Inappropriate antibiotic prescribing for nonbacterial infections leads to increases in the costs of care, antibiotic resistance among bacteria, and adverse drug events. Acute respiratory infections (ARIs) are the most common reason for inappropriate antibiotic use. Most prior efforts to decrease inappropriate antibiotic prescribing for ARIs  have relied on the implicit assumption that clinicians inappropriately prescribe antibiotics because they are unaware of guideline recommendations for ARIs. If lack of guideline awareness is not the reason for inappropriate prescribing, educational interventions may have limited impact on prescribing rates. Instead, interventions that apply social psychological and behavioral economic principles may be more effective in deterring inappropriate antibiotic prescribing for ARIs by well-informed clinicians.The Application of Behavioral Economics to Improve the Treatment of Acute Respiratory Infections (BEARI) Trial is a multisite, cluster-randomized controlled trial with practice as the unit of randomization. The primary aim is to test the ability of three interventions based on behavioral economic principles to reduce the rate of inappropriate antibiotic prescribing for ARIs. We randomized practices in a 2 × 2 × 2 factorial design to receive up to three interventions for non-antibiotic-appropriate diagnoses: 1) Accountable Justifications: When prescribing an antibiotic for an ARI, clinicians are prompted to record an explicit justification that appears in the patient electronic health record; 2) Suggested Alternatives: Through computerized clinical decision support, clinicians prescribing an antibiotic for an ARI receive a list of non-antibiotic treatment choices (including prescription options) prior to completing the antibiotic prescription; and 3) Peer Comparison: Each provider’s rate of inappropriate antibiotic prescribing relative to top-performing peers is reported back to the provider periodically by email. We enrolled 269 clinicians (practicing attending physicians or advanced practice nurses) in 49 participating clinic sites and collected baseline data. The primary outcome is the antibiotic prescribing rate for office visits with non-antibiotic-appropriate ARI diagnoses. Secondary outcomes will examine antibiotic prescribing more broadly. The 18-month intervention period will be followed by a one year follow-up period to measure persistence of effects after interventions cease.The ongoing BEARI Trial will evaluate the effectiveness of behavioral economic strategies in reducing inappropriate prescribing of antibiotics.NCT01454947ClinicalTrials.gov:  Acute respiratory infections (ARIs) constitute about 10% of all ambulatory care visits in the United States and account for 44% all antibiotic prescriptions provided in ambulatory care . AlthougClinicians who prescribe antibiotics for non-bacterial infections expose patients to unnecessary risks of adverse drug events, and increased costs . FurtherRecognizing the limitations of educational and informational interventions, we developed novel interventions, drawing on insights from behavioral economics and social psychology, designed to appeal to provider self-image and social motivation and thereby produce larger and more enduring effects. These interventions take into account a growing body of research indicating that individuals act within broad social contexts and behave in ways that are not always rational but may be predictable -11.This article discusses the rationale, design, development, and implementation of these interventions as part of a cluster randomized controlled trial to evaluate the use of behavioral economics in the treatment of ARIs.The main intent of this study is to determine whether interventions that leverage information technology and apply behavioral economic concepts reduce the rate of antibiotic prescribing for ARIs. Our primary hypothesis is that practices randomized to receive behavioral economic interventions will have lower antibiotic prescribing rates for non-antibiotic appropriate ARIs compared to control practices. We further hypothesize that for the treatment conditions, individual prescribers’ rates of antibiotic prescribing for encounters with a non-antibiotic appropriate ARI diagnoses will decrease relative to their own historical control rates.We recruited physicians and advance practice nurses from 49 primary care clinics affiliated with three healthcare organizations. Providers were eligible if they treated adult patients with acute respiratory infections. Each study clinic was required to have an electronic health record (EHR) system in place and had to have its own physical building .With the assistance of each site’s medical director, we sent providers at participating sites an introductory email that included a description of the broad goals of the study, a general description of the intervention, and a link to the electronic consent form and baseline survey. We also described compensation providers would receive for participation. The leadership of each clinic site decided whether the financial incentives to participate would be paid as a stipend to the clinic as a whole or to the individual clinician. The amount of the compensation provided to the clinic per participating provider was approximately the same regardless of whether the clinic was randomized to no intervention, one intervention, or multiple interventions ($1200 per full-time provider). We sent up to 6 (median of 3) follow up emails to providers who did not respond, and study personnel contacted them in person when feasible.Participating providers completed written informed consent. The consent document indicated that participation was voluntary and that decisions to participate (or not) would have no bearing on any provider’s status at his or her clinic. Providers who gave consent to participate were asked to complete an online survey and brief educational session prior to the intervention phase, permit de-identified patient records pertaining to patients who saw them for ARIs to be included in the study database, and complete a 15 minute post-intervention survey . Individual protocols for Massachusetts and California sites were reviewed and approved by their local IRBs.After providing consent, all providers were asked to complete a 15 to 20 minute online survey and educational module. The educational module contained information about ARIs derived from evidence based guidelines and systematic reviews -21. The We developed intervention components  using current guidelines for ARIs, as well as input from a research team comprised of individuals with expertise in primary care, acute respiratory infections, behavioral economics, clinical informatics, and the capabilities of the existing EHR systems used by each study site. The clinical decision support was customized according to the capabilities of the three EHR systems in use . All interventions were designed to minimize disruption in provider workflow and to avoid limiting the treatment options available.Accountable Justifications and Suggested Alternatives). These model workflows were iteratively modified to accommodate technical constraints and organizational preferences for each of the three organizations. The Figure The research team developed model workflows described below for the two clinical decision support interventions  indicating that prescribing an antibiotic is not recommended. This may make the provider more likely to believe both that not prescribing an antibiotic is the best medical decision and that prescribing when it is not indicated violates professional standards. Second, they incorporate social accountability. Provider justifications become an explicit, separate part of the medical record, so a provider’s decision to prescribe is subject to the review and judgment of the provider’s peers -24. ThirDefaults may affect behavior for a number of reasons: 1) they may be perceived as a recommended action; 2) they require less effort ; 3) they serve as a reference point so that relative disadvantages of alternatives are viewed as losses that loom larger than relative advantages; and 4) they may seem less anxiety-inducing as people tend to regret active choices that lead to poor outcomes more than they regret failures to act that lead to poor outcomes. We expect all of these factors to contribute to a shift away from inappropriate antibiotic prescribing ,26.When a provider orders an antibiotic through the EHR and enters a non-antibiotic appropriate ARI diagnosis  when a patient has certain comorbid conditions recorded in the EHR problem list or a past medical history  or sanctioned behavior (the injunctive norm) . NumerouWhile benchmarks and performance measurement and public reporting have become increasingly common in health care, ,36 theseonly performance that is desirable . Prior studies of provider feedback related to antibiotic use for ARIs have not constructed feedback in this way [Our performance feedback reports for each provider randomized to receive the Peer Comparison intervention will have three key characteristics: (1) each target provider will receive his or her individual performance, (2) benchmarks will prominently feature the performance of providers who would be considered credibly peers of the target provider, and (3) benchmarks will reflect this way -42.In the Peer Comparison intervention, each provider’s individual performance is calculated as the percentage of encounters for non-antibiotic appropriate ARIs listed in Table Providers randomized to Peer Comparison receive, via email, feedback reports presenting their individual performance, updated every 1–2 months. These emails classify their performance as “top performing” (among the 10% of their peers with the “best”—i.e. lowest— prescribing rates) or “not top performing” . The top 10% of participating providers are calculated within each study region: Massachusetts or California. Emails to providers within the top 10% (lowest prescribers) carry a brief message in the subject line: “You are a top performer.” Emails to those not in the top 10% have an equally direct subject line: “You are not a top performer. You are prescribing too many unnecessary antibiotics.” The proportion of “Top Performers” can be greater than 10% of clinicians if more than10% of them had an inappropriate antibiotic prescribing rate of zero.In addition to this overall classification of performance, the feedback reports for each provider include a denominator count , a numerator count , the provider’s own performance rate (the numerator divided by the denominator), and the performance rate cutoff for the best 10% of providers. Emails also include a link to the guidelines for antibiotic usage in ARIs. Additional file We chose a cluster-randomized design at the clinic level to avoid contamination that might occur if individual providers in close proximity were randomized to different interventions. Providers who practice at multiple clinics were assigned to the intervention of the clinic for which they spend at least 85% of their time. One provider who practiced at multiple clinics was assigned to his own cluster.Geographically distinct individual clinics were the unit of randomization. Clinics belonged to one of three larger clinical organizations covering a connected geographic area in either Massachusetts  or Southern California . We carried out a block randomization of clinics by clinic organization using the statistical computing language R . We firsDates for intervention implementation differ across geographical location, and were contingent upon variations in organizational structure, provider recruitment procedures, and EHR-specific development times for intervention features. Interventions began at the first sites in November 2011. The interventions will be in place for 18 months at each site. A one year follow up period after the cessation of the interventions is planned to measure persistence of the effects.We measured provider characteristics and attitudes by survey. We also asked questions about providers’ attitudes toward practice guidelines, clinical decision support, electronic health records, and practice environment. Additional file The primary study outcome is whether a provider prescribes an oral antibiotic , provider gender, or health system affiliation.For clinicians randomized to the Accountable Justification arm, we will use qualitative methods to analyze the content of their written justifications for prescribing antibiotics to patients with ARIs. To do this, we will create a comprehensive codebook to classify each justification, grouping the codes into coherent themes . Two or more trained physician coders will use the codebook to classify each justification independently. After initial independent coding, all cases of disagreements between coders will be resolved by discussion. Using the final codings, we will examine the distribution of justification codes in conjunction with clinicians’ antibiotic prescribing rates and quantify the extent to which persistent ARI antibiotic prescribing among Accountable Justifications clinicians is well-justified .i by provider j.In our primary model, we will test the impact of each of the 3 