World Journal of Emergency Surgery (WJES) has received high numbers of CRs for publication: up until December 2006 they represented 39.2% of all articles submitted. Unfortunately the rejection rate of CRs in WJES, like many medical journals, is quite high, (85.2% of submitted CRs), and is significantly higher than other article types in the journal, where the rejection rate so far is 51.7%.Case series (CS) and case reports (CR) consist either of collections of reports on the diagnosis and treatment of individual patients, or of a report on a single patient. Since its launch in March 2006, Since WJES is an electronic journal, whether or not a CR is published doesn't depend upon the available pages in the journal, but only upon the nature of the competing CRs. Ultimately, the low acceptance rate of CRs happens because, according to the principles of evidence based medicine, they provide a lower strength of evidence among clinical studies, being towards the base of the Evidence Pyramid , just abOn the other hand, observation and description has always been seen as the first step in science, and should be the same in clinical science. For this reason, since ancient times doctors have written CRs in a very "modern" manner by giving a clinical picture of the clinical case, followed by anatomic/physiological diagnosis, prognosis, and then discussion . If the With this editorial, having now clarified our point of view not only about the limits of CRs -13, but As a first step we would like to ask authors to identify the reasons for publishing the CR in WJES. In the Appendix 1 we report the criteria for publishing CRs.In Appendix 2 we describe the format with simple guidelines for writing up a CR. The CR should be structured into the following sections: Abstract, Background, Case Report and Discussion. Further details on each of these sections follows below.CRs should start with an abstract of maximum of 350 words. The aim of the abstract is to allow readers to discern their levels of interest in the CR. The abstract should be structured into the same three sections as the main text in a succinct form: Background, Case Report and Discussion.The background should convince the reader in a concise and relevant manner to continue reading and also provide all the necessary information about what the CR is about, providing its subject, purpose and value. This section should clarify why the CR is novel or merits publication with a brief description of the patient case and also a discussion of similar cases or studies in the context of a wider review of the literature on this topic. The literature review should list the strategy and coverage of the search and should include the database searched and the search terms used, providing enough elements for the reader to easily replicate the search.Within this section, the authors should provide the characteristics of the pathology, all significant data and interesting information about the patient and their lifestyle, which could be in some way linked to the condition. To respect patient privacy, it is important to omit all unessential personal information or data in order to anonymize the case. Informed consent is considered mandatory for publication and should be detailed at the end of this section. The CR should describe the patient's demographics and history, their laboratory and diagnostic data and the history of their medications. The case should be described in chronological order and with enough details to give the reader a chance to formulate their own opinion and evaluate the case's validity. It's important that a report stimulates inquiries, commentaries and remarks. Indeed, readers have the ability to, and are encouraged to post a comment on the published article, generating further discussion. Whilst the author should be succinct, and describe the case without leaving the reader doubtful about the correct management, they should not overload the reader with excess information. Fluency and clarity of the CR can be enhanced by the use of tables, graphs, figures and illustrations. Usually, most of the information contained in these additional parts should not be duplicated in the text. In particular colour pictures of histopathology, roentgenograms, electrocardiographs, and other diagnostic tests; skin manifestations; wounds; and other anatomical parts may be provided and add to the interest of the CR. It is imperative that any identifying features of a patient's photograph should be blocked out and patient permission for obtaining and using photographs must have been sought and included in the consent statement.This is arguably the most important part of the article, because in this section the author should indicate the CR's accuracy, validity and uniqueness, comparing it with the published literature in order to derive new knowledge and applicability to practice. To obtain this the author must point out the value of the CR by demonstrating the validity of the diagnostic hypothesis and the therapeutic decisions, and comparing it with similar CRs if they exist. It is necessary to analyze the limits of the CR, describing the importance of each limit, but the main theme of the discussion should be the "lesson to be learned": if a CR doesn't teach anything new, it doesn't deserve to be published. Highlighting the practical applicability of the CR is important and should be clearly stated, relating to the eventual "evidence" already present in the literature and to the opportunities for future research. The discussion should conclude by briefly summarizing the CR, pointing out the lesson learned and joining it to eventual evidence based medicine recommendations.We hope to have provided readers with a useful overview of the importance and structure of case reports for WJES, and welcome submissions of interesting and important cases to the journal.Publishable CRs should meet one of the categories:□ The first report of a new entity, for example, the first description of a disease, syndrome, diagnostic test, surgical procedure.□ Additional examples that establish an entity from an isolated observation, such as the report of an already described, but rare  or uncommon disease ; the description of a rare, perplexing, or novel diagnostic features of a known disease, example of rare  or uncommon , but not necessarily unexpected, behaviour in any disease.□ Adverse events: the report of life-threatening adverse events, dangerous and predictable adverse effects that are poorly appreciated and rarely recognized in drugs or surgical procedures; the description of new medical errors or medication errors, rare or novel adverse drug reactions; the finding out of a device malfunction that results in patient harm; and the account of a therapeutic failure or a lack of therapeutic efficacy, clinical behaviour contrary to expectations based upon what we think we know.□ A remarkably well-documented example of educational value .□ Other.Specify:......................................................................................................................................................................................1. Abstract□ Structured.□ Background.□ Case report.□ Discussion.□ Not more than 350 words in length.2. Background□ Description of the subject matter.□ Report of the purpose of the CR, its background information and pertinent definitions.□ Details of the complete analytic literature review with its strategy search, using it to justify the merit of the CR.□ Introduction of the patient case to the reader.3. Case Report□ Description of the case in a narrative form, providing patient demographics  and avoiding patient identifiers .□ Description of the patient's clinical picture, listing his/her present illness, medical, family, social and medication history.□ List of the patient's admission and throughout the case report pertinent findings on physical examination and laboratory values that support the case.□ List of the diagnostic procedures that are pertinent and support the case.□ Photographs of clinical findings, histopathology, roentgenograms, TC or RMN as they relate to the case, avoiding patient identifiers.□ Patient's events in chronological order.□ Description of the patient's medical and surgical treatments, with eventual side effects and complications.□ Presence of enough detail for the reader to establish the case's validity.□ Statement of achievement of a written consent from the patient for publishing the CR.4. Discussion□ Comparison of the case report with the literature review, describing similarities and differences between them.□ List of the limits of the case report and description of its relevance.□ Summary of the salient features of the case report.□ Ascertainment of eventual causal and temporal relationship in the patient CR.□ Justification of the eventual uniqueness of the CR.□ Describe how the information learned applies to one's own practice.□ List opportunities for research.□ Indication of evidence-based recommendations and justified conclusion.


The only national drug abuse prevention delivery system that supports the rapid diffusion of new prevention strategies and includes uniform training and credentialing of instructors who are monitored for quality implementation of prevention programming is the Drug Abuse Resistance Education network (D.A.R.E.) linking community law enforcement to schools. Analysis of the organizational structure and function of D.A.R.E. provides an understanding of the essential parameters of this successful delivery system that can be used in the development of other types of national infrastructures for community-based prevention services. Information regarding organizational structure and function around funding issues, training, quality control and community relationships was gathered through telephone surveys with 50 state D.A.R.E. coordinators (including two major cities), focus groups with local D.A.R.E. officers and mentors, and interviews with national D.A.R.E. office staff.The surveys helped identify several strengths inherent in the D.A.R.E. program necessary for building a prevention infrastructure, including a well-defined organizational focus (D.A.R.E. America), uniform training and means for rapid dissemination (through its organized training structure), continuing education mechanisms , mechanisms for program monitoring and fidelity of implementation , branding and, for several states, predictable and consistent financing. Weaknesses of the program as currently structured include unstable funding and the failure to incorporate components for the continual upgrading of curricula reflecting research evidence and "principles of prevention".The D.A.R.E. organization and service delivery network provides a framework for the rapid dissemination of evidence-based prevention strategies. The major strength of D.A.R.E. is its natural affiliation to local law enforcement agencies through state coordinators. Through these affiliations, it has been possible for D.A.R.E. to become established nationally within a few years and internationally within a decade. Understanding how this structure developed and currently functions provides insights into how other such delivery systems could be developed. Substance abuse brings with it a diverse array of human problems in every sphere of life, including decreased health, increased mortality, familial and social dysfunction, impaired educational and vocational opportunities, and increased involvement with the criminal justice system. It also leads to a cycle of abuse, perpetuating these problems and revisiting them on subsequent generations -7. DespiIn addition to insufficient funding, the field of substance abuse prevention lacks the organizational framework through which prevention services could be efficiently offered, organized, delivered, and paid for. Without such an infrastructure, assuring quality, monitoring performance, and rapidly and accurately diffusing new ideas and technologies, is very difficult. Many society-wide institutions – such as medicine, education, and the criminal justice system – have their own well-developed infrastructure that provides an array of services including advocacy, funding, innovation, dissemination, quality assurance, and accreditation and certification. For substance abuse prevention, however, there is no such infrastructure. The current ad hoc system of agencies, programs, curricula and activities is one that is under-funded, fragmented and lacking a central organizing body. This system lacks the ability or authority to accomplish necessarily complex tasks in an organized and professional manner. The current lack of organization of prevention services at any level of society limits the field of substance abuse prevention to efficiently serve the needs of communities, schools, parents and children.Notwithstanding the lack of a formal substance abuse prevention infrastructure, there are numerous national and state-level organizations and entities