 5 = about once a month, 6 = a few times a year, 7 = not at all the last year and 8 = never drink alcohol. As drinking frequency was a categorical variable it was dichotomized in order to distinguish between those with high drinking frequency and those with lower drinking frequency or non-drinking. We defined drinking “4-7 times a week” as the equivalent of consuming alcohol 4 days or more per week in HUNT3 . Our study considered drinking 16 times or more per month as the equivalent of consuming alcohol 4 days or more per week in HUNT2.In HUNT2, participants self-reported use of prescribed drugs with addiction potential. They were asked to report how often they had taken anxiolytic or sleep medication in the last month, with the following response options: 1 = daily, 2 = weekly, but not every day, 3 = not as often as every week and 4 = never. Our study merged response categories 1 and 2 under the description of daily or weekly use of anxiolytic or sleep medication.In the HUNT3 sample, information drawn from the NorPD (2005–2009) about prescribed drugs with addiction potential  was cateTo enable comparisons between prescribed drugs in HUNT2 and HUNT3, we defined a subgroup of addictive psychotropic drugs in HUNT3 as prescribed BZD or z-hypnotics.The possible combination of use of alcohol and prescribed drugs with addiction potential was defined as frequent drinking in HUNT3 and being prescribed drugs with addiction potential at the same time as HUNT3 was completed.Smoking status in HUNT2 was assessed using three categories; 1 = never smoked daily, 2 = previously smoked daily and 3 = daily smoker.Self-reported health status was assessed by one question with four response alternatives. Due to the response distribution, the variable was dichotomized to very good/good and poor/not so good health status.Hospitalization during the last 5 years (yes/no) and history of medical diagnoses  were assessed by self-reported questions in HUNT2.Anxiety and depression were self-reported by the Hospital Anxiety and Depression Scale (HADS) . Seven iOverall life satisfaction was assessed by one question with seven response categories ranging from 1 (very satisfied) to 7 (very dissatisfied). Due to the response distribution, the variable was dichotomized to “satisfied” (response option 1–3) and “dissatisfied/neither satisfied nor dissatisfied” (4–7).Socio-demographic variables.The socio-economic variables were gender, age at the time of survey completion, level of education , urban versus rural living and marital status (living spouse or partner versus not). Age was further categorised into three groups .All participants signed an informed and written consent allowing use of their data for future medical research , 49 and The Regional Committee of Medical Research Ethics (REC) (reference number 2014/1248), the Norwegian Data Inspectorate Authority, the Norwegian Social Science Data Services (project number 40081), the Norwegian Data Inspectorate Authority (reference number 14/01248-2EOL) and the Norwegian Institute of Public Health have all approved the present study.The data was analysed with SPSS version 23. Descriptive analysis of categorical variables was performed using Chi-Square test.We used McNemar’s Exact Test to investigate the change in drinking frequency (≥ 4 days/week) from HUNT2 to HUNT3 and the change in use of prescribed drugs; i.e. self-reported use of anxiolytic or sleep medication in HUNT2 to prescribed addictive psychotropic drugs in HUNT3.p ≤ 0.1) in the unadjusted analyses were included.Logistic regression analysis (the “enter” method) was used to examine the association between independent variables assessed in HUNT2 and three dependent variables assessed in HUNT3: Outcomes 1) frequent drinking  (versus not), 2) prescribed drugs with addiction potential (versus not), and 3) the possible combination of frequent drinking and being prescribed drugs with addiction potential . The independent variables (HUNT2) included in the unadjusted analyses were gender (women reference category), age (54–59 years reference category), level of education (up to ten years education reference category), living in urban versus rural areas, marital status (no living spouse or partner reference category), smoking status (never smoked daily reference category), overall health status (poor/not so good reference category), hospitalized during the last 5 years (versus not), HADS anxiety sum score ≥ 8 (versus < 8), HADS depression sum score ≥ 8 (versus < 8), overall life satisfaction (dissatisfied/neither satisfied nor dissatisfied reference category), frequent drinking   and self-reported use of anxiolytic and sleep medication every week or more (versus not). In the adjusted analyses, gender and age and other covariates associated with the outcome  were drawn from those included in outcome 1 (frequent drinking) and outcome 2 .Statistical tests were carried out to assess for interactions between gender and other covariates. We did not find any interactions. Unadjusted and adjusted analyses were presented with odds ratios (OR) and 95% confidence intervals (CI). Probability values below 0.05 were considered statistically significant.N = 10,656). The participants’ mean age was 62.7 (SD = 6.4) and 53% were women. The prevalence of self-reported medical illness was 4.0% for myocardial infarction, 6.3% for angina pectoris, 1.7% for stroke/brain haemorrhage, 2.5% for hyperthyroidism, 4.3% for hypothyroidism, 4.0% for osteoporosis, 5.0% for fibromyalgia, 3.6% for rheumatoid arthritis and 8% for asthma.Table In total, 3.0% 323/10,656) of older adults (≥ 54 years in HUNT2) were frequent drinkers  when they participated in HUNT3  of the participants who responded to the alcohol frequency question in HUNT2, were excluded in HUNT3 since they did not respond to the alcohol frequency question in HUNT3  in HUNT2 compared to the non-frequent drinker in HUNT3  of participants in HUNT3 were prescribed at least one drug with addiction potential  in two consecutive years , were more likely in HUNT2 to report angina pectoris (8.0% versus 5.5%), stroke/brain haemorrhage (2.7% versus 1.2%), hyperthyroidism (3.2% versus 2.2%), hypothyroidism (5.7% versus 3.7%), osteoporosis (6.5% versus 2.9%), fibromyalgia (9.4% versus 3.1%), rheumatoid arthritis (5.3% versus 2.9%) and asthma (9.7% versus 7.2%).Users of anxiolytic or sleep medication in HUNT2 had more than five times higher odds of being prescribed drugs with addiction potential in HUNT3 compared to non-users of anxiolytic or sleep medication in HUNT2 Table .In adjusted logistic regression analyses, the typical user of prescribed drugs with addiction potential in HUNT3 was found to be an older woman who smoked and was in poor health, suffered from anxiety, had been hospitalized during the last 5 years and had reported use of anxiety or sleep medication every week or more in HUNT2 Table . The expOne per cent of the HUNT3 study sample  were frequent drinkers and had also been prescribed drugs with addiction potential during the same period that HUNT3 was completed Table . With onFrequent drinkers in HUNT2 had about eight times higher odds of having the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3 compared to non-frequent drinkers in HUNT2 Table . Users oIn the adjusted logistic regression analyses, the typical individual with the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3 had more education, smoked, drank frequently and used anxiety or sleep medication in HUNT2 compared to the individual with no such use in HUNT3 Table . The expThis is the first large population-based study to explore factors associated with frequent drinking  and being prescribed drugs with addiction potential  using a longitudinal design in older adults aged 65 years or more at follow-up.In our study, the typical frequent drinker in HUNT3 was younger, had more years of education, lived in urban areas, and smoked and drank frequently (≥ 4 days/week) in HUNT2 compared to the non-frequent drinker in HUNT3. The typical user of prescribed drugs with addiction potential in HUNT3 was found to be an older woman who smoked and was in poor health and suffered from anxiety, had been hospitalized in the last 5 years and used anxiety or sleep medication every week or more in HUNT2. The typical individual with the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3 had more education, smoked, drank frequently and used anxiety or sleep medication in HUNT2 compared to the individual with no such use in HUNT3  in HUNT2 had about 33 times higher odds of being frequent drinkers when they participated in HUNT3. Furthermore, they had about eight times higher odds of having the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3. Thus, it seems that middle-aged drinkers continue their drinking pattern of frequent drinking as they age.Since our definition of alcohol drinking only included frequency of alcohol consumption (≥ 4 days/week), this definition may include participants with both risky drinking (≥ 7 drinks in a week) and non-risky drinking (< 7 drinks in a week) . Thus, iThough the majority of our sample were non-frequent drinkers (< 4 days/week), our study has shown that drinking frequency ≥ 4 days/week increased overall from HUNT2 to HUNT3, and in both genders. The increased number of healthy years experienced by older adults , 7, imprFurthermore, we found that the reported use of anxiolytic and sleep medication in HUNT2 was associated with being prescribed drugs with addiction potential, and the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3. Other studies have found similar results, where previous use of addictive psychotropic drugs was highly associated with subsequent use , 39. UnfWe also found that more men than women in HUNT3 were frequent drinkers, and more women than men were prescribed drugs with addiction potential. These findings are consistent with previous studies , 19, 38.In line with previous studies, we found that the prevalence of frequent drinking (≥ 4 days/week) decreased with increasing age , 31, whiConsistent with other studies, more years of education , 45, 46 Smokers had higher odds of consuming alcohol frequently, being prescribed drugs with addiction potential, and the possible combination of frequent drinking and use of prescribed drugs with addiction potential than non-smokers. This association has been observed in several previous studies, both for alcohol –21, 23 aThis study has several strengths. Firstly, we have followed a large population cohort of community-dwelling adults in Nord-Trøndelag County in Norway . Nord-TrA second and major strength of our study is its longitudinal design, spanning more than a decade. This allowed