interventions and their interactions with each other. That is we will estimate the random effects model that an antibiotic will be prescribed at visit Where PC is Peer Comparison, AJ is Accountable Justifications, and SA is Suggested Alternatives.A Data Safety and Monitoring Board has been established. The board is composed of three physician experts in acute respiratory infection care, and meets biannually throughout the duration of the study to review patient safety and adverse events. Following each meeting, the board makes recommendations to the local IRBs as to whether the study should continue or if changes to the protocol are needed. Data for patients who have a return visit to a study clinic within 30 days of an eligible study visit with a diagnosis that could represent a serious complication of an untreated bacterial infection  will be extracted from study site EHRs and reported to the Board.m-1), where θ is the inter class correlation and m is the number of ARI observations per cluster. In our calculations we assumed an intra-clinic correlation of 0.055 6 and assumed a baseline antibiotic prescribing rate of 50%, an ARI visit rate of 15 visits per month for full time providers, and independence of treatments in the factorials design. We calculated the number of visits needed for an 80% chance to detect a clinically meaningful difference in antibiotic prescribing (7%). We assumed a 75% recruitment success rate for recruiting 376 eligible providers across 49 sites, resulting in 141 providers per study factor  and a one-sided α of 0.05. To achieve statistical power of 0.80 would require a total of 2252 visits at each factor level, or 4504 visits across all study conditions. Therefore, if each provider had a minimum of 16 antibiotic-inappropriate ARI visits over the course of the study, we would have sufficient power to detect a clinically significant effect.Using the correction for inter-cluster correlation from Kish,  we estimWe enrolled 269 of the 376 providers offered enrollment (72% participation rate). For Boston clinic participants, the mean age of providers is 49 years, 60% are female, and 85% are physicians. For Los Angeles clinic providers, the mean age is 45 years, are 61% female, and 71% are physicians. These providers worked at 49 primary care clinics affiliated with the 3 healthcare organizations (22 clinics from the Boston region and 27 clinics from the Los Angeles region). The results of the randomization procedure and the numbers of eligible providers who enrolled in the study are depicted in Table Participating clinics represent diverse practice settings and patient populations. The Los Angeles clinics are predominantly federally qualified community health centers or other safety net clinics. The eastern Massachusetts clinics are academically affiliated and have high proportions of patients with commercial or Medicare insurance. The patient populations served by the eastern Massachusetts clinics are predominantly white (approximately 75%), while the majority of patients served by the Los Angeles clinics is Hispanic (84% at Alta Med and 71% at The Children’s Clinic), with a high proportion of residents living at or below 200% of the Federal Poverty Level.Using a multi-factorial design, three interventions will be tested for their ability to alter inappropriate physician prescribing behavior: 1) Accountable Justifications triggered by guideline-discordant prescriptions that ask providers to provide their rationale for prescribing an antibiotic and include these rationales in the medical record; 2) Suggested Alternatives presented in EHR order sets containing guideline concordant treatment options for ARIs; and 3) Peer Comparisons communicated through emailed performance feedback reports that compare each provider’s own performance to his or her top-performing peers. These interventions build on two main preexisting quality improvement methods: computerized clinical decision support and performance feedback. The main innovation of the current study is that the study interventions are specifically designed to take advantage of irrational (but predictable) behavior patterns common to most human beings—including health care providers. In doing so, we hope to design interventions that will lead to greater provider behavior change than what has been observed in prior studies.This study is being conducted in diverse practices that collectively use 3 different EHRs. This is both a limitation and a strength. Due to their adaptation to each EHR, the interventions differ somewhat across the different sites. The degree to which these differences might influence the effectiveness of the interventions is unknown, and we will examine whether the effects of each intervention are modified by health system. Adapting the study interventions to 3 different EHRs is a strength in that the findings may be generalizable to a wider range of practice settings than would findings from a study conducted within one provider network using a single information system.ARI: Acute respiratory infection; BEARI: Behavioral economics to improve the treatment of acute respiratory infections; EHR: Electronic health record; IRB: Institutional review board.None of the authors have any competing interests relevant to this study.JND, CRF, DM and MWF conceived the study. JND, SDP, MWF, DM, JAL, CRF, NJG, PS, and TKK participated in the design and/or implementation of study procedures. SDP, DM, TKK, and JND drafted portions of the manuscript. JND, DM, MWF, JAL, CRF, NJG, PS, TKK, SDP participated in critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/290/prepubList of Supplemental Materials. Appendix A: Survey and sample educational module at start of study. Appendix B: Post-study survey. Appendix C: Details of development and customization that was required at each site. Appendix D: Example of Accountable Justification decision support. Appendix F: Example of Suggested Alternatives order set. Appendix G: Sample Peer Comparison emails to providers. Appendix H: Oral antibiotics included in outcome measurements.Click here for fileAppendix E New DX code set definitions.Click here for file


Staphylococcus aureus (MRSA) coverage. Limited data are available to directly compare the effect of initial antibiotic choice on treatment outcomes and length of stay (LOS).Empiric therapy of inpatient skin and soft tissue infections (SSTIs) generally require methicillin resistant To assess potential differences in length of hospital stay when inpatients with complex skin and soft tissue infections (SSTIs) were initially treated with either vancomycin, linezolid, or daptomycin.A retrospective review of 219 patients diagnosed with inpatient SSTI who received linezolid, vancomycin, or daptomycin for >48 hours was performed. Data collected included demographics, comorbidities, microbiologic/laboratory data, additional management , hospital LOS, treatment outcome and morbidity/mortality.The three groups evaluated were linezolid (n = 45), vancomycin (n = 90) daptomycin (n = 84). There was no difference between the three groups with respect to gender, age, comorbidities, leukocytosis, fever, antibiotics prior to admission, site of infection culture results and surgical intervention. One death was recorded, not associated with diagnosis of SSTI. No significant difference in LOS was found (P = 0.525) between the 3 groups. The mean LOS in entire cohort was 4.5 days (SD ± 2.5); thirty patients had prolonged LOS for non-SSTI reasons; reanalyzing the data without these 30 patients did not produce any difference in the mean LOS between the 3 groups. Switching vancomycin just prior to discharge to facilitate outpatient therapy was common but did not impact LOS.No difference was detected in hospital length of stay with respect to the initial choice of antibiotic  for SSTI. The three antibiotic regimens were equally effective in treating SSTIs as judged by LOS, irrespective of age, gender, comorbidities or baseline severity of SSTI. Given the large standard deviation in LOS, this result should be confirmed by larger studies. Skin and soft tissue infections (SSTIs) account for a large proportion of hospitalizations. In 2004, approximately 870,000 U.S. hospital admissions were due to SSTIs, an increase of 29% over 2000 data  between January 2009 and September 2010. Charts were selected by ICD-9 codes (680.0 – 686.9) and comprehensively reviewed. One dose of a non-study antibiotic was permitted prior to initiation of therapy with vancomycin, linezolid or daptomycin.Patients between the ages of 18–85 with an acute SSTI, defined as three or more of the following: warmth, erythema, swelling, pain, tenderness, lymph node swelling/tenderness, drainage/discharge, or induration, for less than two weeks. Patients were also included if they had an abscess requiring incision and drainage at bedside or in the operating room. Initial antibiotic treatment was daptomycin, linezolid , or vancomycin and continued for at least 48 hours. The choice of initial antibiotic was entirely dependent on the attending physician’s preference.Patients were excluded if they had osteomyelitis (suspected or proven), decubitus ulcer, necrotizing fasciitis, myositis, gas gangrene, a Gram positive isolate proven resistant to one or more study antibiotics, Gram negative infection, or the presence of concomitant infection upon admission .Hospital length of stay was evaluated in relation to the specific antimicrobial regimen chosen on admission. Length of stay was calculated based on nights spent in the hospital. A prolonged stay occurred when patients were kept in hospital beyond the requisite stay for SSTI treatment for unrelated medical or social problems.Transition to outpatient therapy: .Treatment failure. No clinical improvement after ≥48 hours; switched to a different antibiotic based on physician’s judgment.Staphylococcusaureus or Group A streptococci).De-escalation to a B-lactam antibiotic after organism identification and susceptibility available , clinical presentation , co-morbidities , peripheral vascular disease (PVD), end stage renal disease (ESRD), immunosuppressive therapy, malignancy), social history (tobacco use), and laboratory/radiological data . Treatment data collected included surgical/bedside interventions performed, intensive care unit admission, additional non-study antibiotics administered, and whether a switch in therapy occurred. Switching of antibiotic was defined as a switch from study antibiotic to a different study antibiotic or another non-study antibiotic during the hospitalization. Switching of antibiotics was classified into one of the following categories:X2 test. Age and length of stay measures were analyzed using an ANOVA.Descriptive statistics for all data were collected and stored using Microsoft Excel software. Statistical tests were performed using SPSS software with a p value < 0.05 used to define statistical significance. Nominal data were compared by using the Pearson This research was approved through the Institutional Review Board (IRB) at Orlando Health.Four hundred and seventy two charts were reviewed; a total of 219 patients met the inclusion criteria . No difference in hospital length of stay was observed regardless of initial antibiotic choice for patients admitted to the hospital with skin and soft tissue infection (p = 0.53) , respectively. There was no difference in gender (p = 0.64), history of intravenous drug (p = 0.90) or tobacco use (p = 0.26). The clinical presentation was not significantly different between the three antibiotic groups when evaluated by preadmission antibiotics, site of infection culture results, adenopathy, fever, leukocytosis, drainable foci, radiological evidence of infection, or requirement for surgical intervention Table . FurtherThere was a significant difference in switching of antibiotics during treatment. The vancomycin group had the highest percentage of switching (55%), followed by daptomycin (19%), and linezolid (11%) (p < 0.05). The most common reason for switching antibiotics in all groups was a transition to outpatient therapy; 88% of vancomycin changes were to either daptomycin, so as to facilitate once daily outpatient intravenous antibiotic therapy, or a transition to oral treatment. The vancomycin patients changed to daptomycin almost invariably occurred on the last hospital day and had no influence on LOS. Only one patient in any group (daptomycin) was changed due to treatment failure Table . No patiOne death was recorded, not associated with the diagnosis of SSTI.This retrospective “real-world” study found no significant differences in length of stay between the three most commonly used empiric inpatient anti-MRSA antibiotics for skin and soft tissue infections requiring inpatient care. Previous in vitro work supports daptomycin as the superior agent . Daptomycin is a remarkably easy drug to use, but it may occasionally cause myopathy or serious eosinophilic pneumonia , both to limit cost and the risk of daptomycin or linezolid resistance. How long vancomycin will remain the workhorse inpatient choice remains unclear, and will likely depend on differential resistance among these 3 agents, new drugs such as ceftaroline, and external economic factors.