that service some of the needs of such an infrastructure, including funding prevention activities and research, providing accreditation and certification, providing mechanisms for quality assurance and control, and disseminating information. However, even as some of these services are provided, they are fragmented. Furthermore, the lack of stable funding remains a significant problem as most prevention programming is dependent on government support, most often as a discretionary item and competing with other types of programs ,11.Federal entities such as the Department of Education with its Safe and Drug Free Communities program (SDFS) provides grant support to schools to implement prevention programs, the National Institute on Drug Abuse (NIDA) to support a national research program that evaluates innovative prevention strategies and on the basis of this research has developed its principles of prevention, the Center for Substance Abuse Prevention (CSAP) works to disseminate information about effective prevention strategies and policies and to assist local communities to decide what are most relevant to their needs. State departments or divisions of alcohol and drug abuse/addiction services as well as governors' offices also provide support for local prevention programming including credentialing of prevention specialists. Finally, to some degree, private foundations such as the Robert Wood Johnson Foundation (RWJF) support prevention and treatment service delivery. In addition, since the late 1990s, with recognition of the contributions being made by prevention research, -15 more With all of the promising prevention intervention programs that are currently funded, few pay much attention to the obvious need for developing or expanding an infrastructure to support a prevention service delivery system. What are the characteristics of such an infrastructure? In order to specify infrastructure characteristics it is important to state the aims of a prevention service delivery system. Such a system would prevent the use of tobacco, alcohol, marijuana and other drugs or delay the initiation of use of tobacco and alcohol among those who have not initiated use and reduce or eliminate existing use of these substances among those who initiated use. These aims would be achieved through the delivery of prevention strategies with proven effectiveness by well-trained instructors who implement the prevention strategy with fidelity. Prevention programming would be sustained over time. To achieve these ends, a supportive infrastructure would need to include a national professional organization with ties to local communities that would establish guidelines for the position of prevention specialist and for prevention programming. These guidelines would address ongoing training, monitoring, and technical assistance of credentialed instructors and the types of acceptable prevention approaches. The organization would need to be flexible to revise these guidelines in response to new knowledge about more effective delivery strategies. Public support and recognition of the importance of prevention programming would also need to be addressed as part of the infrastructure organization. Finally, there needs to be assurance that there will be ongoing funding for these services both nationally as well as at the local level from diverse sources including third party payers.th or 6th grade [The only national delivery system for drug abuse prevention in the United States that comes closest to an ideal model is Drug Abuse Resistance Education or D.A.R.E. Essential to understanding how important D.A.R.E. is to the field of prevention is recognizing that this program has two important components, the delivery system itself, made up of thousands of trained local law enforcement officer-instructors, and the curricula that these officer-instructors present to students. This paper will focus on the delivery system and describes the structure, organization and function of D.A.R.E. Prior articles on D.A.R.E. focused on evaluating the short- and long-term impact of the curricula, most often the curriculum offered to elementary students in the 5th grade . Those sth grade . The preIn its twenty years of operations, D.A.R.E. has developed into a national program involving every American state, operating in more than 1,800 school districts with over 15,000 police officers working in 8,300 schools ,20. InteAmerican Journal of Public Health[organizational structure of D.A.R.E. has the potential to serve as a model for informing the development of a substance abuse prevention system.Although there are numerous studies evaluating the effectiveness of D.A.R.E.'s curricula, to date there has been only one comprehensive assessment of the organizational structure and operation of the D.A.R.E. program, by the Research Triangle Institute (RTI) in 1993 , under aic Health. The datIn the current paper, we report the results of interviews with D.A.R.E. America leadership, with all 50 D.A.R.E. state coordinators and two city coordinators  as well as the results of two focus groups held with D.A.R.E. officers. We use this information to illustrate the role of the state programs , the relationship between the states and local initiatives, and the relationship between the states and the ostensible organizing operation at D.A.R.E. America.The interviews provided an outline of the D.A.R.E. organizational structure which consists of an umbrella group, D.A.R.E. America that is located in Los Angeles and a network of local, grassroots law enforcement agencies  (3) entities structured at the state level. To date, 26 states are chartered with a number of others moving in this direction. The emergence of Charter Organizations represents an effort to tighten the organization and to better define the roles of the various levels. They are intended to assure more uniformity of curriculum, of organizational structure in each state, and of program monitoring. Chartered states are required to file annual reports with D.A.R.E. on their activities and financial condition, permitting D.A.R.E. America to monitor state activity, provide assistance where needed and, in the case of a major breach on the part of the state , rescind the Charter. While such Chartered Organizations do not receive services or benefits over and above those available to non-chartered states, the objective is to formalize such arrangements and strengthen the D.A.R.E. organization as a nationwide entity with the addition of a level of more structured oversight and controlThe features discussed in this section include organization, funding, training and quality control, community efforts, and the issues and concerns elaborated by the state coordinators.Although there is no single organizational model at the state level, 44 state networks are affiliated with government agencies in the law enforcement sector while the remaining six are run by private, not-for-profit organizations. The diversity of affiliations for the state-level organizations is probably the result of their grass-roots, bottom-up evolution that met the specific needs and organizational relationships that already existed. For example, overall, the structure for the state-level groups includes a coordinator, the state D.A.R.E. Officers Association and its board, mentors, and D.A.R.E. officersEach state D.A.R.E. organization has a coordinator who fulfills a number of administrative and programmatic functions, including administering the state network of D.A.R.E. officers; liaising between D.A.R.E. and other state agencies, legislature, media, and local police departments; planning and executing training activities; monitoring program fidelity and quality control; and fund-raising. As befits the location of the majority of state organizations many (forty) coordinators are active or retired members of law enforcement agencies. They have a wide range of experience in the coordinator position, from just a few months to 14 years; the average time served is five years while the mode is four years.The ways in which the coordinators spend their time depends on a number of factors, including percentage of full-time effort dedicated to the coordinator position, the funding level of the state organization, and the size and independence of the local police departments involved with the D.A.R.E. Twenty-two coordinators dedicate 80–100% of their time, while twenty dedicate less than 50% This variation in percentage of time devoted to the state-level D.A.R.E. operation is a function of the available resources, as funding levels vary widely across state organizations, and/or the needs of the program in any given state. Funding levels also impact the availability of support staff, thus constraining the extent of the coordinators' efforts.A number of the coordinators also divide their time between the state and the local levels, giving them greater opportunity to participate in local activities. D.A.R.E., when viewed from the local level, is still fundamentally a grass roots organization that is, to a great degree, autonomous, operating independently not only of the state but also of the national organization. The ways in which D.A.R.E. is implemented and supported in any given community and even the extent to which it is implemented across a particular state, is ultimately predicated upon loose-knit agreements between the local police departments, schools, and parents. Moreover, although some local programs apply for the U.S. Department of Education Safe and Drug Free Schools program funding through their state organizations, many cannot rely upon the state D.A.R.E. organization for funding. Therefore, the state organization and by extension, the state coordinator, has limited influence over constituent local programs, including how many officers are trained, whether they are full-time, or even choosing which officers will become D.A.R.E. officer-instructor candidates.The state coordinators have more extensive involvement at the local level with training, monitoring and quality control functions. These functions include evaluation of the delivery of the curricula providing feedback to the officers on their teaching methods. In addition, fifty percent of state coordinators are voting members on the board of their state's D.A.R.E. Officers Association. The state D.A.R.E. Officers Associations (DOA) are private and represent the interests of the local police force membership who are the D.A.R.E. officer-instructors. The position of the state coordinator on the state DOA board confers voting authority on state program issues, facilitates closer working relationships with the D.A.R.E. officers, and results in benefits for the state organization overall, particularly with respect to quality control, curricula implementation fidelity, organization of state trainings (that are often done in partnership with the state's DOA) and communication of updated information from D.A.R.E. America.It is important to note that states do not have any formal financial relationship with D.A.R.E. America, even those with Charter status. To some extent, this fiscal independence informs the nature of the funding models for the state D.A.R.E. organizations which vary widely from state to state in terms of how funding is arranged, the number of funding sources, the amount that is dedicated to program delivery, and how funding is used. Table There are two major and well-established Federal funding mechanisms for state D.A.R.E. organizations, the SDFS and grants awarded under the aegis of the Byrne Amendment . In fiscal year 2000, the SDFS program provided approximately $439 million in grants to various schools and communities , of whicTraining and Quality Control section below. D.A.R.E. America quantified the time and value of police officers (and volunteers) at $217 million for FY 2000 [The main source of funding for the day-to-day operations of the majority of the state organizations is the local law enforcement agencies, that often covers the D.A.R.E. officers' salaries (including overtime costs related to their D.A.R.E. activities), provides D.A.R.E. vehicles, and in many cases, pays the costs for police officers enrolled in the D.A.R.E. training program including associated travel expenses, meals, lodging, and supplies. These law enforcement agencies also cover the salaries of the D.A.R.E. mentors, discussed in more detail in the  FY 2000 , an amou FY 2000 ,27.The variation in funding discussed above is reflected in each state organization's training and quality control activities. Three important components of these activities are formal training programs, mentors, and quality control efforts.th and 6th grade students), the Junior High, Senior High and Parent programs. CORE is an intensive 80-hour program given over two weeks. All officers wanting D.A.R.E. training must receive this more extensive "basic" training and have at least one year of experience with the elementary school curriculum before