us to investigate several factors potentially associated with the later use of alcohol and/or being prescribed drugs with addiction potential.Thirdly, we used data from a nationwide prescription database  which gaDespite the strengths of our study, it still has limitations that should be considered. Firstly, participants who responded to the alcohol frequency question in HUNT2, but not in HUNT3, were excluded from our study. Those excluded, as previously stated, may have quit drinking, and therefore the increased prevalence of frequent drinking in HUNT3 could be overestimated. Even so, a non-participation study conducted after HUNT3  indicateAs in other studies, self-report of alcohol consumption may contribute to less accurate estimates and an underestimation of alcohol consumption, and especially in heavy drinkers . FurtherVariations in how questions about alcohol consumption were asked in HUNT2 and HUNT3 make it necessary to be cautious when interpreting results. In addition, it was not possible to determine whether alcohol and drugs with addiction potential were used simultaneously. Participants may not drink on the day they take the drug, and not all drugs are taken daily. An interaction can only occur if both alcohol and drugs are present in the body simultaneously .Moreover, HUNT2 was conducted in 1995–1997 and HUNT3 in 2006–2008. Thus, a more current survey might have produced different data. The fourth health study in Nord-Trøndelag (HUNT4) (2017–2019) will give us new opportunities to investigate the trend in use of alcohol among older adults in Norway. In the present study we chose to focus on frequent alcohol consumption defined as drinking 4 days or more a week. It could also be of interest to study the trend of other frequency of alcohol consumption.In addition, very few person 80 years or older in HUNT2 participated in HUNT3. These participants were kept in our analyses as they did not differ compared to those 79 years or younger regarding frequent drinking or the possible combination of frequent drinking and use of drugs with addiction potential.2) for the outcome possible combination of frequent drinking and being prescribed drugs with addiction potential was very low (6.8%). This indicates that other factors not included in our analyses have great importance for the association with the possible combination of use of alcohol and drugs with addiction potential. We did not have information about insomnia, pain, polypharmacy and loss of close family members and friends, all of which may be potential factors associated with higher use of alcohol and drugs with addiction potential in older adults [Although we adjusted for various socio-demographic, physical and psychological health factors, the possibility of residual confounding cannot be ruled out . In our r adults , 39, 40.. To avoid potential interaction between alcohol and drugs with addiction potential, there is a need for health personnel to focus on asking older adults about their drinking behaviour and drug use [. However, prior evidence has shown that health personnel often do not have established routines for asking older patients about their alcohol consumption, or informing them about the health consequences of alcohol consumption at older age and the possible harmful interaction effect between alcohol and drugs [Knowledge about factors associated with frequent alcohol consumption and drugs with addiction potential in older adults may help health personnel to identify subgroups at higher future risk . To avoidrug use . Howevernd drugs , 70, 71.Individuals who were identified as frequent drinkers in HUNT2 were more likely to be frequent drinkers in HUNT3, and to have the possible combination of frequent drinking and being prescribed drugs with addiction potential in HUNT3.Understanding factors associated with later use of frequent drinking and the possible combination of frequent drinking and use of prescribed drugs with addiction potential might contribute to increased awareness among health care personnel regarding older patients that could be at higher risk in the future. Health care professionals need to be aware of use of alcohol among older adults using drugs with addiction potential.Additional file 1:Table S1. Sample characteristic of participants in HUNT2 (1995–97) who responded versus did not respond to the alcohol frequency question in HUNT3 (2006–08) (DOCX 16 kb)Additional file 2:Table S2. Unadjusted logistic regression analyses of alcohol consumption and use of prescribed drugs with addiction potential (HUNT3 2006–08). The table shows unadjusted odds ratio for the association between independent variables assessed in HUNT2 (1995–97)  and three dependent variables assessed in HUNT3 (2006–08): Outcomes 1) Frequent drinking , 2) Prescribed drugs with addiction potential and 3) The possible combination of frequent drinking and being prescribed drugs with addiction potential. (DOCX 16 kb)


In 2014, in the United Kingdom, the government made a commitment to spend £3.6 million on the introduction of Skype video calling consultations in general practice, however the efficacy of such technology has not yet been explored fully.The study aimed to explore the views and attitudes of General Practitioners (GPs) towards video consultation in primary care; specifically, in three broad areasThe benefits of video consultations to patients and healthcare professionals.Potential problems with video consultation and its implementation.The cost-effectiveness of video consultation in this setting.A convenience sample of the views of 12 general practitioners across two primary care centres in North London were identified using topic guide based semi-structured interviews. A thematic framework approach was used to analyse the data collected to isolate main and sub-themes.Three main themes were identifiedTechnology – GPs expressed concerns about the ability of patients to use technology, the availability of technology and the quality of technology available.Utility – encompassing GP’s ideas about the usefulness of video consultations to patients, practitioners and the doctor–patient relationship. GPs presented mixed views on the extent to which video consultation would be useful.Practicality – covering the views of GPs on implementation and effects on workload. GPs unanimously felt that it was not a practical substitute for face-to-face consultation. There were mixed feelings about it being used as an alternative to telephone consultation.GPs did see potential benefits to using video consultations but also expressed concerns that need to be addressed if they are to have full confidence in the system. The views of those who are going to use video consultation as a means of increasing patient access are paramount if such tools are to be a core part of primary care. With the advent of better communication modalities in the 21st century, there is growing emphasis on how best clinicians and patients can interact in quick and efficient ways while maintaining safety and overall governance. In particular, the potential for telemedicine to improve accessibility and aid delivery of healthcare to patients has been discussed since the 1990s  ethics board in January 2014 .Before field research could take place, approval had to be given by the specific office of NHS Trust Research and Development (R&D) for the area in which the study was going to be based and from which participants were to be recruited. Interviews were conducted in private rooms and the transcripts were anonymised. Both verbal and written informed consent was obtained from the participants before interview. Participants were reassured that their transcripts – and any quotes which appeared in the final report – would be anonymised.The study was registered with the University College London Data Protection Officer and is still bound by the Data Protection Act 1998. The primary researcher, R.S.R., who is a male medical student trained in qualitative methods during his intercalated B.Sc. S.S., the primary supervisor supporting R.S.R., has an extensive history in published qualitative work. Before study commencement, R.S.R. had developed a relationship with a small number of the GPs interviewed, whom he had shadowed as a medical student. The work was done primarily as means of a thesis for a B.Sc., and this was relayed to the participants.The data collected originated from the semi-structured interviews conducted in the GP practices. The 12 interviews were conducted across the two GP sites by RR alone after verbal and written consent. The topic guide consisted of collecting demographic data pertaining to age, gender, ethnicity and years working as a GP. Then the interviews consisted of open questions exploring the study aims with more in-depth questioning in the areas of interest brought up by the participants. The term video consultation was deliberately undefined to maximise breadth of participants’ responses relating to their interpretation and use of this type of consultation. Interviews ranged from 45 to 60 min in length and were recorded.et al., Familiarisation with the data – R.S.R. transcribed the interviews on the day of the interviews to minimise researcher recall bias. The transcripts were re-read before analysis.Creating primary codes for the data – R.S.R. and S.S. identified possible themes after re-reading of the transcripts.Exploring the data for themes – R.S.R. then coded and indexed the data by common themes.Reviewing the identified themes – the themes were then reviewed by S.S. and final set of agreed themes were compiled.Creating a final report – the final report was written by R.S.R., J.S.C., T.T. and S.S.Interviews were transcribed verbatim, and data analysis was supported by the use of NVIVO (v10). Data analysis was conducted using a thematic framework approach  Male, 45 years old)All the participants felt that video consultation could be useful to patients.‘It’s easy, it’s access, it’s you know it’s easy for patients, some patients do come to the surgery and they want video consultation… the general complaint right now is “I can’t see my GP.” No access, no access, no access’.((1) Female, 48 years old)Some participants felt the use stemmed from improved access to GPs for patients.‘It not only improves access for patients but also for doctors. I mean it’d be much easier for me to go to a patient’s home via the computer than to physically drive there’.((5) Male, 45 years old)For some participants this improved access was reciprocal as it saved GPs time to see their patients.