Though the male were slightly more aware than the female, the relationship is not statistically significant (p= > 0.05). Awareness among S.S.C. passed and above is quite more than the awareness of illiterate (p = <0.01). But there was no relation (p= > 0.05) of level of family income and living pattern with level of awareness. Even being a risk group the garment workers not much aware of HIV/AIDS. The level of awareness increased with age and literacy, which shows the window of opportunity for the policymakers that educational intervention program, may be effective for them.The study was conducted to assess the level of awareness on HIV/AIDS (Acquired Immune Deficiency Syndrome) and the Influence of different socio-demographic factors among the garment workers in Bangladesh. This cross sectional study was carried out among 303 workers in three selected garment factories in Dhaka city from July 2010 to June 1011. Data were collected by face to face interview through a predesigned questionnaire containing desired information. The majority of workers (76.6%) were within the 17–19 years age group. The female respondents predominated (55.1%). A considerable number of the sample population (39.3%) completed the primary education. But majority belonged to low income group (68.4%), followed by the very low income group (22.4%). Almost everyone (98.3%) except five of the respondents heard the word HIV/AIDS and most of them (90.6%) knew that the disease is transmissible from person to person and mainly by sexual intercourse (78.9%). Only 28.2% had some idea about the sign symptoms of HIV. About (64.4%) thought that persons having heterosexual partners (including prostitutes) are high-risk groups. Though many (74.2%) of the respondents thought that HIV/AIDS is preventable, only 45% said HIV/AIDS is not curable. But 70.5% answered that death is the ultimate fate. The main source of information was radio/TV, newspaper. Unfortunately, 76.9% of the respondents had poor awareness while only 10.6% had good awareness. The level of awareness increased with age ( Since discovery of AIDS in 1981 and its causative agent in 1983–1984, there have been significant advances in our understanding of this disorder  and 14 questions related to knowledge of HIV/AIDS with 42 probable answers (see information check list section). Each correct answer carried 1 mark and wrong or unknown answers carried 0 mark. Thus the respondents were given score between 0–42. The level of awareness was measured by arbitrarily ranking the score. A score above 21 was considered good awareness (i.e. a respondent giving at least 50% correct answers), from 17–21 (40–49% correct answer) was labeled as average awareness and those below 17 (<40% correct answer) as poor awareness. The questionnaire was pre-tested among garments workers of a selected garments factory and necessary modification and correction had been done prior to final stage of data collection. The study protocol was approved by the ethical review committee of Dhaka Medical College. Informed written consent was taken from each of the respondents. Information was collected from the respondents through face to face interview of 15 to 20 minutes.2 tests were used to compare proportions. A two-tailed p value of 0.05 was considered significant at 95% CI  level.Statistical analyses of the results were obtained by using window based computer software devised with Statistical Packages for Social Sciences (SPSS-16) . The results were presented in tables, figures and diagrams. During analysis frequency distribution for all the variables were worked out and produced in tabular form. The χI.Socio-demographic variables:AgeSexMarital statusEducationPersonal incomeFamily incomeMonthly income: Housing conditionFamily sizeLiving with family or notII.Variables related to AIDS knowledge:Causative agentRoute of transmissionSign & symptomMethods of preventionPlace to go for treatmentIll effects of AIDSRisk groupEducational status: It is classified into following groups: A.Illiterate: The respondents who can neither read nor write.B.Non-formal education: The respondents who can read or write but have not attended schools or colleges.C.Primary: The respondents who have attended the school upto class V.D.Lower secondary: The respondents attending the school between class V to class VIII.E.Secondary: The respondents attending the school above class VIII to S.S.C. level.F.Higher secondary: The respondents above S.S.C. level upto H.S.C. level.Family income: It is the total amount of money earned by the respondent and by his/her family members in each month. It is classified as follows: A.Very low income: Family income upto 4000 Tk per month.B.Low income: Monthly family income is in between 4001–10000 Tk.C.Moderate income: Monthly family income is in between 10001–20000 Tk.D.Good income: Monthly family income is more than 20000 Tk.Mess: Group of people living in the same residence and regularly taking meals together.Boarding house: It is a house where a paying guest is provided with meals and lodging.Awareness scoring: Total 42 answers, each correct answer carries 1 and wrong answer, do not know or others carry 0.Awareness grading:A.Good awareness: Correct answer ≥ 50% i.e. awareness score is 21 or above.B.Average awareness: Correct answer 40 to 49% i.e. awareness score is 17 to 20.C.Poor awareness: Correct answer < 40% i.e. awareness score is below 17.This cross-sectional study involved 303 respondents. The majority of them, (76.6%) were within the 17–19 years age group. A minor proportion, 2%) were under 14 years. The rest of the respondents, 65 (21.5%) were in 14–16 years group. The female respondents predominated (55.1%) in this study. A considerable number of the sample population (39.3%) completed the primary education, many went to high school (30.7%), but only 9.9% passed secondary certificate examination and 1.6% passed higher secondary exam. About 16.8% were illiterate. On the basis of monthly family income majority belonged to low income group (62.2%), followed by the very low income group (22.4%). Many of the workers lived with their families (58.7%). Among the rest (41.3%), a good number lived in mess (22.8%), some, with relatives (15.2%) and the others (3.3%) in hostels, boarding houses (Table % were unp = <0.05). The study showed that, out of 136 male respondents, 18 had good awareness while among 167 female, 14 had good awareness. That is, male were slightly more aware than the female, though their relationship is not statistically significant (p= > 0.05). Awareness among S.S.C. passed and above is quite more than the awareness of illiterate (p = <0.01). But there was no relation (p= > 0.05) of level of family income and living pattern with level of awareness . Such degree of poor awareness in the later group (<14 year) may be due to the fact that traditional social system and health care service often ignore this group as a separate entity who are treated neither as child nor as adult. Their age remains the main barrier of communication with adults regarding information on sex and sexually transmitted diseases like HIV/AIDS. This is also in close agreement with Bangladesh Demographic and Health Survey (BDHS) (Khan p = <0.01). It is in agreement with  Khan , which rS) Khan , (Paul-MS) Khan  and repoS) Khan , which iS) Khan . The levIn this study almost all the respondents said that they have heard about HIV/AIDS. This is very much similar with (Goel and Pandey Many had good idea about route of transmission. This is a good sign that only few have misconception about the transmission who thought that it might be transmitted by casual contact, shaking hands, eating together which shows the similarity with Goel N.K et al., conducting a study among the nursing professionals (Goel and Pandey We had some limitations in the study. Firstly, we selected the study places semi purposely. Secondly, the study result only from Dhaka city may not reflect completely the whole scenario in Bangladesh. Finally the sample size was also small in relation to the total number of garments worker in the country.The study reveals that most of the respondents think HIV/AIDS as a transmittable disease. But they had no or very little idea about the sign symptoms of HIV/AIDS. Two very important observations have explored out from the study that the awareness is directly proportional to the age and level of literacy. So, it could be proposed, to raise awareness against HIV/AIDS emphasis should be given on increasing the literacy rate and arranging and strengthening the campaign program against HIV/AIDS among the garments workers.Considering the epidemiological characteristics of AIDS pandemic in Asia, it is essential that the youth be given appropriate information and education on reproductive health matters including HIV/AIDS. There is a need for developing and implementing working group based program on HIV/AIDS prevention to reduce HIV related risk behaviors, particularly the unprotected sex. Mass education by a series of interventions and events at industry level, backed by effective interpersonal communication as peer education, factory based teaching and community action should be more extensively considered in this context.