being trained in the other curricula. This basic course is generally offered by each state 1–2 times each year, but its annual periodicity ranged from 0 (North Dakota) to 12 .In fiscal year 2000, the Bureau of Justice Assistance provided more than $2 million for D.A.R.E. regional training centers to support the training of new officers . With thAdditional training and continuing education takes place at the national D.A.R.E. officers' conference and most states hold their own in-service training conferences each year, often in collaboration with the state D.A.R.E. Officers Association conferences. D.A.R.E. America directs the states to use these conferences to administer training for those unable to attend the national conference, and assists in the planning and coordination of these activities. In 2000, attendance at the state's annual conferences ranged from a low of 1% in New York City to a high of 100% in four states. The median attendance rate was 50%.Mentors are usually senior D.A.R.E. officers in the program who have extensive experience teaching the D.A.R.E. elementary school program. Across states, mentors vary in number, quality, and training. The number of mentors in each state ranges from 0 (in Delaware and North Dakota) to 30 (in New Jersey), with a median of eight, while the number of D.A.R.E. officers active in each state varies from 7 (in Delaware) to 1,250 (in New Jersey), with a median of 200. Thus, the ratio of mentors to officers varies from a high of 1: 5 in South Carolina, to a low of 1: 98 in Illinois, with a median of 1: 25. Mentors serve as a resource to the officers, are integral to the infrastructure of D.A.R.E. and the quality control process, provide both formal and informal instruction, and liaise between the officers, schools and state D.A.R.E. programs. Given the diversity and importance of these roles, mentors can mean the difference between more successful and less successful program delivery.formal if there was a preset periodicity of visits to the schools by designated personnel to monitor the in-class performance of the D.A.R.E. officers to assess their adherence to the D.A.R.E. curriculum and pedagogical goals, and if such assessment was supported by and facilitated with standardized forms. Other characteristics of formal quality control included the provision of feedback following monitoring and assessment activities and the use of focus groups to discuss and resolve problems and uncertainties. Informal quality control procedures included limited, random, ad hoc or problem-solving approaches to monitoring of officers with no set periodicity. The officers in these states then had little or no supervision, often receiving no feedback about their performance. Twenty states had formal quality control procedures in place while nineteen states (including the two city organizations) instituted varying levels of informal quality control procedures. The remaining thirteen states had no quality control procedures in place.We assigned states to one of three levels of quality control: formal, informal, or none, based on the levels of three indicators: periodicity of formal quality control visits made to the programs/curricula, use of standardized quality control forms to monitor performance and program adherence, and presence of designated persons to carry out quality control activities. A state's quality control system was considered Overall, quality assessments were completed by observation. The composition of observation groups did vary across states. Half of those states with a formal quality control process in place used D.A.R.E. mentors only while 6 of the states had mentors and teachers do the observations; two of these states used teachers only; one, teachers and students; and one, a combination of a mentor, teachers and students. Thirteen of the states with informal quality control procedures included observations as an assessment tool. Ten of these states used a mentor system only while two used teachers only and two, a combination of mentors and teachers.Thirty-two states used forms to rate the officers' in-class performance . Most states developed their own assessment forms. The majority (56%) of these forms focused on appropriate instructional style while the assessment of content coverage was included on the forms for about 25% of the states. Of the states with no apparent quality control procedures in place, three were in the process of developing them. However, six others reported that no such procedures would or could be initiated due to lack of funds, and two states that previously conducted quality control activities halted them when sufficient financial support could not be found.Although there is some room for improvement in the extent and level of quality control, it is important to keep in mind that the D.A.R.E. organization seems to compare favorably to other current school-based substance abuse prevention programs that have been developed and received federal recognition, such as Project Alert and Life Skills Training. For example, through its website, Project Alert makes implementation assessment instruments available to its trained teachers , howeverno relationships with other prevention programs in their communities. Of the coordinators that did report some contacts, nine said that such contacts were either informal or ad hoc, or consisted of attending rallies and manning booths at annual fairs. Thus, only 17 state coordinators reported any formal involvement with other nationally-recognized entities such as MAAD, SAAD, and Red Ribbon, or more local programs. Formal contact often occurred when the state coordinator also acted as the head of the prevention division in their state, or sat on the board of one of the local programs.D.A.R.E. officers link to their communities at the local level in many ways, such as serving in other roles outside of the schools, as community organizers, facilitators, and referral sources to other programs and resources, all of which enrich and expand the officer's role . In contThe D.A.R.E. officers were connected to the community in thirty-eight states through the D.A.R.E. Parent Education program. This program consists of five lessons designed to educate parents about drugs and about parenting. The D.A.R.E. officer guides discussion groups around a variety of topics. About a quarter of the state organizations were severely limited as to how many of these groups could be provided as only one or two D.A.R.E. officers were available for parent groups state-wide. Twelve states (as well as NYC and DC) had no parent program in place. Parental involvement and program support varied widely both within and between states, regardless of whether a fully functioning parent program was in place. Twenty-six (50%) state coordinators characterized parent involvement as low, and five (9%) reported that involvement varied by location but was often poor. Thirteen coordinators (25%) said that parent involvement in their states was good, and eight (15%) said that involvement was excellent. In general, then, parents overall are very enthusiastic about the program, but this warm feeling does not necessarily translate into participation in parent curriculum classes or attendance at other more formal activities.We asked the coordinators to describe any issues or concerns they had about their relationship with the national organization or the D.A.R.E. network in general. Their responses were organized under the headings: funding, communication, training, program implementation fidelity, and the new curriculum in development. Many coordinators expressed concern over their funding. Some states were in the process of losing their traditional lines of funding and coordinators remarked that some form of national or uniform funding would be beneficial. Communication with D.A.R.E. America was sometimes viewed as poor, especially in terms of the changes in the organizational structure of training. Several coordinators expressed concerns with the fidelity of program implementation; as noted above, a number of states had discontinued their quality control procedures for lack of funds, and others reported that no such quality control procedure could be put in place without increased funds for its implementation and support. Lastly, there were concerns about how the impending new curriculum being evaluated by researchers at the University of Akron would be disseminated, fueled by a perceived lack of communication from D.A.R.E. America about the development and testing of the new curriculum.This paper describes the D.A.R.E. national delivery network. The role of D.A.R.E. America has evolved from a local prevention delivery unit to an international diffusion and dissemination organization. It is through D.A.R.E. America that programs are developed, that national mass training protocols are designed, and that relationships are maintained with state and federal governmental agencies and national law enforcement organizations. Analysis of the network indicates that D.A.R.E. is not a monolithic organization, but is rather decentralized, with clearly differentiated roles, functions, funding, and financial management systems. D.A.R.E. America is the glue that holds together the network of local and state support organizations, and that connects grassroots level D.A.R.E. officers who actually go into the schools and deliver prevention programs, to the broader network of officers within the state and nationally. The state-level D.A.R.E. entities function to recruit and screen new D.A.R.E. officers, to administer local training of these officers and continuing education for all D.A.R.E. officers, to monitor the quality of program implementation, to maintain relationships with state and local governmental agencies, and to help solicit federal, state and local funding for training and mentoring.It is important that the D.A.R.E. delivery network be seen as separate from its programming. Until 1999, D.A.R.E. America in conjunction with educators from the Los Angeles Unified School District developed prevention programs to be delivered in elementary, middle and high schools. These programs had undergone regular periodic revisions every few years, reflecting information from the research literature and the requests of local and national agencies. Local law enforcement agencies in conjunction with local school districts are the ones who decide which of the K though 12 programs offered by D.A.R.E. America will be delivered in the schools. Generally, these decisions have been influenced by the availability of manpower and funding.Eighty percent of school districts in the United States offer D.A.R.E. programs, the vast majority of which are directed to elementary school children . In factThere have been both advantages and disadvantages associated with the decentralization of funding for local D.A.R.E. efforts. By state and local organizations having the responsibility for funding on-going operations, there is more community control over these programs. On the other hand, when funding and manpower are scarce as is the current situation, many communities are eliminating the position of the D.A.R.E. officer and moving more officers onto the streets. The state D.A.R.E. organizations are competing with other social and health services agencies for a decreasing pool of available funds. In addition, those communities that depend on federal funds from the Department of Education's Safe and Drug-Free Communities are struggling to meet the Department's principles of prevention and are either attempting to evaluate their local programs or to seek waivers while waiting for the University of Akron's study to be completed. Clearly, there is a need to address the funding issue to establish continuity of prevention services in our nation's schools. At all levels, D.A.R.E. organizations are meeting with policy makers to maintain D.A.R.E. programming. Success of these meetings varies, depending on the stability of local police efforts. It can be seen by the results in this paper that, although funding is still a concern and many state programs struggle with this issue, some of the D.A.R.E. state programs seem to have found relatively stable and reasonable funding. In our interviews, we were introduced to several funding models, but the more successful ones seem to be those that combine several funding mechanisms, which require time, dedication and knowledge about fund-raising mechanisms on the part of the state-level coordinators.Until recently, all training of new and retraining of existing D.A.R.E. officers had been carried out at regional training centers. The training itself was didactic, a strategy used in the earlier prevention curriculum design for students. At the time that D.A.R.E. America began its collaboration with the RWJF and The University of Akron, a commitment was made to revise its elementary, middle and high school curricula to reflect the latest prevention research findings. This