‘I’ll tell you what though the translators idea is quite good. Because then the translators can work from home and be accessed by multiple practices you know’”((9) Male, 31 years old)Another GP explored the option that other members in the multidisciplinary should have access to the video services such as translators as it could improve the patient experience. This explored the concept that video consultation may be more useful for specific patient cohorts.‘I don’t think it would help in all cases…Management of ongoing problems where you need to speak to the patient, bit of visual assessment would be good as well. But difficult to manage patients who have mental health problems because I think, face to face consultation is a bit different from video with mental health’.((1) Female, 48 years old)Participants had mixed feelings regarding which patients would benefit most from video consultation.‘Definitely for follow up consultations, even with some mental patients or patients with depression. They don’t really have any physical problems and just need a small assessment’.((5) Male, 45 years old)In contrast to the above quote, another participant believed that it would help mental health patients.‘…the other thing is fine but the patient on the other hand has to be competent enough to understand what you are telling him, there could be an educated person, if they’re not then it’s difficult’.((1) Female, 48 years old)In addition, there was a belief that patient knowledge and competence was an important factor for successful video consulting.‘The positive I suppose is for the patient that’s housebound’.((3) Female, 62 years old)‘It’s aimed at patients who can’t make it to the surgery so I suppose patients who can’t get out of the house, housebound patients’.((4) Male, 39 years old)Many of the participants believed that the housebound would benefit most from video consultation:‘It would help to see the patient sometimes because sometimes you know, there’s a level of uncertainty (hmm)…But yeah perhaps if I could’ve seen it then I could’ve told them it was nothing to worry about rather than have to call them in (yeah) so video could be helpful there’((6) Male, 46 years old)‘I mean it’s only really going to be useful for rashes and things like that otherwise you need to see the patient…It’ll be useful for the odd rash or something’.((2) Female, 38 years old)Clearly an examination is not possible using video-technology, however visualising the patient and their condition can increase confidence in the general practitioner’s mind regarding diagnosis:‘Well not being able to physically assess the patient is definitely a problem. I mean even if it’s a rash… you could diagnose occasionally but video consultation won’t show you all the characteristics, whether the skin is raised or rough’((10) Male, 50 years old)Many participants expressed concern that the lack of physical examination was a drawback to video consultation and left the assessment of the patient somewhat incomplete:‘I don’t think I’d refer to secondary care because you can’t really tell for sure unless you do a face-to-face, only for a small range of conditions you know. It might even create a barrier to primary care because like telephone consultations you end up telling them to come in for a consultation’.((11) Female, 30 years old)Interestingly due to these limitations many of the GPs felt that they would not be comfortable referring patients from a video consultation directly to secondary care. With a GP feeling it could create a barrier to face-to-face consultations:‘When you see a patient face to face you can negotiate and you can plan with the patient that look “I don’t know what’s happening but I think there is something going on, we’ll keep an eye on you, come see me in two weeks” that’s more satisfying for the patient than Skype’.((1) Female, 48 years old)Many participants felt that the doctor–patient relationship would be affected by using video consultation when compared with face-to-face consultations, which may affect the patient and doctor’s satisfaction:‘I suppose just being able to see your doctor could go a long way to improving the doctor-patient relationship’.((4) Male, 39 years old)Whereas others felt that a strength of the video method was the ability to see your doctor which could be an improvement on current telephone methods for patient satisfaction.Practicality refers to the attitudes and perceptions of GPs to the real world application of video consultations.‘I find that even with telephone consultations that are supposed to be shorter often they’re not because you’re not seeing things and the patient still wants reassurance and you also want the reassurance that you’ve done a full assessment…if it is a proper complaint then it doesn’t really save any time it’s just that convenience thing’.((12) Female, 36 years old)Many GPs thought that the introduction of video consultation would not save any time in general practice and could ultimately waste time if you ultimately have to bring the patient in.‘I suppose we’d end up having to book even more patients in with the nurse for their check-ups because usually we do them (blood pressure checks) during consultations. But yes if Skype consultations reduce the amount of people coming in then I suppose it would be harder to reach our QOF targets and it might make the nurses day busier…I don’t think they’d reduce the workload…I mean it might increase the GPs workload’.((4) Male, 39 years old)Interestingly some GPs felt that as a result this could ultimately lead to a greater workload for GPs and nurses to get their observations recorded and tasks relating to reaching quality outcome framework (QOF) targets ultimately taking up more time.‘I mean it’d be much easier for me to go to a patient’s home via the computer than to physically drive there …I think it could help reduce home visits to those that are necessary and help reduce the face-to-face consultations to the more necessary ones too’.((5) Male, 45 years old)Other participants thought that there could be some time-saving aspects to video consultation relating to travel time.‘Yes I don’t think there’s anything that can replace the true consultation in person to be perfectly honest?’((6) Male, 46 years old)Many of the participants expressed views that the video consultation was not an appropriate replacement or alternative to face-to-face consultations due to barriers with examination and patients being discouraged to see their GP.‘The lack of clinical experience will most probably hinder the learning …it will prevent younger general practitioners from picking up those patterns to recognise in patients’.((9) Male, 31 years old)Interestingly a few participants thought that video consultation could hinder the learning experience that some GPs gained from face-to-face consultations.‘perhaps if I could’ve seen it then I could’ve told them it was nothing to worry about rather than have to call them in’.((6) Male, 46 years old)However, in comparison with telephone consultations, participants felt the visual aspect of the video consultation would increase certainty in their assessment of patients.‘I mean on a telephone you can’t even tell if you’re really talking to the correct person. There’ve been times when the son of a patient will answer the phone and they just sound so alike you can’t tell’.((7) Female, 54 years old)Some participants felt that it may improve rapport and confidentiality as on camera you can clearly identify who you are speaking to.‘…especially with a video screen you can’t really tell who’s in the room beyond the boundaries of the (camera angle), whereas with a face-to-face consultation I can control who’s in the room and that will change based on the nature of the problem’.((4) Male, 39 years old)Although you can identify who you are speaking to, many of the participants believed that one of the drawbacks of video consultation was that there could be issues with protecting confidentiality as you cannot see the whole room with the webcam.‘Can’t people hack into webcams? They’d be able to watch the GP or the patient’.((7) Female, 54 years old)The security of the software also raised concerns relating to the confidentiality of the consultation:‘This is the way forward, we can’t, we can’t run away from this. It’s happening and it’ll be something we’ll be doing’.((1) Female, 48 years old)Even with the barriers to use, many of the participants felt that the implementation of video consulting was inevitable:‘Well then it (cost) must be quite low because the system itself is free. But then there’s so much to consider, you’ve gotta pay the people to install the system on the system, and then there are the costs of training GPs to use the system’.((4) Male, 39 years old)Many participants believed that from a cost perspective, the initial cost would outweigh the long-term running costs, but that overall video consultation could prove to be cost-effective.‘…it probably won’t save the NHS any money… but I don’t think it’ll cost the NHS too much in the grand scheme of things either, so I suppose it’s not really about cost, it’s more about trying to improve patient care, and access’.((5) Male, 45 years old)Whereas others felt that the introduction of video consultation would not save money and that cost-saving was not the major reason to implement it.The third theme related to the technology itself, which the participants felt could create difficulties for the patients using the service.‘I said the people who need it most are probably the housebound who can’t get to us. Will they be able to use it?’((2) Female, 38 years old)One obvious limitation of the service related to challenges with technology. There was a belief amongst some participants that the older generation and housebound would not be able to use the technology required to make video consultation effective, however these are the very groups who have, potentially at least, most to gain.‘People have access to a smartphone, or an IPad or something yeah. So I suppose that’ll be one drawback so the elderly are often the people that do ask for telephone consultations and things because they can’t make it to the surgery but I’m not sure that they would have access to that’.((12) Female, 36 years old)Some GPs also expressed concern about patients having access to the technology required for video consultation:‘I’m not sure how good it would be but if you put it right up to the thing (yeah), to the whatever it is they do, depends on the image quality but you could do that’.((3) Female, 62 years old)Many participants believed that the quality of the image was an important factor which should be considered when determining whether video consultation could be considered useful:‘Ok yeah I mean it could work, but Skype has a lot of problems. Connectivity issues, sound and image’.