EHP examines strategies for reducing environmental pollution with antibiotics, ARBs, and ARGs from various sources, including traditional agriculture, aquaculture, wastewater treatment plants (WWTPs), pharmaceutical manufacturers, and hospitals.A growing body of literature describes how human pathogens in the environment acquire antibiotic resistance genes (ARGs), a process potentially boosted by selection pressure from antibiotics. Contaminated water and soil may then maintain and spread these antibiotic-resistant bacteria (ARB) and ARGs. A review in this issue of “This information needs to reach a wider audience, especially in the medical and public health fields,” says coauthor Amy Pruden, a professor of civil and environmental engineering at Virginia Tech in Blacksburg.Enterococcus faecium fell from 76% to 13% in Danish broiler chickens and from 90% to 47% in pigs, suggesting that regulations can be useful in reversing antibiotic resistance in food animals.Limiting antibiotics in animal production is the most direct way to control environmental ARB and ARGs, according to the authors.Good animal husbandry practices, such as low animal density and good nutrition, keep animals healthy and reduce the need for antibiotics.,Antibiotics, ARB, and ARGs from farm animals, households, hospitals, and drug manufacturers often end up at WWTPs. These facilities are designed primarily to remove solid organic matter, nitrogen, and phosphorus, although some also apply disinfectants to kill bacteria.WWTPs hold promise as a critical point for removing ARB and ARGs by biodegradation, adsorption, chemicals, and other effective and economical modifications. “More research is needed to identify which treatments are most effective to better design WWTP operations,” says Pruden.Certain drug manufacturing hubs have been identified as “hot spots” that release high levels of antibiotics, ARB, and ARGs into surface, ground, and drinking water.“All solutions must start with changes in local practices and then be implemented at a global scale, or we will get nowhere,” says coauthor David Graham, a professor of ecosystems engineering at Newcastle University, United Kingdom. The problem of antibiotic resistance “will only be reduced if we change our behavior at all fronts,” Graham says. “Greater control of the medical and agricultural uses of antibiotics must be coupled with greater control of our wastes.”Marilyn C. Roberts, a professor of environmental and occupational health sciences at the University of Washington in Seattle, commends the review authors for presenting “the big picture,” but she says providing specific details about what individuals can do would have been a valuable addition. For example, people could demand that food labels state whether food was grown with antibiotics and list the levels of antibiotic residues in a food. “This information would allow consumers to choose not to select products that use antibiotics and/or have measurable amounts of antibiotic residues,” Roberts says.,Antibiotic resistance is now making an appearance on Capitol Hill. A bill titled Strategies to Address Antimicrobial Resistance (STAAR) was reintroduced to the U.S. House of Representatives in June 2013.


The use of Indigenous Knowledge (IK) can help students to form schemas for interpreting local phenomena through the prism of what they already know. The formation of schemas related to HIV/AIDS risk perception and prevention is important for individuals to form local meanings of the HIV/AIDS epidemic. The objective of this study was to explore the indigenous names and symptoms of HIV/AIDS among High School students in NamibiaFocus group discussions were used to collect qualitative data on indigenous names and symptoms of HIV/AIDS from students in 18 secondary schools located in six education regions. Data were grouped into themes.ihule, butuku bwa sihule, and shikumbu. Names such askibutu bwa masapo (bone disease),katjumba (a young child),kakithi (disease), andshinangele (very thin person) were used to describe AIDS. Derogatory names like mbwa (dog), esingahogo (pretender), ekifi (disease), and shinyakwi noyana (useless person) were also used. Other terms connoted death , fear , and subtle meaning using slang words such as 4 × 4, oondanda ne (four letters), desert soul, and mapilelo (an AIDS service organization). Typical (body wasting) and non-typical  symptoms of HIV were also revealed.People living with HIV/AIDS were called names meaning prostitute: The study determined students' IK of the names and symptoms of HIV/AIDS. Programmes to prevent/manage adolescent HIV infection and stigma may be strengthened if they take students' indigenous understandings of the disease on board. Indigenous Knowledge (IK) is an important foundation for sustainable and innovative solutions in education, health, agriculture, and biotechnology. At a regional symposium in South Africa, Nkondo cautioned that the quest to understand and use Indigenous Knowledge Systems (IKS) should not be likened to "primitive anthropology" . AccordiIn terms of the school curriculum, the use of IKS can help students to form schemas for interpreting local phenomena through the prism of what they already know ,5. It haCultural factors are important in health-related schemas , and theSeveral studies have documented the indigenous understandings of HIV/AIDS among traditional healers in Zimbabwe  and schoomukithi gwonena which means modern disease or developmental disease. That label means that HIV/AIDS is deeply embedded into modern living conditions; that AIDS has a lot to do with modernity. AIDS is also called "the disease" or "the three-letter-illness", and the terms "HIV" and "AIDS" were rarely used [In Namibia, the first four cases of HIV/AIDS were diagnosed in 1986 . Therefoely used .Therefore, it is important that the formal school HIV/AIDS curriculum is implemented within a microcosm of IK of HIV/AIDS. Thus, formal HIV/AIDS education should take into account the indigenous jargon of HIV/AIDS that people use. In fact, UNESCO  also recMy Future is My Choice, a UNICEF-sponsored programme which emphasizes the ABC  approach [In Namibia, IK about HIV/AIDS has not been mainstreamed into HIV/AIDS education and interventions. In secondary schools, HIV/AIDS education is delivered through science subjects such as Life Science (for students in Grades 8-10) and Biology (for students in Grades 11-12). In Grade 9 Life Science, HIV/AIDS is taught during the topic on health education. Here, the HIV/AIDS content is restricted to types of HIV tests, knowing one's HIV status, symptoms of HIV, and statistics of the global epidemiology of HIV/AIDS in 2001 . In the approach .Given the importance of IKS to the formation of schemas, social meanings, and subjective realities of HIV/AIDS, we hypothesized that the teaching and learning of HIV/AIDS may be enriched by the inclusion of students' IK into the secondary school HIV/AIDS education curriculum. To our knowledge, uncovering indigenous understandings of HIV/AIDS has not been done among High School students. Thus, the objective of this study was to explore the indigenous names and symptoms of HIV/AIDS among High School students in six regions of Namibia.Ethical permission to conduct the research was obtained from the University of Namibia Post-graduate Studies Committee. Permission to conduct the research in secondary schools was sought from the Permanent Secretary of the Ministry of Education in Windhoek. In the regions, permission to visit the schools was received from the Regional Directors of Education. At the schools, permission was obtained from the school principals, and students were informed that they were free not to participate in the study.Data were collected between October and November 2009. A cross-sectional survey involving a three-stage sampling design was utilized. A cross-sectional design was appropriate because it was a snap-shot exploration that allowed a statistically significant sample of a population to be used in estimating the relationship between an outcome of interest and population variables as they existed at a particular time. The primary sample included six education regions: Caprivi, Kavango, Ohangwena, Omusati, Oshikoto, and Khomas. The regions were purposefully selected because of their high prevalence of HIV/AIDS (> 15.0%). Eighteen government-run secondary schools (three from each region) were randomly selected into the secondary sample. Within the schools, data were collected from randomly selected classes of either Life Science or Biology students (the tertiary sampling units). The Life Science and Biology students were included into the sample because they studied HIV/AIDS in these subjects. Teachers were requested to leave the classroom immediately after the researchers were introduced to the students. This helped to reduce the intimidation of the students. After obtaining their verbal consent, the class of students was divided into two groups.The data gathering phase involved collection of demographic data and focus group discussions. There were a total of 829 students in the 36 focus groups. The students' ages ranged between 13-27 years with a median age of 17 years. They hailed from various ethnic groups: 62.0% were Ovambo, 14.8% were Kavango, 3.5% were Herero, 3.6% were Damara-Nama, and 2.3% were classified as 'others' . There were 44.1% male and 55.9% female students. Focus groups consisted of both male and female