Engaging scientists and veterinarians in strengthening biosecurity systems.

The engagement of both scientists and veterinarians in strengthening biosecurity systems is of paramount importance to ensure resilience and sustainability. Such commitment from scientists and veterinarians begins during their university education, is nurtured by the examples set by their mentors, and continues into their careers through professional development and the wisdom gained from experience. Resilient and sustainable biosecurity systems also require an organisational culture that encourages, recognises and rewards scientists and veterinarians who are committed to biosecurity education, research, outreach and preparedness. At present, such involvement is complicated by the range of definitions of biosecurity used in the life sciences and veterinary medicine, and by the various international organisations with biosecurity responsibilities. Biosecurity represents both a public and a private good. However, the priority given to biosecurity education, research, outreach and implementation differs widely among the public, private and academic sectors. The public sector has the broadest engagement and the broadest mandate for biosecurity. The private sector's approach to biosecurity is governed by business decisions and whether or not they produce consumer goods. In the academic sector, although biosecurity education is gaining increased attention in universities, there are disincentives to research in this field. Strategies for encouraging greater involvement from scientists and veterinarians include agreeing on an inclusive definition of biosecurity, developing teaching materials and experiential learning approaches for use in undergraduate curricula and postgraduate professional development, train-the-trainer programmes, increased involvement of government scientists and veterinarians in university education and professional development, and the fostering of public-private-academic partnerships around shared interests in biosecurity education, research, outreach and implementation.

La participation des chercheurs et des vétérinaires au renforcement des systèmes de biosûreté est d'une importance capitale pour garantir la résilience et la durabilité de ces systèmes. Les chercheurs et les vétérinaires qui s'engagent dans ce domaine le font dès leur formation universitaire, grâce à l'émulation de leurs mentors, et cet engagement se poursuit tout au long de leur carrière grâce au perfectionnement professionnel et à la sagesse acquise avec l'expérience. La durabilité et la résilience des systèmes de biosûreté nécessitent également une culture organisationnelle qui encourage, reconnaisse et récompense les chercheurs et les vétérinaires qui s'engagent dans des activités d'enseignement, de recherche, de vulgarisation et de préparation dans le domaine de la biosûreté. À l'heure actuelle, cette participation est rendue plus complexe par les nombreuses définitions données à la biosûreté dans les sciences du vivant et en médecine vétérinaire, ainsi que par le grand nombre d'organisations internationales compétentes en matière de biosûreté. La biosûreté constitue à la fois un bien public et un bien privé. Néanmoins, suivant que l'on se trouve dans le secteur public, privé ou universitaire, la priorité accordée à l'enseignement, à la recherche, à la vulgarisation et à la mise en œuvre de la biosûreté varie considérablement. Le secteur public compte avec la participation la plus large et détient le mandat le plus vaste en matière de biosûreté. L'approche du secteur privé est gouvernée par des décisions commerciales et dépend de la possibilité ou non de produire des biens commercialisables relevant de la biosûreté. Dans le secteur universitaire, l'enseignement de la biosûreté prend de l'ampleur mais certains facteurs découragent la recherche dans ce domaine. Parmi les stratégies permettant d'accroître la participation des chercheurs et des vétérinaires, l'auteur cite la mise au point d'une définition concertée et inclusive de la biosûreté ; le développement de matériels didactiques et de méthodes d'apprentissage par l'expérience destinés à l'enseignement supérieur et à la formation professionnelle ; la mise en place d'une offre de formation des formateurs ; une meilleure participation des chercheurs et des vétérinaires du service public dans l'enseignement supérieur et la formation professionnelle ; enfin, la promotion de partenariats de recherche public-privé autour de sujets d'intérêt commun relatifs à la biosûreté et à l'enseignement, la recherche, la vulgarisation et la mise en œuvre dans ce domaine.