((8) Male, 47 years old)Other GPs voiced concerns that video consultations would be open to a number of technical issues, primarily issues with connectivity:Utility – all participants felt that video consultation could be useful to their patients. Although it could improve between patients and GPs, it may be more appropriate for certain patient groups over others, and could lead to barriers relating to the ability to examine patients affecting the doctor–patient relationship.Practicality – participants had mixed views about the potential for time-saving benefits. GPs felt it was not a substitute to face-to-face consultations. However, it may be superior to telephone consultations.Technology – participants felt that the success of the service ultimately depends on the literacy, availability and quality of technology accessible to the patients who need the service most. Participants felt that the ultimate success of the service is dependent on the availability and quality of the technology as well as the literacy of the patient with regards to these technology-driven consultations.There were three main themes:how GPs perceive this growing, inevitable development of video consulting.This was a pilot study designed to explore the views of general practitioners about video consultations, with a particular emphasis on the acceptability of the technology. This is an area where there is a dearth of information – especially with regard to The results of Jiwa and Meng’s  study aset al.’s Effect on GP time and workload.How will GPs use this modality and the potential costs to the practice.From this study, the barriers to full implementation include:The results of the study could also be useful to patients who want to know if they should use video consultation for their query. For example, the findings show that some GPs felt that the use of video would not be useful in diagnosing conditions beyond a rash. Patients should be able to look at this research and make a more informed choice as to whether using video consultation is appropriate for their problem and circumstances that they face.Although this research was undertaken using a small number of respondents in two locations, this study can provide the basis for future work to take place exploring GPs views through quantitative methods.UtilityPracticalityTechnologyThe views of general practitioners in the study can be split into three broad themes related to video consultation:These themes need to be considered by those thinking of implementing video consultation and considering conducting future research. The themes encompass concerns that GPs had towards video consultation and measures should be taken to reassure GPs or address concerns that they may have. The warnings of GPs about video consultations should also be heeded in future decision making on the subject.This research received no specific grant from any funding agency, commercial or not-for-profit sectors.None.


Following publication of the original article , the autThe video files are provided in this Correction article as additional files.Additional file 1: Video segment 1 demonstrates examples of dystonia mimics and psychogenic dystonia. (MP4 225047 kb)Additional file 2: Video segment 2 demonstrates select examples of “don’t-miss” diagnoses. (MP4 133675 kb)Additional file 3: Video segment 3 demonstrates example of patients with primary dystonia. (MP4 166317 kb)Additional file 4: Video segment 4 demonstrates doparesponsive dystonia , one of the most crucial “don’t-miss” diagnoses in dystonia, and paroxysmal kinesigenic dyskinesia (Patients 3–5). (MP4 59281 kb)Additional file 5: Video segment 5 demonstrates a variety of focal dystonias. (MP4 186066 kb)Additional file 6: Video segment 6 demonstrates a woman with left hemidystonia. (MP4 68071 kb)Additional file 7: Video segment 7 demonstrates a variety of tardive dystonias. (MP4 103680 kb)


The correct name is Said Yousef. The correct citation is: Hayawi LM, Graham ID, Tugwell P, Yousef S (2018) Screening for osteoporosis: A systematic assessment of the quality and content of clinical practice guidelines, using the AGREE II instrument and the IOM Standards for Trustworthy Guidelines. PLoS ONE 13(12): e0208251. The Funding statement is incorrect. The correct Funding statement is as follows: The publication of this study was supported by the Canadian Institutes of Health Research (CIHR): CIHR Foundation grant (FDN #143237), and the University of Ottawa library.


App participants with excessive drinking according to public health criteria  at a 7 week follow-up were additionally assigned to the skills-based TeleCoach app or waitlist . All participants were followed at 14 and 20 weeks. At 7 weeks, Promillekoll users showed higher risk of excessive drinking (odds ratio (OR) = 1.83; p ≤ 0.01; n = 1558). Students in eBAC app groups with only hazardous use showed fewer binge drinking occasions at 14 weeks and lower eBAC levels up to 20 weeks compared to controls (n = 1157). Also, more highly motivated participants at baseline in both eBAC app groups drank less compared to controls at 7 and 20 weeks. Hidden Markov model analysis revealed a frequent-heavy drinking group , where those with access to TeleCoach had fewer drinking days compared to assessment-only controls (p < 0.001). eBAC apps showed positive effects up to 20 weeks, particularly for motivated students, and a skills-based app can reduce consumption for those with frequent-heavy drinking patterns.Overconsumption of alcohol, from hazardous to excessive, heavy, and harmful levels, is common among university students. Consenting Swedish students were assigned to one of two smartphone apps offering feedback on estimated blood alcohol concentration  or assessment only ( Evidence has accumulated showing that overconsumption of alcohol, particularly heavy drinking over time, is associated with a high burden of disease with a range of negative personal, social, and economic effects, including higher risk of mental health conditions and high comorbidity of severe mental health disorders ,2. AlthoAbout half of young adults aged 18–25 attend college or university , a time Commercially available native alcohol apps are growing exponentially in number, but the evidence for their effectiveness in reducing problematic alcohol use is limited, both in terms of few evaluations as well as negative or null effects in several trials . A systeOur research group has been studying smartphone apps in two consecutive studies including university students with hazardous drinking see . In StudStudy 2, for which the study protocol was published  thereforThe first aim of the present article was to explore whether revisions made to the native and web-based apps used in Study 1 would lead to reduced drinking frequencies at the 7 week follow-up for participants using either of the two apps in comparison to assessment-only controls. The second aim was to explore the native and web-based app effects, for up to 20 weeks, on alcohol consumption in hazardous drinkers with regular binge drinking but without excessive drinking, in comparison to assessment-only controls. The third and final aim was to draw overall conclusions from Study 2 by examining the interrelationship between individual drinking patterns and intervention-related behavior change in subgroups of participants, through hidden Markov modeling (HMM), a technique used to detect hidden trends in repeated measurements, applied occasionally in addiction research . The present article thus reports the parts of Study 2 that have not been previously published. Three analyses are presented. The first analysis, completely new, builds on data for the entire cohort, from baseline to the 7 week follow-up, a replication of Study 1 b 25]. T. T25]. TThis was a three-armed trial evaluating the effectiveness of giving university students with hazardous alcohol use access to one of two smartphone apps offering feedback on real-time estimated blood alcohol concentration (eBAC) levels, with 7, 14, and 20 week follow-ups. Both intervention groups were compared to assessment-only controls. Participants who at the 7 week follow-up reported weekly alcohol consumption at levels above the national recommendations, that is, excessive drinking levels, were offered participation in an add-on randomized trial see c where tclinicaltrials.gov.Hazardous drinking was operationalized as having a baseline score on the Alcohol Use Disorders Identification Test  of at lDetailed information on procedure is available in the research protocol  and is bThose who provided their informed consent also entered their mobile phone number, information on gender, age, and weight, and responded to the Daily Drinking Questionnaire (DDQ) , the AUDn = 257) were informed about their excessive drinking levels and invited to participate in the add-on trial. The 186 participants who gave their consent for this trial were randomized into an intervention or a wait-list group at a 1:1 ratio. Assessment-only controls were extracted from participants in the main trial who had had excessive drinking levels at recruitment [Participants in either of the smartphone intervention groups who reported excessive weekly alcohol consumption at the 7 week follow-up  for analysis of effects at the 7 week follow-up. Second, to analyze the effects of the native and web-based apps in non-excessive drinkers (n = 1157), defined as those drinking 9 or fewer standard drinks per week (women) or 14 or fewer drinks per week (men) at the 7 week follow-up, we conducted a linear mixed model analysis of effects over four timepoints . Additionally, a three-level model was applied, with the six different universities constituting the clusters at the highest level (level three). Descriptive statistics on baseline characteristics are presented, with analyses of variance used to indicate any differences between groups. First, to analyze whether the revised versions of the two apps used in the preceding study yielded the same results in the second study, a linear mixed models analysis was performed, using the entire sample (quantity (standard glasses/week), frequency (drinking occasions/week), binge occasions per week, eBAC per week, and peak eBAC per month. A separate model was run for each of the five drinking parameters. Motivation to change drinking habits was added as a covariate parameter. The contribution to explaining the variance in the data by adding a third level, as compared to a two-level model, was tested with a likelihood-ratio test; the same test was used to compare a random-slope model to a random-intercept model in terms of data fit. The random coefficient