students.Focus groups were allowed to discuss various local names and symptoms that people in their communities associated with HIV/AIDS. The discussions were led by the researchers. The two standard questions in the focus groups were: "what names do people associate with HIV/AIDS?" and "what symptoms do people associate with HIV/AIDS?" Qualitative data were recorded into note books and indigenous terms were later translated into English by experienced local translators. Names associated with HIV/AIDS were grouped into the following themes: sex, prostitutes, HIV infection, AIDS syndrome, fear-factor, derogatory names, witchcraft and slang. Symptoms of HIV/AIDS were divided into two themes: typical symptoms and non-typical symptoms. Cross-checking of data was done in order to determine predominant terms for names and symptoms of HIV/AIDS.simbandembande which is the name of the fish eagle in the indigenous Lozi language. People suffering from HIV/AIDS were also called mapilelo, a name of a local Non-Governmental Organization (NGO) that provides home-based care for people living with HIV/AIDS. In the Kavango region, people living with HIV/AIDS were called ihule (or sikumbu) which mean prostitute, esingahogo (means a pretender or a snake), and zamu zuguma (which means victim).The names that people associated with HIV/AIDS are presented in Table four letters or ekifi (meaning disease). In the northern regions of Ohangwena, Omusati, and Oshikoto, HIV/AIDS was generally called ekiya (or okakiya), which in the indigenous Oshiwambo language means thorn. Other Oshiwambo references to HIV/AIDS included kadhipagi (killer disease), aaholiyiipala (people addicted to sex), nakusa (someone who is about to die), okakwega , osuvi (AIDS), akulyuunona ("child killer" or sex), and kaavulika (someone that does not listen to advice).In the Khomas region, AIDS was often called The symptoms associated with HIV/AIDS are listed in Table Indigenous names used to refer to HIV/AIDS, at least in part, influence how people perceive their susceptibility to HIV/AIDS. Such names signify how people think about the disease. They also might help or hinder efforts aimed at creating interventions based on indigenous understandings of HIV/AIDS. Through such names and caricatures, individuals interpret and find personal meanings, actions, and behaviours towards HIV/AIDS.simbandembande is meant to scare people from engaging in risky sexual behaviours because HIV/AIDS quickly takes away people's lives, much the same way as the fish eagle takes away small fish from the water. Engaging in these discourses therefore fuels the individualistic (micro) and collective (macro) social forces that galvanize preventive sexual behavioural norms in the local community.Some of the indigenous names of HIV/AIDS in this study revealed that Namibians think of HIV/AIDS as a condition that affects individuals that love sex, for example prostitutes. In many African countries, irresponsible, immoral and promiscuous sexual behaviours are commonly believed to be responsible for the heterosexual HIV epidemic, regardless of the epidemiological reality . DerogatFurthermore, people in the Caprivi region that are HIV positive often blame witchcraft as the cause of illness. In this way, HIV/AIDS is likely to be considered a more socially "acceptable" illness narrative . While Hmapilelo, a local NGO providing home-based care to AIDS patients, invokes a sense of helplessness and dependency that accompanies this debilitating disease. It also helps to shape the attitudes of people that would be infected with HIV/AIDS towards help-seeking. Social stereotypes are a type of role schema [The appellation of HIV/AIDS as e schema . Thus, ie schema .On the other hand, local caricatures and social constructions of HIV/AIDS are an important component of the school's hidden curriculum. The hidden curriculum is defined as those unstated norms, values, and beliefs embedded in and transmitted to students . The hidekiya (thorn), katanga kamufifi , and owayapa (HIV-infected). These cultural references to HIV become shared learned meanings that are transmitted for the purposes of promoting individual and societal adjustment to the AIDS epidemic. The slang and derogatory appellations to HIV/AIDS also show that the shared meanings are dynamic and subject to continuous modification in response to the changing epidemic.Again, the point is that the study of HIV/AIDS is too culturally-sensitive, subtle and dynamic to completely capture into a formal school terminology and curriculum. To circumvent such shortcomings, public knowledge of the local caricatures of HIV/AIDS, including their street or village lingo, are a powerful form of the hidden curriculum that, if harnessed properly, may transform secondary school teachers' and students' knowledge and perceptions of HIV/AIDS. Due to the silence around HIV/AIDS, the Ovambo people prefer to be subtle when referring to the condition. Thus HIV/AIDS is called omukithi gwonena is not to be misunderstood as a backlash to Europeans because they have accused Africans to be the source of HIV, but rather as a conceptualization that HIV/AIDS is part of the modern world where traditional behavioural standards are no longer formative and where indigenous or subsistence modes of life have been replaced by external ones. The reality is that Namibians view HIV/AIDS as a component of the social process of modernization.Selikow  assertedThere were also metaphors that equated persons with HIV/AIDS to sex, promiscuity, and death. The danger with some of these indigenous terminologies is that they help to sweep the HIV/AIDS epidemic under the carpet. This is so because they encourage stigma, discrimination, and rights abuses of people living with HIV/AIDS. Many derogatory expressions also subtract from efforts such as Voluntary Counseling and Testing (VCT) for HIV/AIDS, disclosure that one is HIV-positive, and starting or adhering to antiretroviral therapy.On the other hand, the results of this study suggest that slang words and derogatory language towards HIV/AIDS may have helped students and teachers to form localized meanings of the epidemic. The language used to describe persons living with HIV and the symptoms that students associated with AIDS were part of the informal curriculum through which AIDS was understood. In certain cases, local terminologies that were associated with HIV/AIDS were meant to protect individuals by way of instilling fear. Sometimes local descriptions of HIV/AIDS were meant to convey subtle messages, for example, when referring to a person perceived to have been infected with the virus.simbandembande), Kavango (kambumburu), Khomas , Ohangwena , Omusati (kadhipagi), and Oshikoto .The use of certain metaphors very often reflected the students' worldviews of HIV/AIDS. We believe that some of the current efforts to reduce stigma against people living with HIV/AIDS and interventions to prevent and manage HIV/AIDS  may fail if they are not anchored on the local people's IKS. Predominant terms should be included into variegated regional HIV/AIDS education curricula: Caprivi . Yet, there were also novel descriptions of HIV/AIDS symptoms such as big head, red eyes, stiff neck, painful joints, red lips, change of skin colour, and impaired vision. Besides physical body symptoms, psychological manifestations of HIV/AIDS  were also documented. The results also suggest that apart from body symptoms of disease, indigenous experiences of HIV/AIDS were now in transit to more psychological manifestations such as stress and depression.The symptoms noted in this study, including the terms used for AIDS and people with AIDS, were essentially the same in all six regions, thus emphasizing that the etiological and biological reality of AIDS is quite consistent from region to region. However, the cultural constructions of HIV/AIDS differed by region. This revelation has implications for AIDS interventions because while the curriculum for the biology of HIV/AIDS may be the same across regions, the inclusion into the curriculum of cultural schemas and lenses through which students understand AIDS need to be variegated.This study attempted to determine the students' knowledge of the indigenous names, meanings, and caricatures of HIV/AIDS. Symptoms which indigenous people associated with HIV/AIDS were also revealed. Once imbued into the formal school curricula, such indigenous vocabularies may help teachers and students to find local meanings that resonate with their easy-to-understand social constructions of the HIV/AIDS epidemic. We recommend that HIV/AIDS interventions targeting students should be anchored on their IK of the disease. Further, public awareness campaigns should be conducted in order to reduce the use of indigenous caricatures of HIV/AIDS that exacerbate stigma, embarrassment, discrimination, and human rights abuses. This will help change people's attitudes and lead to increased uptake of VCT, disclosure, and improved adherence to antiretroviral therapy.The authors declare that they have no competing interests.KCC participated in the conceptualization of the study, collected data, conducted the analysis, and wrote the manuscript. CDK, CNSS, and DZ participated in the conceptualization of the study, supervised the study, and made critical comments on the draft manuscript. CNSS also conducted Oshiwambo to English translations. All authors read and approved the final manuscript.