La participación de científicos y veterinarios en el refuerzo de los sistemas de seguridad biológica reviste cardinal importancia para asegurar la resiliencia y la sostenibilidad. Esta participación, que empieza en el momento de la formación universitaria, se ve impulsada por los ejemplos que ofrece el profesorado y continúa a lo largo de toda la carrera gracias al perfeccionamiento profesional y a las enseñanzas que depara la experiencia. Para que los sistemas de seguridad biológica sean duraderos y resilientes se precisa también una cultura organizativa que aliente, reconozca y recompense a los científicos y veterinarios que intervienen en labores de pedagogía, investigación, difusión y preparación en relación con la seguridad biológica. A día de hoy, esta participación se ve complicada por las dispares definiciones que se dan de «seguridad biológica¼ en las ciencias de la vida y la medicina veterinaria y por la existencia de varias organizaciones internacionales con responsabilidades en la materia. La seguridad biológica representa un bien de interés a la vez público y privado. No obstante, los sectores público, privado y universitario no coinciden ni de lejos en el grado de prioridad que otorgan a la enseñanza, la investigación, la difusión y la aplicación de la seguridad biológica. El sector público exhibe la participación y el mandato más amplios en la materia. Los planteamientos del sector privado al respecto responden a decisiones empresariales y a su utilidad, o no, para traducirse en bienes de consumo. En los medios universitarios, si bien se presta cada vez más atención a la enseñanza de la seguridad biológica, hay factores que desincentivan la investigación en la materia. Las estrategias para alentar una mayor participación de científicos y veterinarios pasan especialmente por consensuar una definición integradora de «seguridad biológica¼, elaborar material pedagógico y métodos de aprendizaje experimental e introducirlos en los programas de estudios universitarios y de perfeccionamiento profesional de posgrado, instituir programas de formación del profesorado, impulsar una mayor intervención de científicos y veterinarios del sector público en la enseñanza universitaria y de perfeccionamiento profesional y potenciar la colaboración público-privada en la universidad en torno a temas de interés común relacionados con la enseñanza, la investigación, la difusión y la aplicación de la seguridad biológica.

Veterinary medicine: public good, private good or both?

The veterinary profession must develop its public as well as its private good functions if it is to help meet the challenges of the future, says William Hueston.

Knowledge and perceived implementation of food safety risk analysis framework in Latin America and the Caribbean region.

Risk analysis is increasingly promoted as a tool to support science-based decisions regarding food safety. An online survey comprising 45 questions was used to gather information on the implementation of food safety risk analysis within the Latin American and Caribbean regions. Professionals working in food safety in academia, government, and private sectors in Latin American and Caribbean countries were contacted by email and surveyed to assess their individual knowledge of risk analysis and perceptions of its implementation in the region. From a total of 279 participants, 97% reported a familiarity with risk analysis concepts; however, fewer than 25% were able to correctly identify its key principles. The reported implementation of risk analysis among the different professional sectors was relatively low (46%). Participants from industries in countries with a long history of trade with the United States and the European Union, such as Mexico, Brazil, and Chile, reported perceptions of a higher degree of risk analysis implementation (56, 50, and 20%, respectively) than those from the rest of the countries, suggesting that commerce may be a driver for achieving higher food safety standards. Disagreement among respondents on the extent of the use of risk analysis in national food safety regulations was common, illustrating a systematic lack of understanding of the current regulatory status of the country. The results of this survey can be used to target further risk analysis training on selected sectors and countries.

Optimising import risk mitigation: anticipating the unintended consequences and competing risks of informal trade.

The effectiveness of risk mitigation may be compromised by informal trade, including illegal activities, parallel markets and extra-legal activities. While no regulatory system is 100% effective in eliminating the risk of disease transmission through animal and animal product trade, extreme risk aversion in formal import health regulations may increase informal trade, with the unintended consequence of creating additional risks outside regulatory purview. Optimal risk mitigation on a national scale requires scientifically sound yet flexible mitigation strategies that can address the competing risks of formal and informal trade. More robust risk analysis and creative engagement of nontraditional partners provide avenues for addressing informal trade.