research suggested important content elements and instructional strategies that engaged children in the learning process. These new approaches changed the instructor's role from lecturer to facilitator or coach. Such a dramatic change required major changes in training. D.A.R.E. America has therefore eliminated the regional training centers and designed a training-of-trainers approach that involved all of the state D.A.R.E. organizations' educators to conduct all the training within each state. The training is more 'hands on' than was the case before and includes additional training in classroom management and facilitation techniques. An evaluation of this new approach is in the planning stages.One of the major positive features of the D.A.R.E. delivery network has been quality assurance. Mentors were trained to observe the delivery of programs within the classroom setting, to conduct debriefings with the classroom D.A.R.E. officer and to make recommendations for additional training or for dismissal. This study has found that the decentralization of D.A.R.E. weakens this organizational component. Despite the fact that most states had concerns about implementation quality, and many of them had formal forms of quality assurance in place, shortage of funding has limited the availability of manpower to make visits to all classrooms to monitor implementation. This is not solely a problem associated with D.A.R.E., as other prevention program models also do not incorporate ongoing monitoring of implementation fidelity. However, the frequency of quality assurance already in place and the concerns expressed by state coordinators and D.A.R.E. officers suggest recognition of the importance of ongoing evaluation of program delivery.D.A.R.E., the major national network that supports substance abuse prevention programming delivered in our schools is undergoing reorganization to meet the current needs of its constituents and the local D.A.R.E. officers. This is going on at a time when D.A.R.E. is responding to criticisms of its prevention curricula and when it is being challenged financially. Despite its several faults at the organization level, D.A.R.E. is an attractive program for communities as it possesses several characteristics necessary for building a prevention infrastructure. These include uniform training and through its organized training structure, the means for the rapid dissemination of updated prevention programming; through the state and national conferences and websites, continuing education; mechanisms for program monitoring and quality assurance; and models for predictable and consistent financing. As such D.A.R.E. remains as a model of a prevention service delivery system that has survived over twenty years. Key to its survival has been its decentralized structure, using law enforcement agencies as a platform for programming that allows local communities to function autonomously.At the same time an overarching organizational structure has been developed to address the more global issues of development of evidence-based curricula, "accreditation" through the process of selecting and training of officer-instructors, the production of standardized program materials, having representation of all D.A.R.E. units at the national and international level, collecting and disseminating information pertinent to all D.A.R.E. officers and units, and, in some ways most important, control of the D.A.R.E. brand. The retirement of the founder and Chief Executive Officer, Glenn Levant, in 2003 has prompted a reorganization of D.A.R.E. America, a reassessment of its future direction, the building of new collaborations, and the restructuring of old networks. The fragility of funding, the requirement of evidence-based prevention curricula and adherence to "principles of prevention" has forced D.A.R.E. to face both its' strengths and weaknesses. If D.A.R.E. survives these new threats it could serve as a model prevention infrastructure that can be emulated by other national groups.Several conclusions can be drawn from this analysis of the D.A.R.E. delivery system that would inform the development of an integrated national prevention service delivery system. Having a national umbrella organization that sets standards for the delivery of quality services allows control over the "brand" including• the selection of the prevention programming strategies/services,• development of manuals or guidelines for the delivery of the services,• specifying the criteria and knowledge needed by prevention instructors,• training in this knowledge base and how those services are to be delivered, and• monitoring both the delivery and the outcomes of service delivery.This centralized organization would serve as a conduit for the rapid dissemination of new information as improvements in service components and service delivery become available.As essential as an umbrella organization is, there needs to be a supportive structure at the state and local levels. The success of the dissemination of the concept of "D.A.R.E." is most likely due to the interconnectedness of law enforcement agencies. Several national and state organizations of police chiefs and sheriffs exist and through these organizations' newsletters and conferences law enforcement administrators learn about new services and technologies. It was through these networks that the concept of D.A.R.E. disseminated so rapidly.Data for this study came from telephone surveys conducted with the 50 state coordinators and two major city coordinators between January and August 2001. The State Coordinator Survey (SCS) took approximately 40 minutes to complete with a copy of the survey having been mailed beforehand to facilitate preparation for the telephone interview. The New Jersey and Ohio state coordinators were also interviewed in person. Subsequent to the initial telephone and in-person interviews, additional contacts were made by telephone or email to request omitted information or to clarify previous answers. Face-to-face interviews were held with D.A.R.E. America staff.State Coordinator Survey were developed with reference to a number of sources, including a literature review, consultations with key leaders in substance abuse prevention (Drs. Herbert Kleber and Zili Sloboda) and officers and directors from D.A.R.E. America, interviews with two state coordinators (New Jersey and Ohio), and focus groups and interviews with D.A.R.E. officers. Interviews with the D.A.R.E. America personnel were conducted at the national D.A.R.E. offices and at the annual National D.A.R.E. Officers Association Conference in June, 2001. These informal, open-ended interviews provided the background and history of D.A.R.E. and insights into the diversity of the state organizations.Items for the State Coordinator Survey was developed. The final instrument was comprised of five sections, as follows:D.A.R.E. officers and several coordinators were also interviewed at the conference or by telephone and about 8–10 officers participated in each of two focus groups. Most of these officers had been active in the program for many years and about half the officers in each group were mentors. These interviews and discussions provided information about how local D.A.R.E. officers functioned within their agencies and in collaboration with schools. They also provided suggested areas to be pursued with state coordinators regarding the interrelationship between the state and local levels. Following from these various consultations, the 1. Organization: Coordinator's roles; time involvement with D.A.R.E.; links to the D.A.R.E. Officer Association (DOA); other communication channels with officers; relationship between state program and D.A.R.E. America; role of emerging Charter organizations.2. Funding: Major sources and purpose of funding ; competition with other prevention programs; Fiscal Year 2000 state budgets .3. Training and Quality Control: Periodicity and kinds of trainings; quality control and monitoring of officers, including the role of both police and schools in maintaining program fidelity and quality; role of D.A.R.E. mentors/field representatives.4. Community Efforts: Relationships with other programs; parent curriculum; parent involvement.5. Feedback/Concerns: Suggestions from coordinators for modifying or improving the D.A.R.E. organization and the relationships between local, state and national organizational levels.Zili Sloboda is engaged in an ongoing study of a new school-based curriculum based in part on the existing D.A.R.E. program and supported by the Robert Wood Johnson Foundation.JM conceived of the study with ZS. JM participated in its design and coordination and helped to draft the manuscript. IP assisted in the overall conception of the study, participated in its design and coordination, performed data collection and helped to draft the manuscript. LAKJ performed the literature review, participated in data analysis, and performed substantial drafting and rewriting of the manuscript. TD participated in the design and coordination of the study, performed data collection, and literature review. ZS helped to draft the manuscript and wrote the discussion. All authors  read and approved the final manuscript.


EPA assessment of vinyl chloride we are disparaging of U.S. EPA scientists; and c) the pharmacokinetic (PK) model used by the U.S. EPA has been “peer-reviewed, published, and validated.”We provided documentation and extensive references to support two claims: industry urged the U.S. Environmental Protection Agency (EPA) to downplay data suggestive of cancer risks in tissues other than the liver, and the U.S. EPA reduced the cancer potency estimate of vinyl chloride in accordance with industry input. The American Chemistry Council (ACC) is a trade association representing over 150 companies that produce and use chemicals, including the Dow Chemical Company , Georgia Gulf Corporation , and Occidental Chemical Corporation  . These tIn response to Price’s first point, recent studies confirm earlier findings instead of the opposite. At the time of the U.S. EPA assessment  there wePrice’s letter and the U.S. EPA assessment  both refWe believe that the U.S. EPA’s close relationship with industry compromises credibility. The ACC met with U.S. EPA regulators to discuss a vinyl chloride assessment at least 2 years before public notification of an assessment process. At the urging of the ACC , the U.SThe PK model has not been validated, as stated by Price. The PK model developed by industry consultants and used by the U.S. EPA in its assessment has not been validated because assumptions used in the model have not been tested. Importantly, although the model is limited to liver effects only, the implicit assumption that all metabolism occurs in the liver is incorrect .By using a model limited to liver cancer, the U.S. EPA made a radical departure from its cancer guidelines, recommending that the cumulative risks of all tumor types be included in a cancer assessment , 2005. TIn the analysis of animal bioassay data on the occurrence of multiple tumor types, the cancer potencies should be estimated for each relevant tumor type that is related to exposure, and the individual potencies should be summed for those tumors.This inclusive approach is reconfirmed in the 2005 guidelines . This pr