Upper respiratory tract infections (URTIs) are common in children. The cause of URTIs is usually viral, but parents' attitudes often contribute to inappropriate prescription of antibiotics, promoting antibiotic resistance. The objective of this study was to document and analyse parental beliefs on antibiotic use for children with URTIs in Greece, a country with high levels of antibiotic use and antibiotic resistance.A knowledge-attitude-practice questionnaire was developed and distributed to Greek parents caring for children who were 5-6 years old, between January and July of the same school year. The sample of the study contained parents from all geographic areas of Greece.The majority of Greek parents (80%) believed that UTRIs are mostly self-limited, although 74% of them expected to receive antibiotics when such a diagnosis was given. Earache was the most common reason for which parents expected antibiotics (45%). Greek parents rarely gave antibiotics to their children without medical advice (10%) and most (88%) believed that unnecessary antibiotic use drives antibiotic resistance and they were happy to receive symptomatic therapy if instructed by their physician. Almost 70% of parents confused antibiotics with other medicines used for symptomatic therapy for a child with URTI.Greek parents have a trusted relationship with their paediatrician and rarely give antibiotics without medical advice, indicating that parents contribute less than expected to antibiotic misuse. Parents also appreciate the benign course of most URTIs and the fact that unnecessary antibiotic use is harmful. More time needs to be invested in educating mostly physicians on the potential benefit from reducing antibiotic prescribing for children with URTI. Over the past decade, the emergence of antibiotic resistance has been recognised as an important public health problem because discovery of new antibiotics is no longer keeping pace with the spread of highly resistant bacterial pathogens . PrescriAccording to the latest data from the European Centre for Disease Prevention and Control, Greece has the highest rate of antibiotic consumption amongst 27 European member states . There iThe KAP study measures the knowledge (what people know), attitude (how they feel) and practices (how they behave) of the population under study.Our study sample contained parents of all geographical areas of Greece . A school-based stratified geographical clustering sampling was used to select a representative sample of students, whose parents were asked to fill in the questionnaire by a letter explaining the importance of the subject  and their cooperation in the study. The population of children aged 5 or 6 years old in Greece was approximately 240,000, according to the census of 2001. The number of required geographical clusters was calculated to be 200 based on the mean number of students in each class (n = 40). In total, 100 kindergarten (age 5 years) and 100 elementary schools  were randomly selected and stratified according to the population of children in each region. The sample size was estimated taking into consideration the geographical cluster sampling methodology (double the needed sample) and the expected percentage of non-responders (20%). Approval was given by the Ministry of Education to contact the parents through the selected students. A total of 7704 parents with children aged between 5 and 6 years old were invited to participate in the survey. The survey was conducted between January and July of the same school year. The study design and questionnaire was approved by the educational institute of the Ministry of Education and General Assembly of the Medical Faculty at the University of Thessaly (reference number: 401/15 - 02 - 06).The scientific team, which constructed the questionnaire, included one epidemiologist, two paediatric specialists on infectious diseases, one statistician and one MD researcher. The main objective of the study was to include questions based on the methodology of KAP studies conducted in other countries, but to adapt them to the Greek situation and culture. To accomplish this goal, manuscripts and published papers describing similar research and methodological issues were studied. Initially, the draft of the questionnaire included 77 questions. To assure the clarity, accuracy and consistency of the questions, the questionnaire was pre-tested among 30 parents. The scientific team evaluated the pre-test results and after excluding and modifying some questions, the final questionnaire was designed , was structured into three main sections: (1) knowledge that parents possess to understand issues concerning URIs and antibiotics ; (2) attitude concerning parental feelings, beliefs or conceptions towards antibiotic use in URIs ; and (3) practise concerning the ways that parents demonstrate their knowledge and attitude through their actions . Most questions were based on the 5-point Likert scale, which expresses emotions: strongly disagree - disagree - uncertain - agree - strongly agree; frequency: always - most of the time - often - sometimes - never; and quantity: very much - plenty - not much - a little - none. Chronic disease was defined as recurrent URTIs such as asthma.A more detailed description of all methodological aspects of the study, including the design, development and reliability of the questionnaire, and sampling procedures have been presented in a previous paper . The curThe data were entered into a database using the Epi Info program and were analysed by SPSS version 15.0. Descriptive analysis was conducted by using frequencies of the variables and the 95% confidence intervals (CIs) were calculated. Questionnaires that were poorly completed (< 50% of the questions) were excluded from the statistical analysis [We collected 5312 questionnaires out of 7704 that were initially disseminated, representing a response rate of 68.95%. Forty-eight questionnaires were excluded later because of poor completion. The highest response rate was from Northern Greece (74.36%), while the lowest was found in the islands (62.27%). The demographic characteristics of the respondents are demonstrated in Table Ninety percent (CI: 89%-90.7%) of parents obtained information on judicious antibiotic use from paediatricians. Thirty-seven percent (CI: 34.2%-39.3%) of parents obtained information from the media, while just 2.2% (CI: 1.8%-2.6%) declared that they "had never been informed" about appropriate antibiotic use (question 15).When parents were given a list of drugs including antibiotics, antipyretics, bronchodilators and expectorants, and were asked to distinguish antibiotic products from other drugs, 30.4% of them made no mistakes at all, 42.1% made one mistake and 27.5% made two or more mistakes (question 16).Figure Once a child develops URTI symptoms question 24), over 40% of parents would seek a paediatric opinion within 2-3 days . When parents were asked for possible treatment options, they chose antibiotics as a possible therapy 74% of the time. In addition, when parents were asked for the most common symptoms leading to a paediatric visit  (question 26), 95.4% of symptoms were a runny nose (CI: 94.8%-95.9%), often accompanied by other symptoms. Figure 4, over 4Ten percent of parents (CI: 7.5%-14.2%) would consider giving their children antibiotics without previous medical advice (question 28). More precisely, a lack of money or time would lead to over the counter antibiotic consumption in just 1.2% (CI: 0.7%-1.8%) of the participants, while 2.2% (CI: 1.6%-3%) would administer antibiotics to their child because they thought that symptoms were not important enough to visit the paediatrician.Figure Figure This is the first published population-based study on KAP of parents from Greece in relation to treatment of URTIs. The overall response rate was almost 69%, which is satisfactory, although it varied amongst different regions of Greece. The highest rate of a low educational status was noted in the islands, indicating that this could be a factor for the low response rate of the islands. On the other hand, in Northern Greece, since the immigrant population was less compared with other regions, it is likely that the respondents understood the Greek language and medical terms better than in the other regions, and therefore, a higher proportion participated in the study. In contrast, the islands have the highest percentage of immigrants (data shown in a previous paper) .According to the geographical clustering methodology, we had to double the sample required, and therefore, this required a large sample size. The number of clusters was also increased to cover the likelihood of non-respondents (20%). Finally, we wanted to achieve the highest accuracy and consistency during the elaboration of responses and make safe conclusions about regional comparisons.This study showed that Greek parents and physicians have a trusted relationship because most parents were happy with the information provided to them and they would not change their private paediatrician if antibiotics were used too much or too little.Parents also believed that URTIs are mostly self-limited (80%) although 74% of them expected to possibly receive antibiotics when such a diagnosis was given. However, it is incorrect to assume that 74% of the parents desired only antibiotic therapy because the majority of them also preferred other drugs given for symptomatic therapy. In contrast, the answers of question 27  or immigrants (because of the language barrier) leading to inaccurate answers or even to no answers at all. It was also difficult to document if the responses were in fact a reflection of the paediatricians' view on antibiotic use and not the parents' view. Finally, subjective appreciation of URTI symptoms  may have influenced the responses.This is not the first study indicating public misconceptions with regard to antibiotic use for common URTIs. In our study, although parents believed that most URTIs are self-limiting, they expected to receive antibiotics when this diagnosis was made. Similarly, in a web-based questionnaire among a sample of the general Dutch population, Cals et al showed that nearly half of the responders (47%) incorrectly identified antibiotics as being effective in treating viral infections . In the Greek parents also reported that information regarding unnecessary antibiotic use and resistance came from their private paediatricians, which is different from findings of a public survey published by Hawkings et al where respondents reported that most information regarding antibiotic resistance was derived from the media . In the Amongst European countries, Greece has the highest antibiotic consumption rates . AntibioIf all the above findings are representative for Greece, who is to "blame" for the fact that Greece has a high antibiotic consumption and resistance? There are two likely explanations: (1) physicians are overprescribers failing to follow guidelines or (2) physicians misinterpret parental expectations for antibiotic use.Currently, there is strong evidence to support a "no prescribing policy "for URTI and such guidelines have already been implemented in other European countries . RecentlThe specialty of general practitioners in Greece has progressed during the last few years, but there are still few general practitioners and they are mainly located in health centres of villages, small towns and small islands. Therefore, the vast majority of children are directly referred to paediatricians or to children's hospitals. Results from the current study indicated that Greek parents do not apply pressure to their paediatrician to prescribe antibiotics. Other studies have also shown that most parents seek consultation of a physician to determine whether antibiotics are needed ,24 and pAll studies that attempt to explore the reason for overprescribing and overuse of antibiotics have a single initiative: to find new tools in the fight against antibiotic resistance and consequently reduce morbidity, mortality and health care costs. There is sufficient evidence to support the notion that high prescribing rates of antibiotics drive antibiotic resistance ,25 and pGreek parents have a trusted relationship with their paediatrician and rarely give antibiotics without medical advice, indicating that they contribute less than we expected on antibiotic misuse and over the counter antibiotic consumption. Parents also appreciate the benign course of most URTIs and the fact that unnecessary antibiotic use is harmful. We need to invest more time in educating mostly physicians on the potential benefit of reducing antibiotic prescribing for children with URTI.The authors declare that they have no competing interests.CSH, MNT, VP, GAS and SGP designed the study. SGP, GPG and KMT collected the data. CSH, SGP, GPG and KMT performed the statistical analysis and interpreted the results. CSH, NS and SGP wrote the manuscript. CSH, GAS, MNT VP and NS provided valuable insight for revising the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/11/60/prepubQuestionnaire. Final form of the questionnaire disseminated to the parentsClick here for file


A shoe lift (SL) is often used in the treatment of scoliosis curves in two main cases: (1) an identified discrepancy of the legs' lengths in order to obtain a better balance of the pelvis or (2) a recognized improvement of some specific outcome, like the hump magnitude, when the SL is adopted.The purpose of this study is to measure the trunk pattern in response to the use of a SL . In case of a pre-existing coronal decompensation, we observed the trunk reaction when the SL is respectively under the short leg.We evaluated 27 consecutive patients  who visited our Institute for spine diseases (scoliosis or hyperkyphosis). With the patient in a standing position, we performed a set of tests with a 3-dimensional rastereography (DIERS Formetric 4D) with different SL  placed alternatively under each foot. We assessed the variations of two important elements: the change of pelvic inclination and the change of the line that joins C7 and the middle of the sacral spine (C7-MSS). For simplicity, we divided the entire group of patients into two subgroups. One subgroup of patients (13) showed  a physiological inclination of the line between C7 and the center of the sacrum towards the right (average 7.08mm ± 6.79). The other subgroup of patients (15) showed a physiological inclination of the line between C7 and the center of the sacrum towards the left (average –12.13mm ± 8.58).We found that the use of the SL was not efficient for the improvement of C7-MSS. When the patients showed a physiological inclination of the spine towards the left, we expected a progressive improvement of this inclination if the patients used a SL under the left foot, and a relative worsening if the patients used a SL under the right foot. The situation was the same if the patients had a physiological inclination of this line towards the right. The results show a completely different pattern. Tables 1 and 2 below show the mean inclinations of this line, using the three SL:The use of a SL  positioned under each foot did not change the pattern of the inclination  measured in standing and normal positions. The spine seems to have an individual anti-gravity pattern that cannot be modified by the use of a SL.