Science, politics and animal health policy: epidemiology in action.

Public policy decisions underlie society's response to current animal health issues ranging from emerging diseases and public health threats to food safety concerns and sustainable animal agriculture strategies. Despite strong calls for "science-based" decisions, animal health policy most commonly emerges at the interface of science and politics. Too often scientists' disdain for politics limits their involvement in formulating policy. By contrast, epidemiologists are ideally qualified to bring scientific skills to complex policy issues through analytical, macro-epidemiological approaches that consider the economic, legal, and cultural context of policy issues as well as the biological and medical aspects. Risk analysis provides a systematic approach to evaluating animal health issues and comparing policy options. Capturing these opportunities for applied epidemiology requires an understanding of the policy-making process as well as the basic principles of epidemiology. Furthermore, epidemiology training programs must incorporate communications skill building and experiential learning opportunities in a team environment.

Outcomes assessment of the Center for Government and Corporate Veterinary Medicine at the Virginia-Maryland Regional College of Veterinary Medicine.

INTRODUCTION: The objective of this study was to evaluate the effectiveness and usefulness of the Virginia-Maryland Regional College of Veterinary Medicine's Center for Government and Corporate Veterinary Medicine (CGCVM or Center) as a national resource. METHODOLOGY: Questionnaires were mailed to graduates of the Virginia-Maryland Regional College of Veterinary Medicine (VMRCVM) from the classes of 1993 through 1997, as well as to graduates of other veterinary schools in the United States and Canada in the classes of 1994 through 1997 who had completed externships with the Center. Agencies and corporations that had hosted student clerkships in the 1997/1998 academic year and Deans of each veterinary school that has utilized the Center for student clerkships were also surveyed by mail. CONCLUSION: The results indicate that the Center for Government and Corporate Veterinary Medicine is a valuable national resource for veterinary students interested in public practice veterinary medicine and for veterinarians already in the work force seeking career advancement and/or career redirection.

Use of microalbuminuria testing in persons with type 2 diabetes: are the right patients being tested?

OBJECTIVE: Our goal was to determine whether adult patients with type 2 diabetes who had gross proteinuria or were already taking angiotensin-blocking drugs were screened for microalbuminuria. STUDY DESIGN: This was a retrospective cross-sectional study. POPULATION: We included a total of 278 adult patients with type 2 diabetes seen during 1998 and 1999 at the family medicine practices of the Medical University of South Carolina. OUTCOMES MEASURED: The outcomes were microalbuminuria testing during either 1998 or 1999 and the initiation of medication if the screening test result was positive. RESULTS: We found that patients who could derive the greatest benefit from testing (ie, those without preexisting proteinuria or who were not receiving an angiotensin-blocking drug) were no more likely to be screened for microalbuminuria than those with existing proteinuria (16% vs 18%, P=.84) or those who were already being treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (16% vs 16%, P=.83). Also, when the microalbuminuria test result was positive, only 40% of the patients were placed on angiotensin-blocking drugs. CONCLUSIONS: Physician use of microalbuminuria screening does not follow established guidelines. The test appears to be used for many patients who might not need to be screened, and it is not always used for patients who should be screened. Consideration should be given to other strategies to prevent nephropathy in persons with type 2 diabetes.

Female and underrepresented minority faculty in academic departments of family medicine: are women and minorities better off in family medicine?