Public health authorities worldwide discourage the use of chest radiography as a screening modality, as the diagnostic performance of chest radiography does not justify its application for screening and may even be harmful, since people with false positive results may experience anxiety and concern. Despite the accumulated evidence, various reports suggest that primary care physicians throughout the world still prescribe chest radiography for screening. We therefore set out to index the use of chest radiography for screening purposes among the healthy adult population and to analyze its relationship with possible trigger factors.The study was designed as a cross-sectional survey. Five thousand four hundred and ninety-nine healthy adults, coming from 26 Greek provinces were surveyed for screening practice habits in the nationwide anticancer study. Data were obtained for the use of screening chest radiography. Impact of age, gender, tobacco exposure, family history positive for malignancies and professional-risk for lung diseases was further analyzed.we found that 20% (n = 1099) of the surveyed individuals underwent chest radiography for screening purposes for at least one time during the previous three years. Among those, 24% do so with a frequency equal or higher than once yearly, and 48% with a frequency equal or higher than every three years. Screening for chest radiography was more commonly adopted among males , pensioners  and individuals with a positive family history for lung cancer . Multivariate analysis confirmed these results.Despite formal recommendations, chest radiography for screening purposes was a common practice among the analyzed sample of Greek adults. This practice is of questionable value since the positive predictive value of chest radiography is low. The implementation of even a relatively inexpensive imaging study on a national scale would greatly burden health economics and the workload of radiology departments. Chest radiography has a long tradition in medical care, however its prescription for screening purposes among healthy individuals is discouraged by public health authorities -5. In faThe diagnostic performance of chest radiography does not justify its application for screening neither in the general population nor in "high risk" groups like smokers or people with a family history of lung cancer ,7. ScreeDespite the accumulated evidence and the clear guidelines, various reports suggest that primary care physicians throughout the world still prescribe chest radiography for screening both in the general population and in selected "high risk" subgroups -16. ConsNevertheless, since the proportion of physicians believing in and recommending a screening test may consistently differ from the proportion of healthy individuals undergoing the test (still dependent on patients' will), the negative impact of screening chest radiography on health and economics may be only speculated. Little is in fact known in peer-reviewed literature about how chest radiography for screening purposes is practiced among the general healthy adult population -18.We therefore tried to evaluate the rate of screening chest radiography practice among a large sample of Greek healthy adults. Furthermore, we analyzed the resulting chest radiography screening practice for the impact of professional risk for lung diseases, family history of cancer and smoking practice.This study is part of a large ongoing survey on cancer screening and preventive practice in Greece, which is organized by PACMeR , and has the purpose to reveal the current rate of cancer screening among the Greek adult population, to evidence possible barriers to early diagnosis of cancer and to analyze over-practice events and possible sources of worthless costs. For the project, PACMeR physicians had dedicatedly prepared two medical questionnaires  for face-to-face interviews that were employed during the research program. The exact phrasing of the chest radiography questions used is provided in the supplementary note for the facilitation of the peer-review process.The project was ethically approved by PACMeR's Scientific Committee (protocol number 08_020720) and conformed to the ethical guidelines of the 1975 Declaration of Helsinki. A written informed consent form was obtained from all the participants before completing the study questionnaire and the data retrieved were analyzed in anonymous and codified form.The study population was composed of a nationwide convenience sample: adults bringing or visiting their relatives while getting healthcare in Hospitals and Health Centers of 26 Greek provinces Fig. . Most poNinety-two physicians employed in primary care activities were involved in the study, 87 of them as interviewers, and five as data managers and quality control personnel. Data storing was assured by SESy, a dedicated database ,20 tailoData were extracted for overall chest radiography practice. For each individual we retrieved the chronological period that elapsed from the last chest radiography and the cause for which chest radiography was performed. We further evaluated the proportion of individuals who assessed that they underwent chest radiogram last time for screening purposes. For people who performed it within three years we still analyzed the frequency by which they underwent the test.Since the diagnostic performance of chest radiography does not justify its application in any screening setting, we considered chest radiography being done for screening purposes in any of the following situations: 1) periodic health examination ; 2) check-up visit ; 3) chest radiography in asymptomatic individuals due to patients' will; 4) regulatory reasons .We analyzed the rate of screening chest radiography by the following parameters: age , professional category , cancer family history, smoking activity , number of daily cigarettes smoked , duration of tobacco exposure .In order to evidence population subgroups at higher probability of undergoing screening chest radiography, we performed univariate and multivariate analysis. Only subjects for whom there were data about the time elapsed from last chest radiography and about the reason for which they underwent chest radiograms, were considered (n = 5282).Individuals entering the analysis were therefore divided in:(1) Subjects at higher probability of undergoing screening chest radiography: people who performed chest radiography for screening purposes (regulatory reason excluded) within the last three years (n = 1080);(2) Subjects at lower probability of undergoing screening chest radiography exposure: individuals who underwent chest radiography for any other reason (than screening) at any time and those who underwent chest radiograms for screening purposes but more than 3 years had elapsed (n = 4202).Univariate analysis was used in order to examine the association between over-practice and all subgroups previously defined. Multiple logistic regression analysis was performed to analyze the relationship between over-practice and some relevant covariates of interest: sex, age, professional category, smoke and family history of lung cancer. All independent variables were taken as categorical, dichotomized where appropriate. We used SAS statistical package, version 8.2 , for anaThe characteristics of the individuals involved in the study are reported in table 76.6% of the population analyzed (n = 4212) referred that they underwent at least one chest radiogram during their life; 29.5% (n = 1622) assessed that they underwent it last time for screening purposes; 43.4% (n = 2385) performed it in out-patient basis for medical reasons; and 3.7% (n = 205) underwent it in in-patient basis.Among people who underwent chest radiography for screening purposes, Table  we foundUnivariate analyses evidenced that the risk of screening radiogram performance was statistically higher among pensioners . Trends to higher chest X-ray practice were still found among individuals of male gender  and those with a family history positive for lung cancer , although these trends were not statistically significant. Interestingly people with professions at risk for lung diseases showed lower probability to undergo screening chest radiograms . Chest radiography performance for screening purposes was not influenced by age, tobacco consumption, and family history positive for malignancies ; and trends for male gender , and professions at risk for lung diseases  became statistically significant , as previously hypothesized . MoreoveThe retrieved rates of screening chest radiography should not surprise. In a recent Greek survey of 211 physicians, 88% declared to recommend chest radiography for early diagnosis procedures: 78% prescribed it during usual check-up visit, and 77% recommend it for cancer screening .High chest radiography prescription rates may still be explained by the absence of national guidelines and it might be guessed that the European Code Against Cancer recommendations  do not hSome limitations should be discussed. First, despite the fact that screening chest radiography is being studied from the sixties and onwards, this is the first study analyzing its practice among the general population. Since the Greek primary care system based on specialized physicians is "newborn", it might be precarious to generalize these findings globally. Second, we analyzed only patients that underwent chest radiography within three years. This may under-estimate the proportion of individuals screened since many of them may have undergone screening chest radiograms in an antecedent date. Furthermore, data were derived from a cross-sectional study on a large convenience sample of the Greek healthy adult population. This design has limited internal validity and is sensitive to a variety of biases. Nevertheless, cross-sectional surveys are most commonly used, and are considered appropriate and easy to perform.Chest radiography practice for screening purposes is an old habit that dies hard. More research should be conducted concerning the causes and possible remedies of this phenomenon.The author(s) declare that they have no competing interests.KK was the coordinator of the Greek branch of the study. He was still actively involved in the discussion of the project & study planning, and manuscript writing. GC: statistician, main co-operator from the University of Milan , dept. statistics, he was still actively involved in the discussion of the project, statistics and manuscript writing. DM: main coordinator of the Italian and Greek braches of the study. He was still actively involved in the discussion of the project, realization of the draft & study planning, review of data abstraction and manuscript writing. VL was involved in study planning and he was responsible for data collection in Peloponnesus and Cephalonia island. He was still actively involved in the discussion of the project and manuscript. IC: statistician, second co-operator from the University of Milan , dept. Statistics, he was still actively involved in the discussion of the project, statistics and manuscript discussion. AX: responsible for double-blind controls of data inserted by data-managers . He was still actively involved in the discussion of the project & study planning, and manuscript writing. CP: main data-manager. She was involved in the study planning and was responsible for data collection in the north-western part of Greece. She was responsible of data entering in the peripheral units of SESy database. She was involved in manuscript discussion. VG was actively involved in the discussion of the project, realization of the draft, discussion of the outcomes, reviewing and formatting the manuscript. AM was involved in the study planning and was responsible for data collection in north-eastern Greece. He was still actively involved in the discussion of the project and manuscript. DK was involved in the study planning and was responsible for data collection in north-central Greece. He was still actively involved in the discussion of the project and manuscript. GZ was involved in the study planning and was responsible for data collection in the wide area of Attika. Hhe was still actively involved in the discussion of the project and manuscript. IK was involved in the study planning and was responsible for data collection in Athens area and the province of Kozani. She was still actively involved in the discussion of the project and manuscript. GF: PACMeR internal statistician. He was involved in study planning, definition of outcome, and draft writing. He constitutes a basic internal support (Greek branch of the study) that avoids possible miss-understanding in the international collaboration. He still participated in the discussion of the results. AP was involved in the study planning and was responsible for data collection in Piraeus area. He was still actively involved in the discussion (any study phase) since his area of expertising is respiratory-diseases. All authors read and approved the final manuscript.Exact phrasing of the tobacco and chest radiography related questions used for both males and females during the questionnaire-based interviewsTobacco-related questions:Are You a smoker? [No] [yes]How old did you start smoking? How old did you stop smoking? How many cigarettes/tobacco do you daily smoke?......................................................Chest radiography related questions:When did you perform chest radiography last time?ϒ never ϒ Within 1 year ϒ 2 years ϒ 3 years ϒ 5 years ϒ more than 5 yearsFor which reason did you do it?.....................................................................................At what frequency do you undergo chest radiography?.................................................The pre-publication history for this paper can be accessed here:


Correction for:10.1371/journal.pmed.0020100Cockburn R, Newton PN, Agyarko EK, Akunyili D, White NJ (2005) The Global Threat of Counterfeit Drugs: Why Industry and Governments Must Communicate the Dangers. PLoS Med 2(4): e100. doi:San Francisco Examiner [12] that states that 192,000 people died in China in 2001 as a consequence of fake drugs. This story was sourced to the Shenzhen Evening News of January 25, 2002. However, the authors are grateful to Professor Jin Shaohong, Executive Director-General of the National Institute for the Control of Pharmaceutical and Biological Products in Beijing, China, for pointing out that the English translation of the Shenzhen Evening News story used by the San Francisco Examiner and other newspapers is incorrect. The article does not mention counterfeit drugs, but claims that 192,000 people died of drug-induced diseases from the irrational use of drugs in 2001. As this statistic is often quoted in the literature on counterfeit pharmaceuticals, the authors wish to correct this error.The authors quoted a news story from the http://medicine.plosjournals.org/perlserv/?request=read-response&doi=10.1371/journal.pmed.0020100#r1765.Further discussion by three of the authors of this correction is available at


