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Clozapine treatment for schizophrenia is typically long-term and is associated with a high rate of diabetes. Mental health and diabetes specialist teams at a local hospital in Australia have undertaken a series of joint specialist case conferences (JSCCs) where the diabetes team works with the psychiatry team to improve diabetes management. In this retrospective cohort study conducted between 2013 and 2018, we found that glycemic control in clozapine clinics linked with JSCCs was improved significantly compared with that in the non-JSCC clinics. In the non-JSCC clozapine clinics (control), the poor glycemic control rates stayed at a similar level: 23% in 2013 and 24% in 2018. In contrast, whereas the control patients' poor glycemic rate in JSCC clozapine clinics in 2013 was 24%, it decreased markedly in 2018 to 13%. This study indicates that JSCCs can improve diabetes outcomes in a group of patients with severe mental illness.

ObjectiveThe aim of this study was to explore how people with diabetes and diverse health literacy levels conceptualise their experience and efforts to engage in self-management behaviours (their self-management 'schemas').DesignA qualitative design was applied.MethodsTwenty-six people in Sydney, Australia, took part in semi-structured interviews, which were audio-recorded and coded using Framework analysis.ResultsHalf the participants (54%) had limited health literacy, whereas 38% adequate health literacy (using Newest Vital Sign). Regardless of health literacy, people described how monitoring increased self-management awareness and signalled periods of low self-management ('lulls'). Accounts of monitoring to sustain motivation were more apparent for participants with adequate health literacy. Most participants described simple and flexible rules (e.g. use artificial sweeteners; eat in moderation). Two schemas related to 'lulls': a 'problem-solving orientation' depicted lulls as inevitable and was associated with varied coping strategies; a 'willpower orientation' attributed lulls to lack of 'willpower,' and described willpower as a main coping strategy.ConclusionThere is considerable variation in how people think about their diabetes self-management and the strategies they use. Health literacy may contribute to some of this variation. Self-management interventions could benefit from depicting motivation as fluctuating and challenging ideas about willpower and self-blame.

Examining pre-diabetes and diabetes rates using glycated haemoglobin (HbAEpidemiological study of HbA1c measurements in individuals ≥18 years receiving a blood test (1) in the hospital setting of the ED at Blacktown/Mt Druitt hospital (1/06/2016 to 31/05/2018) and (2) in primary care involving Bridgeview Medical Practice (BVMP) (1/03/2017 to 01/02/2018) as well as other general practices (June 2018 only).Totals of 55,568 individuals from ED and 5911 individuals from GP. The prevalence of diabetes in tested individuals was 17.3% (n = 9704) in ED and 17.4% (n = 1027) in GP. The prevalence of pre-diabetes in ED was 30.2% (n = 16,854) and 26.6% (n = 1576) in GP. Regression controlling for age, season, and gender revealed a weekly increase of 1.1% in odds for diabetes and 1.5% for pre-diabetes (p 0.001), in line with the yearly absolute increase of 1% in rate for both tested and coded hospital patients. In BVMP the rate of diabetes rose by 22% during the testing period from 8.9% to 11%.There exists a high burden of diabetes both in hospitals and general practice. Testing in ED and general practice revealed similarly high burdens of diabetes across different areas of the healthcare system. In the appropriate hospital and primary care setting, HbA1c can be used to identify individuals with diabetes that may benefit from targeted intervention.

The Problem - Theory Type 2 diabetes is the leading burden of disease in Australia, with rates more than tripling in just 20 years. Western Sydney is particularly vulnerable, with its large socio-economically and culturally diverse population of >1 million people. Approximately 12% of the Western Sydney population have diabetes, 35% are at high risk of diabetes and >50% are overweight/obese, far higher than both the state and national averages. The Initiative - Description/Aims/Timeline Western Sydney Diabetes (WSD) initiative was established in 2012, and is led by Western Sydney Local Health District (hospital care), Western Sydney Primary Health Network (primary healthcare), Diabetes NSW and ACT (NGO), and PricewaterhouseCoopers, as well as a range of partners from healthcare and non-healthcare sectors. WSD represents an embedded integrated healthcare initiative that is world-leading in several areas of practice, including both primary prevention, secondary prevention, management of diabetes, and efforts to mobilize the public. Underpinning this is a rigorous data effort to measure and demonstrate the benefits of the initiative. Since inception, WSD has brought together the Diabetes Alliance, which now has over 130 dedicated members. These include organisations within government, health, and the private sector, as well as NGOs and other charities. The WSD programs are a unique blend of primary/secondary prevention and management efforts, including: Primary Prevention - healthy urban design, healthy eating, physical activity programs, advocacy and public awareness campaigns, employee wellness efforts Secondary Prevention/Management - HbA1c testing to identify the burden of diabetes, General Practice (GP) support, health pathways, practice nurse training, diabetes masterclasses, complex diabetes clinics, joint-specialist case conferencing, high-risk foot services, CGM for diagnostics, a bariatric obesity clinic, a new community diabetes clinic, and many more. The Impact - Discussions/Lessons Learned WSD represents an integrated initiative that is imbedded into regular practice, drawing together the hospital and community, for more than half a decade. While the efforts are not yet enough to cool the western Sydney diabetes hotspot, WSD has demonstrated benefits in a number of areas. The joint-specialist case conferencing work has led the way in healthcare innovation in the state, with demonstrable benefits to both individual patients and GP clinics. WSD has made great strides in identifying the diabetes burden, with published evidence that >20% of patients in hospital in the region have diabetes, numbers which are echoed in GP clinics nearby. This research has also shown that more than 20% of patients are unaware that they have diabetes. A recent research initiative between WSD and the Ministry of Health for NSW has shown that people whose GPs are unaware of their diabetes status have more than double the risk of unplanned hospitalization compared to people who are aware of their disease. With PricewaterhouseCoopers, WSD has developed business cases for funding opportunities, as well as integrated diabetes dashboards that display essential information to a wide range of partners. WSD represents a fully developed model that can transfer across regions, with a structure and framework that can be applied in many areas. We can beat diabetes, together.