BACKGROUND: Several studies have shown that the percentage of women represented in senior academic positions at US medical schools is lower than the percentage of men in senior positions. Similarly, the percentage of minority faculty members represented in senior academic positions is lower than that of their majority counterparts. This study assessed whether these findings were also present in departments of family medicine and identified any factors related to the institution or department that favored academic success for women and minorities. METHODS: Data regarding faculty workforce composition, including faculty rank and rank for women and underrepresented minorities, were extracted from a comprehensive survey of departments of family medicine at US allopathic medical schools. The data are based on faculty workforce in 1997 and include responses from 58 (51%) of all schools with a department of family medicine. RESULTS: Faculty in departments of family medicine were more likely to be female (41% versus 25%) and an underrepresented minority (9% versus 4%), compared with all academic medicine disciplines. However, women in full-time positions were less likely than men, and minorities were less likely than nonminorities, to be either an associate or full professor. We could find no institutional or departmental characteristics that were associated with academic success for women or minority faculty members. CONCLUSIONS: While women and underrepresented minorities are more common to the faculty workforce in family medicine, members of both of these groups are not well represented in senior faculty ranks.

Do rural and urban children have comparable asthma care utilization?

This study compares asthma-related health care visits and drug therapy for rural and nonrural Kentucky children with Medicaid health insurance in 1995. The 8,634 children with asthma had a mean age of 5.7 years. Ninety-two percent made at least one asthma office visit, and 13 percent were hospitalized. The urban and rural patterns of care for childhood asthma varied in some potentially important ways. Urban children were twice as likely as rural children to see an asthma specialist (5 percent vs. 2.5 percent, P < 0.05), 2.7 times as likely to receive asthma care in an emergency department (19 percent vs. 7 percent, P < 0.01) and 1.4 times as likely to receive oral steroids (16 percent vs. 12 percent, P = 0.04). If given inhaled anti-inflammatory medication, rural children were more likely to receive inhaled steroids while urban children were more likely to receive cromoglycates.

Provider distribution and variations in statewide cesarean section rates.

Cesarean section rates vary among states from approximately 15% to over 26% of all deliveries. Since it is unlikely that patient factors alone contribute to this wide variation, other non-clinical factors that are unique to each state must influence cesarean section decisions. To explore if provider workforce and specialty was associated with differences in statewide cesarean rates, we compared statewide cesarean rates for 1996 with (1) the volume of deliveries in a state per board-certified obstetrician; (2) percentage of deliveries performed in the state by nurse midwives, and (3) the percentage of family physicians in the state performing obstetrics. In a linear regression model that adjusted for state rurality and median income, we found that only the percentage of family physicians participating in obstetrics was related to cesarean delivery rates. As the percentage of family physicians offering obstetric services increased in a state, the rate of cesarean delivery for that state declined. This effect appeared to be independent of other provider effects, state rurality, or statewide income. Family physician participation in obstetrics is unlikely to be the cause for lower cesarean rates, but is likely a marker for a medical environment and practice style that supports non-operative obstetric care.

The financial status of departments of family medicine at US medical schools.

BACKGROUND: This report examined the financial health of departments of family medicine in US allopathic medical schools. METHODS: We conducted a survey of departments of family medicine at US medical schools, using academic year 1997-1998 as the index year. A total of 52 (46%) of medical schools that have a department of family medicine responded to the survey. The survey examined sources of revenue and categories of expenditures. Analysis assessed the overall financial status of departments at that period of time. RESULTS: Responding departments of family medicine received 32% of their funding from state or university sources and an additional 32% of funding from clinical services. Grants and hospital support comprised another 17% each. Departments in public institutions received higher levels of support from hospitals (22% of revenue versus 8% for private schools). The overall balance sheets for departments of family medicine showed that 56% of departments have financial reserves, while 19% had no reserves but no debt. Twenty-five percent of all departments were in debt, including 2% with debt exceeding $1 million. CONCLUSIONS: The majority of departments of family medicine remain fiscally healthy, but these departments are dependent on funds from state and medical school sources. A substantial proportion of departments are in debt. Lower levels of grant support and the difficulty in increasing clinical revenue may create future funding problems for primary care faculty as medical schools increase dependence on these sources of income.

Antibiotic resistance and the need for the rational use of antibiotics.