A comprehensive malaria control intervention was initiated in February 2004 on Bioko Island, Equatorial Guinea. This manuscript reports on the continuous entomological monitoring of the indoor residual spray (IRS) programme during the first two years of its implementation.(kdr) using polymerase chain reaction (PCR) to assess the efficacy of the vector control initiative from December 2003 to December 2005.Mosquitoes were captured daily using window traps at 16 sentinel sites and analysed for species identification, sporozoite rates and knockdown resistance Anopheles funestus and Anopheles gambiae s.l. respectively were captured throughout the study period. Both M and S molecular forms of An. gambiae s.s. and Anopheles melas were identified. Prior to the first round of IRS, sporozoite rates were 6.0, 8.3 and 4.0 for An. gambiae s.s., An. melas and An. funestus respectively showing An. melas to be an important vector in areas in which it occurred. After the third spray round, no infective mosquitoes were identified. After the first spray round using a pyrethroid spray the number of An. gambiae s.s. were not reduced due to the presence of the kdr gene but An funestus and An. melas populations declined from 23.5 to 3.1 and 5.3 to 0.8 per trap per 100 nights respectively. After the introduction of a carbamate insecticide in the second round, An. gambiae s.s. reduced from 25.5 to 1.9 per trap per 100 nights and An. funestus and An. melas remained at very low levels. Kdr was found only in the M-form of An. gambiae s.s. with the highest frequency at Punta Europa (85%).A total of 2,807 and 10,293 All three vectors that were responsible for malaria transmission before the start of the intervention were successfully controlled once an effective insecticide was used.Continuous entomological surveillance including resistance monitoring is of critical importance in any IRS based malaria vector control programme. This paper demonstrates that sufficient resources for such monitoring should be included in any proposal in order to avoid programme failures. Anopheles gambiae sensu stricto (s.s.), Anopheles melas and Anopheles funestus are responsible for malaria transmission on the island [An. gambiae s.s. and An. funestus respectively [Malaria is a major endemic disease in the Central African tropical island of Bioko, Equatorial Guinea. High prevalence of infection with malarial parasites in children has been reported ,2. Anophe island ,4 resultBioko has an all year round humid climate with a short dry season from November to March. The population is estimated at 250,000 most of who live in or around Malabo, the capital of Equatorial Guinea.In February 2004, The Bioko Island Malaria Control Project (BIMCP) initiated a comprehensive malaria control intervention consisting of indoor residual spraying (IRS) and effective case management, funded by a consortium led by Marathon Oil Company in partnership with the government of Equatorial Guinea, Medical Care Development International (MCDI), One World Development Group (OWDG), Medical Research Council of South Africa (MRC) and Harvard University. The intervention was monitored by entomological, clinical and population indicators [This paper reports on the continuous entomological monitoring of the IRS programme during the first two years of its implementation 2004–2005). Monitoring of the impact of the intervention on prevalence of infection in children has previously been reported [004–2005.The intervention consists of vector control through (IRS) aimed at covering all domicillary structures, and an extensive programme of case management by provision of definitive diagnosis, treatment with artemisinin-based combination therapy, and intermittent preventive treatment (IPT) to pregnant women.Deltamethrin™ and Fendona™ was carried out between March 2004 and August 2004. In 2005, two spray rounds took place, during February-July and August-December respectively, mainly using the carbamate insecticide Ficam™. Approximately 100,000 houses were sprayed each round.The first round of IRS using the synthetic pyrethoids et al. [Spray operations were similar to those developed in the Lubombo Spatial Development Initiative (LSDI) in Mozambique, Swaziland and South Africa . Progreset al. .In November 2003, prior to the implementation of the control programme, window traps were installed at six houses at each of sixteen sentinel sites Figure . Collectkdr).Mosquitoes were collected prior to the onset of the programme to allow for comparison between pre- and post intervention periods. The number of mosquitoes caught was compared over time, between sentinel sites and with respect to species composition, infection rates and the pattern of pyrethoid knockdown resistance  method described by Scott et al [An. gambiae s.s were identified using the protocol of Favia et al. [et al. [An. funestus group were identified using PCR as described by Koekemoer et al. [Plasmodium falciparum sporozoites was determined using the PCR protocol by Snounou et al. [kdr mutation was based on the PCR method of Martinez-Torres et al. [DNA was extracted from the head and thorax of a sub-sample of mosquitoes using the Livak method . Memberstt et al . Molecula et al.  and all  [et al. . Membersr et al. . The preu et al. . The dets et al. .Numbers of mosquitoes per trap per night were calculated for each vector species, both pre- and post-IRS, based on day of capture of the specimen in relation to spray status of the site in which the window trap was located. Using the species specific estimated sporozoite prevalence, the number of infective mosquitoes per trap per night, by species was calculated; the ratio of infective numbers per trap per night post spraying, relative to pre-spraying, was defined as the relative transmission index.All culicenes caught were recorded to ensure that in the absence of anopheline catches, the traps were being successfully operated.An. gambiae s.l. and 2,807 An. funestus were collected and morphologically identified. Of these, 2,043 An. gambiae s.l. and 588 An. funestus were subjected to species specific analysis . An. funestus was identified from ten sites . After the third spray round, An. gambiae s.s. was identified from eight sites  and An. melas only from Punta Europa. No An. funestus were caught in window traps after the third spray round.During this study, which comprised 59,307 trapping nights, 10,293 An. gambiae s.s. accounted for more than 80% of the An. gambiae s.l. captured over the duration of the study period and both the M and the S molecular forms were identified. An. melas predominated at one site, Riaba, accounting for 94% of the An. gambiae s.l. identified at this site prior to IRS (n = 108). After the third spray round, no An. melas were identified from this locality.An. gambiae s.s. per window trap per 100 nights, pre spraying was >20 with A. melas markedly lower at <5. An. gambiae s.s. showed an increase in the estimated number per window trap post spray round 1 (from 23.9 to 25.5 per trap per 100 nights) but was markedly reduced to two mosquitoes per trap per 100 nights after the second spray round with carbamate insecticide (Table An. melas and An. funestus showed significant reductions after the first spray round (from 5.3 to 0.8 and from 23.5 to 3.1 respectively) and continued to drop further with the subsequent spray round (to 0.2 and 0.04 respectively).The estimated number of An. gambiae s.l. and An. funestus ranging from <1 per trap per 100 nights to 182.9 (Punta Europa) and 140.9 (Sacriba) per trap per 100 nights respectively.Prior to the onset of IRS, large variations in mosquito numbers existed between sentinel sites with densities of An. gambiae s.s., An. melas and An. funestus respectively. After the first spray round with a pyrethoid spray, these reduced to 1.8%, 3.1% and 2.3% and after the second spray round, no infective mosquitoes were identified  was 0.26, 0.07, 0.08 for ed Table .culicene densities were 130.2 per trap per 100 nights. Post spraying, densities were 108.0, 115.6 and 81.4 per trap per 100 nights for each spray round respectively. Large variations in culicene numbers existed between sentinel sites, throughout the study period with densities ranging from 6 to 461 per trap per 100 nights.Prior to the onset of IRS, An. gambiae s.s. were identified as S-forms and 36% as M-forms (n = 362). The proportion of M forms rose steadily with each spray round and by the end of the third spray round, 80% of An. gambiae s.s. were identified as M forms (n = 63). S-forms only were found at Baney, Batete, Bilelipa, Musola and Rebola and M-forms only from Central and Bacake Grande. M and S forms were sympatric at all other localities. No hybrids were identified.Prior to the onset of spraying, 64% of kdr/kdr) or the heterozygous susceptible (kdr/+) kdr genotypes . The present findings corroborate this study and show that in areas where both vectors cohabit (Punta Europa and Riaba), regardless of which one is dominant, infectivity rates were similar.o et al.  found tho et al. , found sAn. gambiae s.s., the molecular M form and S form were both identified throughout the study period. The data indicated a strong selection for the M form over the IRS intervention period, which is linked to the presence of the kdr mutation.The two genetic variants of kdr in the An. gambiae s.s. population despite the use of pyrethoid-impregnated bednets [kdr in 50% of M-forms tested but absent in the S form (Table et al. [kdr gene present in 55% of molecular M-forms of An gambiae s.s. from Malabo but absent from the S-form. The frequency of the kdr allele continued to rise and by the end of 2005, was present in 78% of M-forms, but absent in S-forms and reached a maximum frequency of 85% at Punta Europa sentinel site. Pyrethroids were mainly withdrawn from use in IRS in 2004 after the first spray round and replaced with a carbamate insecticide. However, pyrethroids were still frequently used in the form of vehicle and hand fogging in Malabo [An. gambiae s.s. due to the presence of the kdr gene. Figure An. gambiae s.l. caught exiting houses from March 2004 in spite of the implementation of the IRS programme using a pyrethroid. The failure to control An. gambiae s.s. effectively with a pyrethroid due to kdr is demonstrated by the effective reduction in the seasonal peak in An. gambiae s.s. after the introduction of carbamate IRS (Figure An. gambiae s.s. the relative abundance of house leaving An. funestus and An. melas was dramatically reduced following the first round of IRS using a pyrethroid and remained low with the introduction of a carbamate. The efficacy of a carbamate insecticide for large scale IRS was recently also demonstrated in Mozambique for both An. arabiensis and non kdr pyrethroid resistant An. funestus [A study on Bioko between 1998 and 2001 reported no evidence of  bednets . It was An. funestus and An. melas in the first spray round and An. gambiae s.s. by the second spray round, and the substantial decrease in the transmission index after the first year, a finding supported by the significant decrease in the parasite prevalence in children by one third after the first year of IRS [This study further emphasizes the importance of monitoring and evaluation in any large scale insecticide based vector control programme. The efficacy of the IRS programme in Bioko is demonstrated by the dramatic reduction in r of IRS .These results lead us to emphasise the critical importance of continuous entomological surveillance including insecticide resistance monitoring based on an extensive system of window traps in any IRS based malaria vector control programme. It is recommended that proposals for such interventions include sufficient resources for such monitoring to avoid programme failures that may result from the ineffective control of important malaria vectors.BLS: Co-designed the study, participated in analysis and interpretation of data and contributed to the drafting of the manuscript. FCR carried out the laboratory analyses of mosquitoes, assisted with data analysis and interpretation and was involved in the drafting of the manuscript. DG: Managed the database, assisted with the analysis of results and contributed to the manuscript. JK: Management of IRS and the collection of field samples and contributed to the manuscript. IK: Co-designed and coordinated the study, participated in the analysis and interpretation of results, and was involved it the drafting of the manuscript and critical evaluation thereof.All authors read and approved the manuscript.