was included at level two since the randomization to the apps was applied at the individual (student) level. Regarding justification of the three-level model with a random intercept and a random coefficient, it should be noted that the likelihood-ratio test comparing a random-coefficient model to a random intercept model yielded a highly significant chi-square value of 75.96 (degrees of freedom (DF) = 1, p = 0.000). The intra-class correlation value on the third level in an empty model was as low as 0.014. However, a comparison of the three-level model to the two-level model with a likelihood-ratio test yielded a chi-square value of 9.50, which was also highly significant .The 1157 students constituted the second level. Level one consisted of repeated measures over time, with outcomes expressed as five drinking parameters: n = 2166) to identify hidden (latent) patterns in student drinking behavior over 20 weeks, and to evaluate whether these patterns might be associated with stable groups (classes) of students as well as with app assignment. For this analysis, the day-by-day weekly drinking records for all participants were used, for one specific week at each of the four timepoints. Hence, in total, 7 × 4 = 28 daily alcohol use quantity observations (1 per day) were available for each participant. The HMM is essentially a sequence model. Using HMM, a number of hidden states or classes were identified in the data on the basis of the characteristics of each student’s sequence of 28 drinking records. Each of the students was initially associated with one of the identified states. On the first day for which drinking data was collected for each student , each student was associated with a certain state. However, students were able to transition from state to state. To model this process, a transition matrix was inferred from the data, which described the probability that a student moved from one state to the next state, for any given day on which drinking data were collected. The HMM is a probabilistic model in the sense that it computes the best-fitting state and the probabilities in the transition matrix on the basis of a probability distribution [Third, we conducted an HMM analysis  on the eribution ,38. For The response rates ranged from a low of 55% for the PartyPlanner group at the 14 week follow-up to a high of 83% at the 7 week follow-up for the assessment-only control group, rates that are not atypical for app studies among university students where no non-automated human contact occurs ,27. Missn = 2166) are shown in n = 1462) and the mean age was just under 26 years . The mean AUDIT score was 10.98 (SD = 4.33), whereas the mean consumption of standard drinks per week was 9.4 (SD = 6.69). On average, participants reported 2.39 (SD = 1.23) drinking occasions per week, with the number of binge drinking occasions per week averaging 1.04 (SD = 0.91). The eBAC level per week was on average 0.018 (SD = 0.023), whereas the mean peak eBAC over the past month was 1.35 (SD = 0.89). With regard to the national recommended drinking levels, 31% of the participants drank excessively at baseline, that is, over the national recommended levels. The baseline level of motivation to change drinking habits was 4.07 (SD = 2.61). A priori drinking frequency was slightly lower in the PartyPlanner group compared to the control group ; otherwise the groups did not differ in any of the characteristics.A total of 4615 students provided their informed consent. Participant characteristics for those who fulfilled criteria for inclusion at baseline . In comparisons between the PartyPlanner group and controls, there were no significant differences  at baseline, 7, 14, and 20 week follow-ups indicated that eBAC levels per week were lower for both the PartyPlanner and Promillekoll groups compared to controls at 7, 14, and 20 weeks. Binge occasions were lower for the Promillekoll group compared to controls at 7 and 20 weeks. At 14 weeks, binge occasions were lower for both groups compared to controls . Motivation to change drinking habits at baseline was significantly associated with lower quantity of alcohol consumption per week for both app groups at 7 and 20 week follow-ups compared to controls  and 20 week follow-up . The three-level model showed that motivation at baseline had a reduction effect on drinking among the group of non-excessive drinkers (n = 2166) revealed the existence of eight ‘hidden’ states in the data according to the model with the lowest BIC value. Examination of the transition matrix indicated that seven of these states were associated with drinking patterns on one specific weekday  and the remaining sample (n = 2020). In summary, the frequent-heavy state differed from the rest of the cohort in that it included a higher proportion of men (52.1% vs. 31.1%) and older members (means of 29.5 vs. 25.6 years). In terms of alcohol consumption, the AUDIT score at baseline was higher (13.8 vs. 10.8), with higher quantity (16.4 drinks/week vs. 8.9) and frequency (4.6 occasions/week vs. 2.2). Also, the response rates of the frequent-heavy state members were somewhat higher than those of the remaining sample at the 7 week follow-up (79.5% vs. 71.4%), 14 week follow-up (76.0% vs. 64.6%), and at the 20 week follow-up (75.3% vs. 62.7%).The HMM analysis of all participants over time . There were no differences between those who had access to the PartyPlanner app and those who had access to the Promillekoll app   in the control group reduced their probability of drinking on any of the days per week to a lesser extent over time compared with those who had access to the Promillekoll app . The difference in downward slope between waitlisted control participants and TeleCoach participants was not statistically significant (OR = 1.03; SE = 0.02; CI = 0.99–1.08; p = 0.144; see also Frequent-heavy drinkers who were in the assessment-only control group had a less pronounced downward slope in terms of reduced drinking days compared to TeleCoach participants (OR = 1.06; SE = 0.02; CI = 1.03–1.09; This study contributed findings on differential effects for apps targeting hazardous drinkers, with both non-excessive and excessive drinking. Overall, eBAC apps had a positive effect for non-excessive drinkers up to 20 weeks, and positive app effects were found for frequent-heavy drinkers, who benefited over time from access to the Promillekoll eBAC app, as well as from the TeleCoach skills-training app in comparison to assessment-only controls. However, access to the Promillekoll app was associated with a higher risk of excessive drinking compared to the control group over 7 weeks, in alignment with our prior finding of a short-term negative effect for Promillekoll app users . NonetheStudy strengths included a design following a stepped care approach, and identification of a hidden sub-group that differed in baseline characteristics and intervention response from other participants. Because the overwhelming majority of apps on the market have not been the subject of any research at all, this study makes a major contribution to the literature by beginning to disentangle relationships between time, severity of use, individual drinking patterns, and intervention content. In terms of limitations, the study was limited by reliance on self-report data, lack of information on actual app use, attrition, and a complex study design. Retention of participants in the study may have been mediated by motivation to reduce drinking, thus reducing external validity in relation to the university student population; however, motivation was analyzed as an independent factor influencing the study findings, thus mitigating the effect of any biased retention. Regarding self-report data, limitations were mitigated by use of questionnaires having been validated in Swedish and online contexts, as well as the fact that participants had no obvious incentive to underreport their drinking behaviors. Regarding information on app use, this has previously been assessed via self-report , but dueThis study had a complex design but contributed a framework for distinguishing between university students who are non-excessive and excessive drinkers, yielding findings suggesting that their need of support differs and that research in this area should attend to distinct sub-group needs. Specifically, our findings suggest that app-based interventions for university students could benefit from specific adaptations to student characteristics, particularly engagement, motivation, and problem severity. First, given the positive effects identified over a period of up to 20 weeks, in contrast to the negative and null findings over 7 weeks, apps targeting university students should include features designed to engage and maintain use over a longer period of time than a few weeks. A recent systematic review identified 19 randomized, controlled trials on apps targeting problematic alcohol use ; the autFuture research should target university students as well as community and clinical samples of treatment-seeking adults. While our findings concern adult university students with baseline AUDIT scores in the hazardous zone, the results may also apply to adults with excessive drinking and higher AUDIT scores who are seeking help via internet interventions ,42,43. FIn summary, future research should begin to disentangle differential effects of eBAC and skills-based apps, more extended digital programs, and guidance versus no guidance, in relation to baseline characteristics including severity of alcohol use, drinking patterns, and motivation. The effects of combining apps with clinical face-to-face treatment in blended care is an emerging area of research that is in its infancy and holds significant promise in the area of addictions as well as mental health issues . We look