Antibiotic resistance has increased dramatically over the past 10 years. In many countries, penicillin resistance to Streptococcus pneumoniae is nearly 50% with resistance to other drugs rising as well. One of the mechanisms responsible for the development of resistance is the widespread use of antibiotics in the primary care setting, chiefly for the treatment of respiratory disorders. Reduction in antibiotic prescribing for respiratory diseases in primary care has been associated with decreases in drug resistance in Streptococcus pneumoniae. This article will review common reasons for overuse of antibiotics in primary care settings and some strategies for reducing injudicious antibiotic prescribing.

Treatment of hypothyroidism.

Thyroid disease affects up to 0.5 percent of the population of the United States. Its prevalence is higher in women and the elderly. The management of hypothyroidism focuses on ensuring that patients receive appropriate thyroid hormone replacement therapy and monitoring their response. Hormone replacement should be initiated in a low dosage, especially in the elderly and in patients prone to cardiac problems. The dosage should be increased gradually, and laboratory values should be monitored six to eight weeks after any dosage change. Once a stable dosage is achieved, annual monitoring of the thyroid-stimulating hormone (TSH) level is probably unnecessary, except in older patients. After full replacement of thyroxine (T4) using levothyroxine, the addition of triiodothyronine (T3) in a low dosage may be beneficial in some patients who continue to have mood or memory problems. The management of patients with subclinical hypothyroidism (a high TSH in the presence of normal free T4 and T3 levels) remains controversial. In these patients, physicians should weigh the benefits of replacement (e.g., improved cardiac function) against problems that can accompany the excessive use of levothyroxine (e.g., osteoporosis).

Does drug treatment of patients with acute bronchitis reduce additional care seeking? Evidence from the Practice Partner Research Network.

BACKGROUND: Considerable discussion has focused on treatment methods for patients with acute bronchitis. OBJECTIVE: To examine whether antibiotic or bronchodilator treatment is associated with differences in follow-up visit rates for patients with acute bronchitis. METHODS: A retrospective medical chart review was conducted for patients with a new episode of acute bronchitis over a 3-year period in the Practice Partner Research Network (29,248 episodes in 24,753 patients). Primary outcomes of interest were another visit in the next 14 days (early follow-up) or 15 to 28 days after initial treatment (late follow-up). RESULTS: Antibiotics were used more commonly in younger patients (<18 years), whereas older patients (>65 years) were more likely to receive no treatment. Younger patients treated with antibiotics were less likely to return for an early follow-up visit, but no differences were seen in adults and older patients. Late follow-up rates were not affected by the initial treatment strategy. When patients did return for a follow-up visit, no new medication was prescribed to most (66% of younger patients and 78% of older adults). However, compared with patients who did not receive an antibiotic at their first visit, patients initially treated with an antibiotic were about 50% more likely to receive a new antibiotic at their second visit. CONCLUSIONS: Initial prescribing of an antibiotic reduces early follow-up for acute bronchitis in younger patients but seems to have no effect in adults. However, reductions in future follow-up visits might be outweighed by increases in antibiotic consumption because patients who return for a follow-up visit seem to receive additional antibiotic prescriptions. Arch Fam Med. 2000;9:997-1001

A comparison of family medicine research in research intense and less intense institutions.

BACKGROUND: Family medicine is a relatively new specialty that has been trying to develop a research base for 30 years. It is unclear how institutional research success and emphasis have affected the research productivity of family medicine departments. OBJECTIVE: To examine the research infrastructure, productivity, and barriers to productivity in academic family medicine in research intense and less intense institutions. DESIGN, SETTING, AND PARTICIPANTS: A survey of 124 chairs among institutional members of the Association of Departments of Family Medicine. Departments were categorized as being associated with research intense institutions (defined as the top 40 in National Institute of Health funding) or less intense institutions. MAIN OUTCOME MEASURES: Prioritization of research as a mission, number of funded research grants, total number of research articles published, and number of faculty and staff conducting research. RESULTS: The response rate was 55% (N = 68). Of 5 potential ratings on the survey, research was the fourth highest departmental priority in both categories of institutions. Departments in research intense institutions were larger, had more faculty on investigational tracks, and employed more research support staff (P<.05). Neither category of department published a large number (median = 10 in both groups) of peer-reviewed articles per year. Controlling for the number of full-time equivalent faculty, the departments in less intense institutions published a median of 0.7 articles, while the research intense institutions published 0.5 (P =.30). Departments in research intense institutions received more grant funding (P<.005) in both unadjusted and adjusted analyses. Chairs reported a scarcity of qualified applicants for research physician faculty openings. CONCLUSION: Future initiatives should focus on prioritizing research and creating a critical mass of researchers in family medicine. Arch Fam Med. 2000;9:1100-1104