Malaria is by far the greatest cause of morbidity and mortality in Angola, being responsible for 50% of all outpatient attendance and around 22% of all hospital deaths, yet by 2003 only 2% of under-5s used insecticide-treated nets. Entomological studies are an essential foundation for rational malaria control using insecticide-treated nets and indoor residual spraying, but there have been no published studies of malaria vectors in Angola over the 27 years of the civil war, to its end in 2002. This paper describes studies arising from a WHO-sponsored visit in support of the National Malaria Control Programme.Anopheles species present, their sporozoite rates and the frequency of a kdr allele conferring resistance to pyrethroid insecticides.During April 2001, mosquitoes were sampled by indoor pyrethrum spray collection from four sites in the semi-arid coastal provinces of Luanda and Benguela and two sites in Huambo province, in the humid tropical highlands. Collections took place towards the end of the rainy season and were used to determine the Anopheles gambiae complex showed a preponderance of An. gambiae, with indoor resting densities ranging from 0.9 to 23.5 per house. Of 403 An. gambiae identified to molecular form, 93.5% were M-form and 6.5% S-form. M and S were sympatric at 4 sites but no M/S hybrids were detected. The highest proportion of S-form (20%) was in samples from Huambo, in the humid highlands. Anopheles funestus was found at one site near Luanda. The sporozoite rate of mosquitoes, determined by an ELISA test, was 1.9% for An. gambiae (n = 580) and 0.7% for An. funestus (n = 140). Of 218 An. gambiae (195 M-form and 23 S-form) genotyped for the West African kdr-resistance allele, all were homozygous susceptible.A PCR test for the An. gambiae M-form is the most important and widespread malaria vector in the areas studied but more extensive studies of malaria vectors are required to support the malaria control programme in Angola. These should include standard insecticide resistance biossays and molecular assays that can detect both metabolic resistance and target site insensitivity. Anopheles gambiae, Anopheles arabiensis and Anopheles funestus are the main vectors of malaria, although Anopheles melas, a member of the An. gambiae complex, is known to be a malaria vector in some coastal areas [In West Africa, al areas -3.An. gambiae comprises two molecular forms, M and S, recognisable from rDNA sequence differences, either in the intergenic spacer [kdr), which confers resistance to pyrethroid insecticides and which is assumed to have first developed in the S-form, has subsequently passed from the S-form to the M-form, presumably due to hybrid formation and consequent introgression [It has been shown that c spacer  or in thc spacer ,6. The ggression ,8. Recengression . The S-fMalaria is endemic throughout much of Angola territory, and is by far the highest cause of morbidity and mortality. During the period from 1999 to 2002 (last year for which data are available) there were 1.47 million cases of malaria annually, out of a mid-period population of c.11.4 million. Malaria continues to be responsible for 50% of all outpatient attendance and around 25% of all hospital deaths, yet by 2003 only 2% of under-5s used insecticide-treated nets . Due to An. gambiae and An. funestus complexes, their potential role in malaria transmission and to provide information on the status of kdr-based resistance to pyrethroids in An. gambiae in Angola.During April 2001, the senior author (NC) visited Angola at the request of WHO, to assist in "strengthening malaria vector control especially the promotion of insecticide-treated bed nets". As one part of this mission, a rapid mosquito survey was carried in some of the malarious regions of the country with a focus on areas around the capital Luanda, the semi arid coastal cities of Benguela and Lobito and Huambo city in the tropical highlands. The main malaria transmission season in Angola lasts from November to April. This paper is based on data from that rapid survey and subsequent laboratory studies. The primary objective has been to gather information on species composition within the Mosquitoes were collected towards the end of the rainy season during the period 11–19 April 2001 from seven localities in Angola, all close to or within urban areas; five in the semi-arid, coastal strip south from Luanda to Benguela and two in the humid tropical highlands of Huambo Province,  band of 195 bp. To eliminate errors in scoring, all kdr allele assays were carried out twice (by NC and KSC) and discrepancies checked.The presence of s et al. . The PCRPlasmodium falciparum were determined by the ELISA method [Sporozoites rates for A method ,16, usinCulex spp are included for comparative purposes but are not discussed further here. The numbers of individuals for the different species and/or molecular forms of the An. gambiae complex are shown in Table An. gambiae s.s. collected, the M-form was predominate, representing 93.5% (n = 403). The S-form was restricted to localities in the municipality of Benguela on the coast, where it comprised 3.8% (n = 184), and Huambo in the humid highlands, where it comprised 20% (n = 94) of An. gambiae s.s. collected. These differences in proportions of S-forms between coastal and highland sites are significant (p < 0.001). No M/S heterozygotes were found.The numbers of mosquitoes found resting indoors at each locality in Angola are shown in Table An. melas was found, together with An. gambiae M-form, resting indoors in the coastal area of Cacuaco. In the larval collection from Samba, one An. arabiensis was found along with 21 specimens of An. gambiae M-form. Forty-six specimens of An. funestus s.l. from indoor collections in Cacuaco were identified to species; all proved to be An. funestus s.s.An. gambiae M and S-forms are shown in Table The results of assays for kdr resistance alleles in An. funestus (n = 140) and 1.9 % in An. gambiae (n = 580).The results of sporozoite ELISA assays are shown in Table Little is known of malaria vectors in Angola and, with one exception (discussed below), all published studies preceded the war of independence and subsequent civil war, which finally ended in 2002. Although Angola is building up a cadre of technical staff to assist in the distribution of ITNs , as yet An. gambiae [An. gambiae M-form. The low proportion of the S-form among An. gambiae in Benguela and its absence in samples from Lobito and Luanda mirrors the findings in Carrara et al. [et al. [A recent analysis of published and unpublished data on the distribution of the molecular forms of  gambiae ,17 has dAn. gambiae s.s. of 1.9% (95% CI 0.8–3.0), which is based on samples from localities where the M-form was predominant (97.6%). Despite these samples being collected in the rainy season when nullipars predominate, it is nevertheless higher than the 0.4% for An. gambiae s.s. in the studies of Carrara et al. [In our study we found a sporozoite rate in a et al. .An. arabiensis specimen was found in this study, in a larval collection. The scarcity of this species in samples from a semi-arid region that might have been expected to favour this species may be a reflection of seasonal abundance or exophily, although it is notable that this species was also scarce in the studies of Carrara et al. [Only a single a et al. .An. gambiae complex, hybridisation between species and forms may be more likely at certain seasons as densities are undergoing change.There is evidence (reviewed in ) that thAn. gambiae s.s. mosquitoes for kdr resistance and no resistance alleles were found. We did not expect to find resistance to pyrethroids, since these insecticides have not been available in significant quantities during the periods of civil strife, when agricultural production was severely disrupted. Carrara et al. [kdr-allele (about 18%)" in the Cabinda enclave, but did not find the resistant alleles in samples (of unstated size) from other sites in Angola. Whilst kdr resistance does not yet appear to have a highly significant effect on the performance of ITNs for malaria control, it would be prudent to increase monitoring for resistance using standard WHO bioassays and molecular tests that can detect both metabolic resistance and target site insensitivity [In this study we tested only 218 a et al.  reportedsitivity ,20.An. funestus complex.NC carried out the field collections of malaria vectors in Angola together with staff of the National Malaria Control Programme. He conducted the laboratory analysis of sporozoite rates and the PCR assays for identification of the An. gambiae complex, and the assays for kdr. All assays of molecular forms and kdr resistance were double-checked and any discrepancies resolved. HT advised on the experimental methods, results and interpretation of these assays.NC and KSC jointly carried out PCR assays for species and molecular forms of the NC and HT took the lead role in data analysis and interpretation. All three authors were closely involved in writing the paper and read and approved the final manuscript.