Research has shown the effects of climatic factors on shigellosis; however, no previous study has evaluated climatic effects in regions with a winter seasonality of shigellosis incidence. We examined the effects of temperature and precipitation on shigellosis incidence in Korea from 2002–2010. The incidence of shigellosis was calculated based on data from the Korean Center for Disease Control and Prevention , and a generalized additive model (GAM) was used to analyze the associations between the incidence and climatic factors. The annual incidence rate of shigellosis was 7.9 cases/million persons from 2002–2010. During 2007–2010, high incidence rates and winter seasonality were observed among those aged ≥65 years, but not among lower age groups. Based on the GAM model, the incidence of shigellosis is expected to increase by 13.6% and 2.9% with a temperature increase of 1 °C and a lag of two weeks and with a mean precipitation increase of 1 mm and a lag of five weeks after adjustment for seasonality, respectively. This study suggests that the incidence of shigellosis will increase with global climate change despite the winter seasonality of shigellosis in Korea. Public health action is needed to prevent the increase of shigellosis incidence associated with climate variations. Shigella dysenteriae, Shigella flexneri, Shigella boydii, and Shigella sonnei. Symptoms of shigellosis include loose feces, fever, nausea, endotoxemia, vomiting, abdominal cramps, and tenesmus. Shigella bacteria are transmitted via direct or indirect fecal–oral routes from a symptomatic patient or a short-term asymptomatic carrier.Shigellosis is an enteric infection caused by Gram-negative bacillus-shaped bacteria of the genus Shigella. The genus Shigella includes the species The World Health Organization classifies shigellosis as a waterborne and foodborne disease for which the development of a vaccine is imminent . In the S. flexneri and S. sonnei outbreaks occurred in Korea during the 1950–1980s and 1990–2000s, respectively [S. sonnei in Korea [In Korea, shigellosis is classified as a Group 1 nationally notifiable infectious disease because of the possibilities of shigellosis epidemics. ectively . In addiin Korea .It has been predicted that there will be unprecedented global climate change that will lead to increases in waterborne and foodborne infectious diseases. Previous research has shown a positive association between temperature and shigellosis incidence; these studies were executed primarily in tropical and subtropical regions and showed a summer seasonality of shigellosis incidence ,14,15,16The incidence of shigellosis from 2002–2010 was determined from nationally notifiable infectious disease data, which is managed by the surveillance division of the Korean Center for Disease Control and Prevention . Infectious disease cases are reported by health providers working at hospitals or clinics to their regional health center, and the reports are transferred to the KCDC . FinallyRaw climatic factor data were collected by the automatic weather system (AWS) of the Korean Meteorological Administration  from 2002–2010. The KMA operates 494 AWSs all over the country to provide real-time weather information, and raw data is collected at 10 min intervals . PopulatThe incidence rates for each sex and age group were determined and age-standardized rates were calculated using Microsoft Excel 2010 . The population number in 2006 was used as the standard population when calculating the age-standardized rate. The age groups were categorized as 0–2 years (infant), 3–6 years (child), 7–17 years (juvenile), 18–64 years (adult), and 65 years and over (elderly) . We compared seasonal patterns and age-specific incidence rates between 2002–2006 and 2007–2010 because shigellosis incidence and seasonal patterns changed from 2007. A generalized additive model (GAM) was used to evaluate linear and nonlinear associations of shigellosis incidence with temperature and precipitation, respectively. The unit of analysis was province, and datasets were constructed across seven metropolitan cities and nine provinces.Equation (1). GAM for evaluating the effect of temperatureEquation (2). GAM for evaluating the effect of precipitationEquation (3). GAM for smoothing plotsEquation (4). GAM for seasonality stratificationPenalized thin plate regression splines and logarithm link functions were applied to the GAM. We considered shigellosis incidence as a quasi-Poisson distribution because the scale estimate was calculated to be ≥10 . Model spopulation is the population number in the province, α is the dummy variable for the incidence of shigellosis, df is the upper limit on the degrees of freedom, and The lag time between the change in climatic factors and the incidence of shigellosis was set from 0–6 weeks, including the time required for Shigella growth, contamination of water or food, occurrence of the intestinal infection, diagnosis of the infection, and notification of the shigellosis incident ,25. FurtThe annual average incidence rate of shigellosis from 2002–2010 was 7.9 cases per 1,000,000 persons. The annual incidence rate was the highest in 2003 with 23.0 cases per 1,000,000 persons and it gradually declined after 2006. The incidence rate was higher among women than men in every year. The incidence rates decreased significantly after 2006 for all of the age groups except the elderly. Additionally, from 2008–2010, the incidence rate was twice as high for the elderly  than for children  and four times higher than for the other age groups . From 20The incidence rate of shigellosis showed positive associations with temperature and precipitation at all lag times. The associations of incidence of shigellosis with temperature (lag week: 0–6) and precipitation  were statistically significant. A 1 °C increase in temperature and a 1 mm increase in precipitation were associated with a 13.6%  9.2–18.0%) and a 2.9% (95% CI: 0.5–5.2%) maximum increase in shigellosis incidence after two-week and five-week lags, respectively .There was an overall positive association between temperature and the shigellosis incidence rate. The degree of the association was larger below 4 °C than above it, although the precision of relative risk was lower below 4 °C than above it; the lower the temperature below 4 °C was, the wider the 95% confidence interval of relative risk was as observed in The associations between the incidence rates of shigellosis and temperature and precipitation differed for each season. In the spring, a 1 °C increase in temperature and a 1 mm increase in precipitation were associated with a 16.1% (95% CI: 7.8–24.5%) and an 8.4% (95% CI: 4.7–12.1%) maximum increase in shigellosis incidence after a two-week lag, respectively. In summer, a 1 °C increase in temperature and a 1 mm increase in precipitation were associated with a maximum 17.5% (95% CI: 3.2–31.7%) increase and a maximum 2.9% (95% CI: 0.1–5.7%) decrease in shigellosis incidence at one-week and two-week lags, respectively. In autumn, a 1 °C increase in temperature and a 1 mm increase in precipitation were associated with a 20.0% (95% CI: 8.0–32.0%) and a 11.8% (95% CI: 3.1–20.4%) maximum increase in shigellosis incidence at two-week and zero-week lags, respectively. In winter, a 1 °C increase in temperature and a 1 mm increase in precipitation were associated with a 17.4% (95% CI: 12.6–22.2%) increase and a 15.3% (95% CI: 4.2–26.4%) decrease in shigellosis incidence after two-week and zero-week lags, respectively .This is the first study to confirm the association of climatic factors with shigellosis in a region that has shown winter seasonality for shigellosis. The shigellosis incidence rate in Korea associated positively with temperature and precipitation at all of the lag times. After stratification by season, the effect of temperature was prominent, whereas the effect of precipitation was variable.The reduction in shigellosis incidence among children and juveniles may be attributed to active public hygiene interventions for daycare and food service facility workers since 2006 ,30,31,32There have been limited studies on winter patterns of shigellosis seasonality, and they have failed to clearly identify the mechanism underlying these winter patterns ,38. FromIn this study, the estimated effect of rises in the weekly average of the daily peak temperature and the weekly average of the daily precipitation was an increase in the incidence rate of shigellosis. Previous studies from tropical and subtropical regions of China and Vietnam also reported a similar effect of temperature on shigellosis ,14,15,16According to the smoothing plot, the risk of shigellosis increased linearly with increases in temperature, whereas the risk of shigellosis waxed and waned with increases in precipitation yet displayed an overall increase. The larger association between temperature and shigellosis incidence below 4 °C observed in the smoothing plot suggests that a 1 °C increase in temperature may cause a greater increase of shigellosis incidence in cold temperatures than in warm temperatures. A previous study that used GAM modeling showed a positive linear association of shigellosis with temperature and a fluctuating nonlinear association of shigellosis with precipitation, which is consistent with our results . The waxThis study had several limitations. First, although various factors, such as the ecology of the infectious agent and the behavior of the population, may affect the incidence of shigellosis, we only considered the influence of climatic factors on the incidence of shigellosis. Future studies should include other factors, such as humidity and the behavior of the population, which may affect the incidence of shigellosis. Second, because nationally notifiable infectious diseases are reported by health care providers, the statistics do not reflect all cases of infections. Although the reporting rate is lower than the actual incidence rate, it cannot be concluded that the level of underreporting was affected by the climatic factors, and this causes non-differential misclassification. If all cases had been reported, the associations may have been higher than observed in this study. Although the reporting rate of sporadic infections is usually low, the reporting rate is higher if infections occur in educational or daycare facilities where investigations of epidemics are conducted regularly. Differences in reporting rates, which vary according to emerging patterns of infections, may have affected this analysis on the association between shigellosis and climatic factors.This study was meaningful in that it was the first to analyze the association between the incidence of shigellosis and climatic factors in the Korean population and to perform a stratified analysis to identify vulnerable seasons. Second, the study revealed that the winter patterns of seasonality that have been observed since the late 2000s occurred primarily among the elderly population; thus, we recommend enforcement of sanitary control in this population.In this study, the incidence of shigellosis in Korea associated positively with temperature and precipitation, and we predict that the incidence of shigellosis will increase with global climate changes in the future. Therefore, consistent and careful monitoring of the incidence of shigellosis is necessary from a public health perspective. Moreover, further analyses on the association of shigellosis with climate and identification of populations vulnerable to climate change in Korea are necessary.