Patients with autoimmune pancreatitis have a striking polyclonal elevation of total IgG4 in serum. This observation has been confirmed and extended to other fibrotic conditions  but as yet remains unexplained. The affected tissue contains many IgG4-producing plasma cells embedded in a fibrotic matrix originating from activated mesenchymal (stellate) cells. We propose that the process results from an unusual interaction between two regulatory systems: the regulatory arm of the immune system (including Bregs) and the tissue repair regulatory components orchestrated by the activated stellate cell. This interaction results in ongoing mutual activation, generating TGFbeta, IL10, and vitamin D. This environment suppresses most immune reactions but stimulates the development of IgG4-producing plasma cells. IgG4-related disease IRD, see  is a groA 5–50-time elevation of total IgG4 levels is found in patients with IRD. This results in a markedly increased IgG4/IgG ratio, both for serum immunoglobulin levels and for plasma cells in the affected tissue. It is not clear if the increased levels of IgG4 contribute to the pathology of IRD. So far, convincing support for the hypothesis that (auto-) antibody activity of IgG4 is driving the pathology is lacking. Several candidate autoantibodies have been suggested in IRD, such as antibodies directed against pancreatic trypsin inhibitor, lactoferrin, and carbonic anhydrase, mainly in patients with pancreatic involvement . These aToll-like receptor and Nod-like receptor stimulation have also been implied in IRD, since PBMCs of IRD patients produce IL-10 and high levels of IgG4 in response to stimulation of these receptors in a BAFF-dependent manner .Recently, some IRD patients have been treated with Rituximab, a monoclonal antibody drug that targets CD20 . PatientHere, we will discuss two features related to IgG4 that may be involved in the preferential recruitment and retention of IgG4-switched B cells into the affected tissue in IRD. First, as explained below, IgG4 has been linked to “tolerogenic” immune responses. Second, there are indications of unusual Fab glycosylation in (part of) IgG4. Our hypothesis is that the B-cell receptors (BCRs) of some B cells are Fab glycosylated with an oligomannose glycan, which is recognized by an endogenous lectin found on the tissue-resident myofibroblast (stellate cell). This interaction may result in an ongoing mutual stimulation of two regulatory systems: the blood-derived immune regulators, including IgG4-committed B cells, and the tissue-resident damage-controlling stellate cell, resulting in the pathology observed in IRD.in vivo [IgG4 is a peculiar subclass of human immunoglobulins. It represents about 5% of total IgG in serum of healthy adults . However, IgG4 antibody can represent up to 80% of total IgG antibody after chronic exposure to antigen . Since Iin vivo , 13. Thiin vivo .All in all, the immunochemical properties of IgG4 antibodies point towards a dampening role in the effector phase of the immune response. This fits well with the requirements for IgG4 production. IgG4 responses require frequent and/or high antigen exposure and are observed in situations associated with tolerance induction, such as during immunotherapy. IgG4 responses are also often associated with IgE-mediated allergy, but IgG4 responses are distinct from IgE responses. Although both IgG4 and IgE need the Th2 cytokines IL-4 and/or IL-13 , producteffector responses and of the production of human IgG1 antibodies. It is only then that the IgG4 response develops to its full extent. One of these regulatory signals is the above-mentioned cytokine IL-10. This explains why upon chronic exposure to antigen, IgG4 levels increase. It is likely that IL-10 needed for the development of an IgG4 immune response is in part produced by Tregs present in the lesions of IRD patients as demonstrated by in situ hybridization [In the case of prolonged and/or high-dose antigenic stimulation, immune regulatory circuits play an important role. They counteract the effects of antigenic stimulation and dampen the immune response, resulting in, amongst others, the decrease of Tdization , as welldization . Besidesdization ), some odization . There are indications that IgG4 may sometimes be unusually glycosylated in the Fab region: two sets of information point to a link between IgG4 and Fab glycosylation of the oligomannose type. First, a subject that has been studied for many years by Margni and coworkers is the association between oligomannose-type Fab glycosylation and nonprecipitating antibodies. They fractionated antigen-specific polyclonal antibodies based on their glycosylation pattern by ConA lectin chromatography, which preferentially binds oligomannose glycans. The bound fraction was unable to form an immune precipitate with antigen. The lack of immune precipitation was found to be due to asymmetric Fab glycosylation, that is, glycosylation of only one of the two antigen-binding domains. A possible mechanism explaining the formation of asymmetrically glycosylated antibodies is the aforementioned Fab arm exchange of IgG4. Fab arm exchange between glycosylated and nonglycosylated IgG4 would result in a nonprecipitating asymmetrically glycosylated antibody. Conditions that lead to enhanced production of asymmetrically glycosylated antibody (such as pregnancy) are similar to the tolerizing conditions that promote IgG4 production. These data suggest that IgG4 might be preferentially Fabglycosylated with oligomannose glycans.The other set of information comes from a study on IgG4 antibody responses in infancy to a panel of food allergens . In this+ B cell is a regular antigen. The above-mentioned indications of unusual glycosylation of the Fab of (part of) IgG4 suggest that, instead, an endogenous lectin may function as an alternative trigger of the BCR. The B cell would be activated by the lectin upon cross-linking of the BCR via its Fab glycan. In a way, the lectin would act as an endogenous superantigen, resulting in recruitment of IgG4-switched B cells in particular.As already mentioned, because of the highly elevated levels of IgG4 in serum of IRD patients , we consider it unlikely that the signal for activation of the IgG4Support for an “oligomannose Fab glycan + endogenous lectin” scenario for IRD comes from the work of Stevenson and coworkers on the activation of B cells in follicular lymphoma (FL). They found that the majority of FL cases involve a mutation resulting in the incorporation of a glycan acceptor site in the variable region of the Ig . They shBased on the requirements for IgG4 production and the link between IgG4 and Fab oligomannose glycans, we propose a model in which B cells in circulation are entering into the inflamed tissue, where IgG4 cells are preferentially retained and differentiate in the tolerogenic environment of the lesion . The iniin vitro, for example, using BanLec-1, something that is currently being pursued in our lab; (2) what is the phenotype of the T cells  and B cells  within the affected organ?; (3) what is the relation between the lymphocytes in the tissue and those in the blood, particularly in relation to their chemokine receptors and (for the B cells) their Fab glycosylation profile?Some of the many questions that need to be answered are the following: (1) upon stimulation, is the stellate cell capable to initiate or increase the production of the hypothetical oligomannose-specific lectin, and of chemokine receptor ligands that attract Tfh and class-switched B cells? Possible involvement of BCR stimulation via oligomannose could be studied


IgG4-related disease (IgG4-RD) encompasses a wide range of extrapancreatic manifestations. Albeit some are relatively well known, others such as autoimmune prostatitis remain poorly described. We present a 61-year-old Latin-American male with autoimmune pancreatitis (AIP) who presented with lower urinary tract symptoms (LUTS), normal prostate specific antigen (PSA) test, and prostate enlargement attributed to benign prostatic hyperplasia (BPH). He underwent a transurethral resection of the prostate (TURP) after which symptoms were resolved. On histopathology, prostatic stroma had a dense inflammatory infiltrate rich in plasma cells and lymphocytes; immunohistochemical morphometric assessment showed >10 IgG4-positive plasma cells/high power field (HPF). The diagnosis of IgG4-related prostatitis was postoperatively. We compared the patient characteristics with those of previous reports on Asian patients. Shared findings included prostate enlargement, LUTS (symptoms that can be confused with BPH), and PSA within normal limits or mild elevations. IgG4-related prostatitis is rarely considered as a preprocedural diagnosis, even in patients with evidence of IgG4-RD. Involved prostate zones include mainly central and transitional zones and less frequently the peripheral. Currently, there is insufficient data about the natural history and outcome. Whether steroids, transurethral resection, or both are the treatment of choice needs to be elucidated. Increasing interest on the study of autoimmune pancreatitis (AIP) has led to the characterization of several extrapancreatic manifestations , 2. WithA 61-year-old Latin-American male with past medical history of LUTS attributed to BPH was treated with alpha-blockers during 5 years with symptoms remission. He presented with significant weight loss (13 kg/one month), nonspecific abdominal pain, and biliary tract obstruction secondary to a fibrotic pancreatic-duodenal mass noted during an exploratory laparotomy. He suffered from several episodes of acute pancreatitis with undetermined etiology during the following year. An abdominal computed tomography (CT) scan showed diffuse pancreatic swelling, and endoscopic ultrasound (US) biopsy resulted in chronic inflammation with common bile duct fibrosis. Because of persistent abdominal pain, a second exploratory laparotomy was performed in which a peripancreatic tumor was found and a biliodigestive derivation was carried out. Histopathological features revealed chronic pancreatitis with periductal lymphoplasmacytic infiltrate without granulocyte infiltration consistent with the diagnosis of autoimmune pancreatitis. Laboratory exams showed hypergammaglobulinemia and positive antinuclear antibodies (ANAs), and serum IgG4 was 32 mg/dL .During followup, evidence of autoimmunity in other systems aroused. He received the diagnosis of vitiligo and persistent elevation of serum IgG. He had xerostomia and xerophthalmia with a negative Schirmer test and gland scintigraphy with mild dysfunction of submaxillary glands. Episodes of painful axillary and cervical lymphadenopathy associated with significant weight loss and arthralgias appeared. LUTS worsened throughout the following months. Transrectal ultrasound noted a prostate enlargement. Levels of PSA always remained within normal limits 0.15–1.62 ng/mL .He underwent a transurethral resection of the prostate (TURP) due to the persistence of moderate LUTS despite adequate medical treatment under the suspicion of BPH. Numerous fragments of prostatic tissue underwent analysis. The specimen weighed 25 grams. On light microscopy, prostatic stroma had a dense inflammatory infiltrate rich in plasma cells and lymphocytes . In someData on IgG4-RD involving the lower urinary tract is limited. It is restricted to case reports and a small case series to which we compared this case –10 Tabl. ReporteMisdiagnosis of IgG4-RD with malignancy is frequently encountered . Given tNonetheless, association of IgG4-RD and malignancy has been described . From thThe natural history of the disease leads to fibrotic tissue replacement in different glandular structures , 12. MosIgG4-RD, whether AIP or with organ involvement elsewhere, has a clear tendency to be effectively treated with corticosteroids , 2, 5. PLimited evidence is available to judge which prostatic zones are involved. Given that documentation of our case was on specimens from TURP, only the central and transitional zones were subject to analysis. Both were found to have infiltration by lymphocytes and plasmatic cells. Previous reports in which patients have undergone radical prostatectomy reported diffuse inflammatory changes in the periphery as well , 9. NeveA noticeable finding when comparing data is that our case stands out for being the only report with normal serum IgG4. Given that this is an isolated case report, no conclusions can be stated. A possible explanation is that IgG4 as a serum marker may fluctuate according to disease activity. Systematic measurement of IgG4 serum levels instead of an isolated determination may have yielded distinct results. As other serum markers, it is as a helpful tool but not a synonym of disease diagnosis. Finally, we did the diagnosis on histopathological findings. Systematic measurement of IgG4 serum levels instead of an isolated determination may have yielded distinct results. As other serum markers, it is a helpful tool but not a synonym of disease diagnosis.After analyzing published data, the inevitable emerging question is whether autoimmune prostatitis is really an unusual manifestation or just an underdiagnosed entity. Even when patients have a clear history of IgG4-RD, clinicians rarely consider this diagnostic possibility when aged men present with LUTS. It is important to highlight that this is a recently described form of the disease. Its natural history is under description. The fact that most initial reports are on Asian patients might reflect a tendency to affect certain ethnicities and thus its high prevalence in this part of the world. More evidence will be published on the disease; case reports on other populations might appear and show this disease to be a more frequent manifestation than it is now believed.Certainly, clinicians will face autoimmune prostatitis long before the immunopathogenic basis of disease is understood. Recently a patient with an abnormal digital exam and steroid-responsive urinary symptoms due to IgG4-related prostatitis was reported. While sufficient evidence is gathered to define the best treatment modality, physicians will take the challenge to start immunosuppressive medications or indicate procedures such as TURP as an attempt to control symptoms.