This year CytoJournal celebrates the second full year of publication with its Best of CytoJournal: 2006. Like last year, it recognizes the work of the authors in thyroid FNAB. And, importantly, this years award, which was handed out at USCAP, was endowed by a gift from the Pathikonda family. In 2005 CytoJournal established a "Best of..." award and we were pleased to recognize the work of Nguyen, et al. . For 200Interestingly, both articles are about thyroid fine-needle aspiration biopsy (FNAB). And, like last year, the article by Deveci et al. is, notably, one of the 'highly accessed' articles during the past year . As I sthttp://www.cytopathology-foundation.org/page12.html.The award presentation was made by Dr. Vinod Shidam, the journal's Executive editor and Co-Editor in Chief, at the just past USCAP meeting in San Diego, and can be viewed at: In closing, we congratulate the authors on their article and hope that at the same time this will interest other authors in submitting their articles to CytoJournal.


Anopheles gambiae s.s. is a highly anthropophilic mosquito and is the major vector for human malaria in sub-Sahara Africa, while Anopheles quadriannulatus, largely due to its zoophilic behaviour, is considered a non-vector species in the same region. Careful studies of olfaction in these sibling species may lead to insights about the mechanisms that drive host preference behaviour. In the present study, the external anatomy of the antenna, the principle olfactory organ in the female mosquito of both species, was examined as an initial step toward more detailed comparisons.Volatile odors are important sensory inputs that shape the behaviour of insects, including agricultural pests and disease vectors. An. gambiae s.s. and An. quadriannulatus. Sensory structures, called sensilla, were categorized and counted; their distributions are reported here as well as densities calculated for each species.Scanning electron and light microscopy were used to examine the antennae ultrastructures of adult female An. gambiae s.s. and An. quadriannulatus bear five classes of sensilla on their antennae: chaetica (bristles), trichodea (hairs), basiconica (pegs), coeloconica (pitted pegs), and ampullacea (pegs in tubes). Female An. quadriannulatus antennae have approximately one-third more sensilla, and a proportionally larger surface area, than female An. gambiae s.s. antennae.Both An. quadriannulatus has greater numbers of each sensilla type, sensilla densities are very similar for each species, suggesting that other factors may be more important to such olfactory-driven behaviours as host preference.The same types of sensilla are found on the antennae of both species. While  An. gambiae s.s. and An. quadriannulatus, display very different patterns of blood meal host preference. An. gambiae s.s. exhibits a high degree of anthropophily, while An. quadriannulatus exhibits strong zoophily [An. gambiae s.s. females is a major contributing factor to human malaria transmission, a disease that afflicts more than 200 million people and causes as many as 3 million deaths annually [An. quadriannulatus, because of its preference for cattle, is not considered a malaria vector [Odors are the principle sensory signals that direct female mosquitoes to their preferred blood meal hosts ,2. Antena vector .An. gambiae s.s. Accordingly, comparisons of the peripheral and central olfactory events between behaviourally divergent sibling species, such as An. gambiae s.s. and An. quadriannulatus, should provide valuable insights into the mechanisms that determine their respective host preferences. Understanding the basic molecular events that underlie blood feeding may ultimately lead to the design of new ways to interfere with the human/mosquito interaction and thereby reduce the associated disease burden.In order to understand the specifics of the attractiveness of humans to the mosquito, a major focus of this laboratory is the study of components in the olfactory signal transduction and coding process of An. gambiae s.s. and An. quadriannulatus, which may suggest areas of future investigation. As such, a comparative examination of the olfactory apparatus of An. gambiae s.s. and An. quadriannulatus as a prelude to future comparative molecular studies has been undertaken.Antennal sensilla have previously been described for several mosquito species , inclAn. gambiae s.s. (G3) and An. quadriannulatus (SANGQUA) were reared as described previously [An. gambiae s.s. was received from Dr. Mark Benedict at the Centers for Disease Control and Prevention and is described in more detail at: . An. quadriannulatus (SANGQUA) was the kind gift of Dr. Willem Takken .eviously . The G3 An. gambiae s.s. or An. quadriannulatus were fixed with 4% paraformaldehyde, 0.1% Triton X-100 in phosphate buffered saline (PBS). Heads were then dehydrated; first in an ethanol series from 50% to 100% in 10% increments, followed by ethanol:hexamethyldisilazane (HMDS) at 75:25, 50:50, 25:75 and 0:100. HMDS was decanted and heads were dried in a fume hood. Heads were then glued onto aluminum pin mounts with colloidal silver paint and sputter coated for 30 seconds with gold-palladium. Samples were viewed using a Hitachi S-4200 scanning electron microscope and digital micrographs of each flagellomere were collected using Quartz PCI version 6.0 image acquisition software .Heads from 4- to 6-day-old adult An. gambiae s.s. (G3 strain) or An. quadriannulatus were hand dissected from cold-anesthetized animals and placed in 25% sucrose, 0.1% Triton X-100 in water. These antennae were mounted on glass slides with a cover slip and sealed with clear enamel nail polish. Slides were stored at 4°C and observed under an Olympus BX-60  microscope at 400× magnification. Photomicrographs were captured using an Olympus DP70 digital camera.Antennae from 4- to 6-day-old adult n [t-tests (two-tailed) were performed as described [Antennae were initially observed by SEM on both the dorsal and ventral aspects to look for any bias in sensilla arrangements. Thereafter, heads were mounted such that the antennae were most often observed from the lateral aspect, with some variation between individuals. Sensilla on each micrograph were classified by type and counted. Mean values for each sensillum type were calculated for 10 individuals per species and then multiplied by a factor of 2, assuming that only half the sensilla could be seen in each micrograph. For brightfield counting, all sensilla of a given type could be observed on each flagellomere by continuous focus adjustment through the specimen. Mean values for each type were calculated for 20 individuals. Standard deviations were calculated for each data set as described previously [t-tests (two-tailed) were performed to determine whether the mean surface areas differed significantly between species. Sensilla densities were calculated by dividing the mean number of sensilla by the total mean surface area where the particular type of sensilla was found.Flagellomeres 1–13 were viewed using brightfield optics, as described above, at 400× magnification. The length of each flagellomere was measured with an Olympus DP70 digital scale bar, and the width (diameter) was measured at the midpoint of the length Figure . The meaAn. gambiae s.s. and An. quadriannulatus adults are equipped with three types of appendages – the antennae, maxillary palps, and proboscis (labellum) – each with associated chemosensory functions . Externally, male and female proboscises appear identical. However, males often lack or have highly modified forms of stylets enclosed within the proboscis [The proboscis, or modified labium in mosquitoes, is also longer than the antennae and is the most ventral of the head appendages Figure . At the roboscis .An. gambiae s.s. and An. quadriannulatus, this study focuses on a structural comparison of their antennae. The following are detailed descriptions of the types, numbers, distributions, and densities of female antennal sensilla.Because of the major importance of the antennae on host seeking and other behaviours in female An. gambiae s.s. and An. quadriannulatus. The large sensilla chaetica are arranged in a whorl on the basal end of each flagellomere 2–13 and distributed evenly around the circumference . Similarly, An. quadriannulatus had 6–8 on the first seven flagellomeres, 4–6 on the next five flagellomeres, and 1 or 2 on the 13th flagellomere. The number of small sensilla chaetica averaged 50.5 in An. gambiae s.s. and 57.5 in An. quadriannulatus.Small sensilla chaetica were generally found on the dorsal surface and nearer the distal edge of flagellomeres 2–13 . The sharp sensilla trichodea seemed to be randomly distributed around the circumference of each flagellomere 2–13. An. gambiae s.s. females had, on average, about 615 trichoid sensilla per antenna, and An. quadriannulatus females had about 770 per antenna in this study.The most numerous sensilla found along the flagellum of ed Table . Two dised Table , 4A, C. tephensi . While gtephensi . The numAn. gambiae s.s. and An. quadriannulatus, blunt sensilla trichodea were the least numerous class of sensilla quantified in this study  small sensilla coeloconica , or environmental factors are more likely to contribute to the host preference divergence of An. gambiae s.s. and An. quadriannulatus. A recent comparison of candidate olfactory receptor genes in An. gambiae s.s. and An. quadriannulatus showed an extremely high level of conservation between their amino acid sequences . This study provides an essential foundation for these and other future comparative analyses that will focus on the molecular genetics and physiology of olfaction in these two species.There are at least six species in the recently . Furtherentified . While tl organs . ClearlyAn. gambiae s.s. and An. quadriannulatus mosquitoes carry the same morphological types of sensilla and the densities of each type are effectively equal between the two species. Therefore, the lack of specialization at the gross morphological level of the antennae implies that other factors are more likely to account for the olfactory-driven host preference difference between An. gambiae s.s. and An. quadriannulatus. This study establishes a foundation for future neurological, physiological, and molecular comparative studies aimed at elucidating potential differences in olfaction between these sibling species.The antennae of adult female RJP and LJZ conceived and designed the study. RJP carried out all microscopy and analysis (with some assistance from undergraduate researchers as listed in the acknowledgements) and drafted the manuscript. Both authors read and approved the final manuscript.