Given the difficulties in diagnosing and treating head-and-neck cancer, care is centralised in the Netherlands in eight head-and-neck cancer centres and six satellite regional hospitals as preferred partners. A requirement is that all patients of the partner should be discussed in a multidisciplinary team meeting (MDT) with the head-and-neck centre as part of a Dutch health policy rule. In this mixed-method study, we evaluate the value that the video-conferenced MDT adds to the MDTs in the care pathway, quantitative regarding recommendations given and qualitative in terms of benefits for the teams and the patient.A sequential mixed-method study.One oncology centre and its partner in the Northern part of the Netherlands.Head-and-neck cancer specialists presenting patient cases during video-conferenced MDT over a period of 6 months. Semistructured interviews held with six medical specialists, three from the centre and three from the partner.Percentage of cases in which recommendations were given on diagnostic and/or therapeutic plans during video-conferenced MDT.In eight of the 336 patient cases presented (2%), specialists offered recommendations to the collaborating team (three given from centre to partner and five from partner to centre). Recommendations mainly consisted of alternative diagnostic modalities or treatment plans for a specific patient. Interviews revealed that specialists perceive added value in discussing complex cases because the other team offered a fresh perspective by hearing the case ‘as new’. The teams recognise the importance of keeping their medical viewpoints aligned, but the requirement  was seen as outdated.The added value of the video-conferenced MDT is small considering patient care, but the specialists recognised that it is important to keep their medical viewpoints aligned and that their patients benefit from the discussions on complex cases. The study evaluates in depth the video-conferenced multidisciplinary team meeting (MDT) between the centre and the partner in the head-and-neck oncology care pathway and refocuses on benefits and drawbacks (strength).Participating specialists from different specialisms and locations were interviewed and identified benefits and drawbacks of the video conference meetings (strength).The researcher’s presence during video-conferenced MDT may have influenced the communication between the centre and the partner, also called ‘Hawthorne effect’ (limitation).Only one of the six centres and its preferred partner in the Netherlands was studied (limitation).Most tumours in the head or neck region  are fast growing tumours.In 1997, after an informal collaboration period of 4 years, the Medical Centre Leeuwarden became the formal preferred partner of the Head-and-Neck Cancer Centre of the University Medical Centre Groningen,The DHNS and the Dutch Health Care Inspectorate (DHCI) require that all new patients of the partner are discussed in a weekly MDT with the centre.Recommendations from both teams to the decision-making regarding diagnostic and therapeutic plans may add value to the quality of patient care.The aim of this study was to analyse the value of video-conferenced MDT in the treatment of head-and-neck cancer patients in the care pathways, resulting in two questions.How often are recommendations given on diagnostic and/or therapeutic plans by the teams during video-conferenced MDT?What benefits and drawbacks of the video conference are perceived by the specialists in the teams?This mixed-method studyThe video-conferenced MDT was held in dedicated multidisciplinary meeting rooms, where screens can be operated with two to four computers with monitors. While the patient data are presented on the first screen, teams can see each other on the second screen. The videoconferencing is operated via the ‘Webex’ application and a camera. Both locations call into a special safe ‘chat room’.Centre: dedicated 20-seat videoconferencing room with three screens—beamers  and five camera inputs. Four computer stations, one dedicated for radiology showing Picture Archiving and Communication System (PACS) imaging.Partner: dedicated 10-seat videoconferencing room with one screen with possibility to see patient data and the other team; one computer log-on to patient dossiers showing data and imaging.Data of all patients presented by one of the teams during the video-conferenced MDT video conferences between September 2016 and February 2017 were included. The tumour localisation, histology and tumour stage were registered for all patients that were presented.Patients were not involved in the study because the main purpose of the study was to evaluate the added value of the DHCI requirement in a weekly video-conferenced MDT.In a 4-week pilot study of 4 sessions including 46 cases, carried out 9 months before study start, we found that in approximately 20% of cases a recommendation was given. To estimate this percentage with a 10% precision (95% CI: 15.5% to 25.4%) would require 250 cases. On average, 15 cases were discussed at each weekly video-conferenced MDT. We estimated that 6 months would be sufficient to acquire the necessary 250 cases. The pilot study was also used to operationalise the primary outcome measure.Recommendations were registered with the relevant data from electronic and written medical records on a clinical registration form by LSvH during the video conference. Each recommendation was assessed by the two teams with respect to change impact )Semistructured interviews were conducted with six medical specialists that attended the meetings most frequently, one from the OMS, ENT and RT department of each team, to explore the added value of the video-conferenced MDT. The field notes taken by the researcher during the video-conferenced MDT were used to develop the questions for the semistructured interviews. After receiving verbal informed consent from the specialists, the semistructured interviews started with providing information about the recommendations given. Thereafter, it continued with the open question ‘What do you think is the value of the video conference between the head-and-neck cancer centre and their preferred partner?’. LSvH then guided the interview using a short topic list including ‘added value’ and ‘perceived possibilities for change or improvement in the video-conferenced MDT’ . The difInterviews lasted between 25 and 40 min, were audio recorded and transcripts of the interviews were made. The participants were asked to review the transcripts and extracted quotes, related to perceived added value, possible improvements and the role of a specialist in the video-conferenced MDT.Quotes were anonymised and coded for their relevance to possible benefits or drawbacks for the collaboration between the teams and for patient care. The first stage of this inductive analysis of the interviews involved two authors, JR and JGMvdH, in an initial open coding procedure that resulted in a list of codes corresponding closely to the text fragments extracted from the six interviews. The codes were placed in a coding tree using a thematic analysis approach with main themes recommendations, added value, collaboration and planning.From September 2016 to February 2017, 82 patients were presented by the centre and 177 by the partner in 18 weekly video-conferenced MDTs . In thisMost of the centre’s patients (71 out of 82—86%) were presented only once, nine were presented twice (11%), one patient was discussed three times and another four times. Whereas 111 patients were presented only once (63%) by the partner. Generally, patients of the partner where presented twice or three times: the first time their diagnostic plan, the second time the therapeutic plan and sometimes surgical results the third time (55 out of 177—31%). Only one patient was discussed four times; five patients on the partner’s list were not discussed at the first opportunity because imaging was not complete.The partner presented significantly (p<0.001) more cases with infections that were initially suspected malignancy, T1-stage patients and non-complex cases. Tumour localisation and histology differed also significantly between centre and partner . In 61% Recommendations were given in 8 of the 336 cases presented  relating to 8 of the 259 patients .Of these recommendations, five were major and three minor . Four reDuring May 2017, six interviews were held. From the transcripts of the 6 interviews, 107 quotes were registered. During the coding procedure, items were placed in a coding tree with relevance to the primary research question (recommendations given) and the secondary research question (perceived benefits and drawbacks) by the researcher in consultation with the coders. For each major theme, minor themes were derived from the researcher’s field notes. In total, 282 scores were given . In seveBenefits were more frequently mentioned by specialists of the partner, and the drawbacks more frequently by specialists of the centre. But the majority of codes had a positive connotation for the video-conferenced MDT .Six main items were important according to the specialists .1. The video conference adds value when discussing complex cases, through assisting in fine tuning and aligning medical procedures .A patient is presented about which the own team had some discussion that can be discussed with the partner. In that manner, you get a confirmation or advice to