Why are antibiotics prescribed for patients with acute bronchitis? A postintervention analysis.

BACKGROUND: Despite the findings in controlled trials that antibiotics provide limited benefit in the treatment of acute bronchitis, physicians frequently prescribe antibiotics for acute bronchitis. The aim of this study was to determine whether certain patient or provider characteristics could predict antibiotic use for acute bronchitis in a system where antibiotic use had already been substantially reduced through quality-improvement efforts. METHODS: A retrospective chart review was performed in an academic family medicine training center that had previously instituted a quality-improvement project to reduce antibiotic prescribing for acute bronchitis. Patients who had acute bronchitis diagnosed during an 18-month period and who had no other secondary diagnosis for respiratory distress or a condition that would justify antibiotics were selected from a computerized-record database and included in the study (n = 135). Charts were reviewed to document patient symptoms, physical findings, provider and patient characteristics, and treatment. RESULTS: Thirty-five (26%) patients received antibiotics for their acute bronchitis. Adults were more likely to receive antibiotics than children (34% vs 3%, P < .001). Analysis of 20 different symptoms and physical findings showed that symptoms and signs were poor predictors of antibiotic use. Likewise, no significant differences were found based on prescribing habits of individual providers or provider level of training. CONCLUSION: In a setting where antibiotic use for acute bronchitis had been decreased through an ongoing quality-improvement effort, it did not appear that providers selectively used antibiotics for patients with certain symptoms or signs. Other factors, such as nonclinical cues, might drive antibiotic prescribing even after clinical variation is suppressed.

Improving quality or shifting diagnoses? What happens when antibiotic prescribing is reduced for acute bronchitis?

BACKGROUND: A quality improvement project in an academic practice demonstrated a reduction in antibiotic prescribing for acute bronchitis. However, it was unclear whether this represented a reduction in antibiotic use or whether physicians assigned new diagnoses to the same patients to avoid scrutiny and continue to use antibiotic therapy. OBJECTIVE: To examine whether a substantial amount of diagnostic shifting occurred while antibiotic prescribing for acute bronchitis decreased during a 14-month period (from January 1, 1996, to February 28, 1997). METHODS: All patient diagnoses of acute bronchitis, acute sinusitis, upper respiratory tract infection, and pneumonia were determined for the 14 months of the acute bronchitis intervention. The relative distribution of patients among these 4 diagnostic categories was compared to determine if the percentage of patients with acute bronchitis decreased while those with acute sinusitis and pneumonia increased during the acute bronchitis intervention. RESULTS: The percentage of patients with the diagnosis of acute bronchitis remained unchanged during the 14-month period while antibiotic use for this condition decreased from 66% of cases to less than 21% of cases. Instead of the patients being assigned a different diagnosis such as acute sinusitis so that antibiotic prescribing would not be scrutinized, as we hypothesized, the relative number of diagnoses for acute sinusitis compared with acute bronchitis actually declined during the 14 months. No change was noted in the relative frequency of acute bronchitis cases compared with pneumonia cases. CONCLUSION: During a 14-month period when an intervention was successful at reducing antibiotic use for acute bronchitis, there was no evidence that physicians shifted patients from the diagnosis of acute bronchitis to other diagnoses.