HIV (Human immunodeficiency virus) transmission has been reduced by protected sex and screening of blood products and other body fluids in the developed countries. It has been reported that Pakistan is at high risk of HIV/AIDS infection but presently the prevalence rate is considerably low. The number of reported cases of HIV/AIDS in Pakistan has been continuously increasing since 1987. By 2010 the total number of registered cases has reached to 6000 and this figure is on the rise with the passage of time. Some serious strategies must be implemented to control this deadly disease. Pakistan's first HIV/AIDS case was detected in 1987 . The numPakistan, located in South Asia, is the sixth most densely packed country populated by 168.79 million people by the end of 2009 .Like other Asian countries Pakistan is also HIV epidemic, characterized by different risk factors Formerly Pakistan was considered to be a low prevalence country, but now it is in the group of "Countries in Transition" with a concentrated epidemic among high risk groups, where the AIDS problem is increasing since last five years, according to the private newspaper The News and NACP NIH . The numThe geographic trend of the epidemic has recently expanded from major urban cities and provincial capitals to more rural town and smaller cities. Although national adult HIV prevalence in the general population remains < 0.1%, exceptions were observed as in Jalalpur Jattan (Gujrat) where 90 HIV positive cases were found, out of 342 samples from the general population that included a large number of sex-migrant workers . Among mAccording to the study conducted by Pakistan Demographic Health Survey, 2007-08, from all the four provinces of Pakistan along with FATA and AJK. In the light of the above said study, total 1998 patients were identified as HIV infected out of which, 1765 were HIV positive only while 233 developed AIDS. The study above said study showed that HIV is most prevalent in the Sindh province while least prevalent in AJK  is one of the pioneer institutions providing free treatment to any person found to be suffering from AIDS through its 20 AIDS Treatment Centers all over the country.1. In a country with low literacy rate one should expect low level of awareness about HIV/AIDS. Awareness needs to be created at all levels especially in rural areas.2. The government should know its responsibilities and should provide the necessary legal and regulatory frame work for dealing with this silent killer disease.3. This disease is spreading continuously without knowing the boundaries. Further strategies must be implemented. Otherwise it will be impossible to get rid of this lethal wave.NIH: National Institute of Health; NACP: National AIDS Control Program; ARV: Antiretroviral; FANA: Federally Administered Northern Areas; HIV: Human immunodeficiency virus; AIDS: Acquired Immunodeficiency syndrome.The authors declare that they have no competing interests.MI and AS conceived the study, participated in its design and coordination and gave a critical view of manuscript writing. SA, LA and MS performed and analyzed the data. SB and MTS edited the manuscript and helped MS in literature review. All the authors read and approved the final manuscript.


Aim: The aim of this experimental study is based on a comparison between the effect of expanded versus nonexpanded full-thickness skin grafts (FTSGs) on survival and secondary wound contraction. Methods: A total of 20 quadrangular-shaped, full-thickness skin defects with dimensions of 2 × 3 cm were created on the backs of 10 rats. Two groups were specified in this study depending on the coverage of the aforementioned defect areas using expanded versus conventional full-thickness grafts (n = 10 per group). The survival area of each graft and the amount of graft/wound contraction (secondary contraction) were measured by computerized planimetry on days 0, 7, 30, and 90. Results: The mean graft areas achieved were 5.8 ± 0.6, 4.2 ± 1.5, and 1.2 ± 1.1 cm2 (P < .001) in the expanded FTSGs group and 5.3 ± 0.9, 3.3 ± 1.3, and 0.98 ± 0.8 cm2 (P < .001) in the nonexpanded FTSGs group on days 7, 30, and 90, respectively. Graft area reductions (secondary contraction) were 1.7 ± 0.9 and 2.1 ± 1.2 cm2 (P = .8) on day 30 and 2.1 ± 1.3 and 2.86 ± 0.8 cm2 (P = .3) on day 90 in the expanded and nonexpanded groups, respectively. Conclusion: According to this study, FTSGs that were harvested from tissue expansion revealed biological behaviors that were comparable with those of conventional grafts. This study presents an animal model to compare survival area and secondary contraction between expanded and nonexpanded FTSGs.In this experimental study, a total of 10 Sprague-Dawley male rats that each weighed between 350 and 400 g were used. All of the selected animals were the same age and were disease free. All experimental interventions and animal care were performed in accordance with the Institutional Animal Care and Use Committee of Tehran University of Medical Sciences.Each rat was initially anesthetized with an intramuscular injection of ketamine hydrochloride at 90 mg/kg  and xylazine at 9 mg/kg , followed by a single prophylactic dose of cephazoline (60 mg/kg). Prior to wounding, the dorsal surface of each rat was shaved with clippers and aseptically prepared with ethanol and a povidone-iodine solution, followed by an evaluation of anesthesia depth using the pinch flexion/withdrawal test. A rectangle-type, 25-cc tissue expander  was inserted through a 20-mm, full-thickness horizontally oriented incision, wherein a subcutaneous pocket that was correlated with the dimensions of the expander was created immediately external to the (deep) muscle fascia  for Microsoft Windows.A paired-sample P = .13). The survival areas of the grafts in the 2 groups were observed after 1 week (Table P > .05). The final mean wound size reached 1.2 cm2 in the expanded FTSG group and 0.9 cm2 in the nonexpanded group. The area of the necrosis zone  was 0.2 cm2 in the expanded animals and 0.7 cm2 in the nonexpanded animals; the difference in the graft loss areas between the 2 groups was significant (P = .04). Overall, no statistically significant differences in the clinical behavior of the expanded or conventional full-thickness grafting techniques were observed after 30 or 90 days (Table Initially, 22 FTSGs were photographed in 11 rats. During the course of the study, one rat died from unknown causes. All of the remaining 20 grafts in 10 rats were analyzed in 2 distinct expanded versus nonexpanded groups. The mean weight gain of the rats at the end of the first month was 5%. There were no differences between the 2 groups in terms of skin texture, hair growth, color match, or evenness with the surrounding skin (This experimental study comparatively investigated the effect of tissue expansion on FTSG viability and secondary contraction. According to this study, expanded FTSG exhibited survival areas and secondary contractions that were comparable with those of nonexpanded FTSGs.-5-Secondary contraction and graft take are the most significant determinants of FTSG outcome.12In this experimental study, we have demonstrated the effect of tissue expansion on the outcomes of expanded FTSGs versus conventional FTSGs. No difference in graft survival area was detected between the expanded and nonexpanded FTSGs. We have shown that expanded FTSGs exhibited the same degree of secondary contraction in comparison with that of conventional FTSGs. For this reason, the liberal use of expanded FTSGs may be considered when primary closure of the donor site is not possible or when adequate skin of similar color and texture to that undergoing expansion is not available.