change your treatment plan. This advice can be given by the same specialism but also by other members of the head-and-neck oncology team (ENT).2. Communication is essential for cooperation between teams ; furthermore, it is important to know the partner well, not only via videoconferencing , and to interact respectfully  with mutual trust .The most important feature of the video-conferenced MDT is to communicate with each other on substantive medical matters, to be on speaking terms, and to know each other (RT).During the videoconferencing, we respect each other, we listen to each other and we are open to each other’s additional comments. We trust each other as partners (OMS).3. Recommendations are suggested alternatives on diagnostic modalities and treatment plans for specific patients .The video-conferenced MDT has the character of a collegial discussion, in which in collaboration the best diagnostic or treatment plan for your patient is reached. Confirmation on your treatment plan adds value too (OMS).4. For routine cases that fall within guideline for treatment, the video conference meeting adds little value as for changes in medical content, it can even irritate the participants in such cases .The video-conferenced MDT sometimes changes the treatment plan for an individual patient. The video conference is not the meeting where new procedures or guidelines are developed (RT).5. There is a wish to integrate the video conference with the site multidisciplinary meeting in both hospitals, the centre and the partner .Integration of the two local multidisciplinary meetings with the video-conferenced MDT could be valuable (ENT).6. The DHCI requirement  has no added value. It is seen as old-fashioned or outdated .It is better to prepare at a high level and discuss, than to present all the patients and deal with each one briefly. Mutual preparation on special request could have added value, for example, a literature search on a complex osteosarcoma case (OMS).Our results show that the added value of the weekly video-conferenced MDT between the head-and-neck cancer centre and the partner hospital was small given the few recommendations made on the initial diagnostic and/or treatment plan. Nevertheless, the specialists from both sites recognised the importance of keeping their medical viewpoints aligned through this type of communication. Whenever discussing complex cases in which a major change was recommended (in five of the eight recommendations), for example, to change the surgical approach to save functionality of organs or tissue, the recommended change in treatment had a large impact for that patient .The data from the interviews suggest that especially complex patients would benefit from intercollegial consultation via video-conferenced MDT. If the teams were not obliged to discuss so many routine cases, they could use the time saved to prepare and discuss complex cases in greater depth.Because of an increase in patients to be presented in the meeting, we were looking for a more efficient meeting, which could be reached not discussing the ‘formalities’ or ‘routine patients’ (about 70% of patients); developing an evidence-based working method would need more research. This result is supported by a large survey in the UK after 10 years of use of an MDT format, where specialists also said they wanted to change many components and refocus to spend more time on complex cases in detail.The qualitative part of this study showed that medical specialists perceived added value in discussing complex cases in a collegiate consultation, because the other team offers a fresh perspective by hearing the case ‘as new’. Although remarks were often about nuances, the confirmation on the chosen treatment by the other team was experienced as helpful. This view is supported in literature where medical specialists found videoconferencing useful in at least one aspect of their practice.An important requirement to communicate through video conference is that participants know each other from personal meetings to support mutual trust and respect as the basis for cooperation. The finding that collaboration and cooperation improves when each discipline understands each other’s roles and that specialties working together for a long time do not need many words to come to a decision was supported previously.The video-conferenced MDT can be used to introduce and discuss new developments, protocols and guidelines leading to comparable quality of care in both locations. Comprehensive cancer centre teams working together over videoconferencing with a peripheral hospital team, reviewing radiotherapy planning align their treatment plans (7% major and 21% minor changes)The video-conferenced MDT differs from the local MDT: complex cases are discussed with a second ‘expert team’ of head-and-neck oncology specialists. The patients treated by the centre and partner are similar, although diagnostics and treatment might differ slightly,The perceived value of the video-conferenced MDT might be influenced by the expertise of specialists. The recommendations given during the evaluation period were mostly given to ENT by an OMS oncologist who had considerably more clinical experience than his opposing colleague had, and was one of the instigators of the collaboration. It could be that recommendations given were accepted more easily if given by a more experienced specialist.Contrary to our findings from the 4-week pilot study (n=46), where advice was offered in 20% of the presented cases, the actual 2% recommendations is much lower. Although it is difficult to explain this difference in amount of ‘agreed recommendations’, we think that the pilot served mainly as a feasibility check that helped us to define our research questions and to operationalise the definitions. Other factors may also have played a role in the difference between the pilot and the actual study. First, the long-lasting collaboration between the centre and the partner had led to a high level of alignment on diagnostic and therapeutic ‘strategies’ or medical viewpoints. Second, the participants were not blinded for the research question. Thus, awareness of being part of an experiment may have led to a drive to perform well and to present the patients with an optimal diagnostic and treatment plan (Hawthorne effect). Additionally, the presence of the researcher might have influenced the communication between centre and partner. Often, the teams mentioned that the other team was asked to give collegial advice, and therefore, a suggestion was not always seen as a recommendation. This nuance could also be interpreted as a social desirable answer, possibly due to the long existing collaboration between the centre and the partner before study start. Third, some patient cases were only presented as interesting to discuss. Finally, during the pilot study, the advice given was not assessed for its impact.In this study, we evaluated the added value of a video-conferenced MDT between one oncology centre and its preferred partner. In line with other studies,In summary, we believe that the DHCI requirement  is unnecessary in the case of routine patients, since it does not add value to the quality of their treatment. It is more useful to spend time to discuss complex cases in greater detail. We propose the following measures that will add value to the weekly video-conferenced MDT:All the participating medical specialists should be granted freedom to select only complex or interesting cases that could serve to keep medical procedures aligned.The partner should not be obliged to present cases seen as ‘routine patients’ since this does not add value.The video-conferenced MDT should be organised as an integral part of the partners’ MDT and not as a separate weekly meeting.Accepted, mature processes should be regularly reassessed and refocused to enable new collaboration strategies.Based on our findings on the added value of the multidisciplinary video conference between the head-and-neck centre and its partner and our suggestions for improvements, we would advise the DHNS, along with healthcare policymakers, to reconsider the DHCI requirement.In our study, we found that there are clinical and practical implications on how and when to start with videoconferencing instead of meetings with physical attendance. Videoconferencing must be seen as a supportive medium for communication within a sustainable collaboration of parties that understand each other’s roles and work with guidelines or protocols.Participants of a video conference should:Know each other and meet face-to-face on a regular basis, which serve cohesion .Respect each other as ‘expert/knowing’ colleague and know each other’s role in the multidisciplinary treatment of patients.Trust each other in follow-up of changes to diagnostic and treatment plans.In view of the above-mentioned implications, we would not recommend starting with videoconferencing for multidisciplinary meetings if a majority of participants do not know each other.The video-conferenced MDT has added value in the collaboration and in the care pathway management. When interpreting national multidisciplinary guidelines, centre and partner align their medical policies. This leads to a more efficient use of resources and work force.Conversely, discussing non-complex cases is seen as a burden and the DHCI requirement to discuss all the partners’ cases as outdated.