The cost and comorbidity of obesity in hospitalized inpatients, is less known. A retrospective study of patients presenting to a large district hospital in Western Sydney (April 2016-February 2017) using clinical, pathological as well as diagnostic coding data for obesity as per ICD-10. Of 43 212 consecutive hospital presentations, 390 had an obesity-coded diagnosis (Ob, 0.90%), of which 244 were gender and age-matched to a non-obesity coded cohort (NOb). Weight and BMI were higher in the Ob vs NOb group (126 ± 37 vs 82 ± 25 kg; BMI 46 ± 12 vs 29 ± 8 kg/m2 , P 35 kg/m2 were 5× more likely to require intensive care (OR 5.08 [1.43-27.3, 95% CI], P = .0047). The initiation of obesity-specific interventions by clinical teams was very low. People with obesity who are admitted to hospital carry significant cost and complications, yet obesity is seldom recognized as a clinical entity or contributor.

Background: Past research has demonstrated that ethnically diverse backgrounds have a greater risk of Diabetes Mellitus and/or Chronic Kidney Disease (CKD), which both contribute significantly to the disease burden placed on the Australian Healthcare system. The purpose of this study was to investigate the differences in DM associated CKD between ethnicities in Western Sydney, NSW Australia, which is known to be an ethnically diverse geographical region.Method: Using data from Blacktown and Mt Druitt Hospitals and a retrospective approach, individuals with diabetes and CKD were identified based on HbA1c and eGFR results. Using univariate analysis and past research, a logistic regression modelling was carried out on the data to identify relationships between ethnicity and DM associated CKD.Results: Out of 73,001 observations, 24,009 individuals were included in the analysis with 3,934 individuals with HbA1c consistent with diabetes and kidney function at eGFR at Stage 2 and above. 47% were female and 53% were males and the median age was 76 ± 12 years. Using a forward-method model building process, ethnicity was compared to a reference of Caucasian. The model showed that Pacific Islanders have the most risk (OR: 5.63, p Conclusion: The results show a clear difference in risk between ethnicities in DM associated CKD and its associated risk factors. These differences should be accounted for when considering interventions for at risk communities.

BACKGROUND Chronic disease represents a large and growing burden to the health care system worldwide. One method of managing this burden is the use of app-based interventions; however attrition, defined as lack of patient use of the intervention, is an issue for these interventions. While many apps have been developed, there is some evidence that they have significant issues with sustained use, with up to 98% of people only using the app for a short time before dropping out and/or dropping use down to the point where the app is no longer effective at helping to manage disease. OBJECTIVE Our objectives are to systematically appraise and perform a meta-analysis on dropout rates in apps for chronic disease and to qualitatively synthesize possible reasons for these dropout rates that could be addressed in future interventions. METHODS MEDLINE (Medical Literature Analysis and Retrieval System Online), PubMed, Cochrane CENTRAL (Central Register of Controlled Trials), and Embase were searched from 2003 to the present to look at mobile health (mHealth) and attrition or dropout. Studies, either randomized controlled trials (RCTs) or observational trials, looking at chronic disease with measures of dropout were included. Meta-analysis of attrition rates was conducted in Stata, version 15.1 (StataCorp LLC). Included studies were also qualitatively synthesized to examine reasons for dropout and avenues for future research. RESULTS Of 833 studies identified in the literature search, 17 were included in the review and meta-analysis. Out of 17 studies, 9 (53%) were RCTs and 8 (47%) were observational trials, with both types covering a range of chronic diseases. The pooled dropout rate was 43% (95% CI 29-57), with observational studies having a higher dropout rate (49%, 95% CI 27-70) than RCTs in more controlled scenarios, which only had a 40% dropout rate (95% CI 16-63). The studies were extremely varied, which is represented statistically in the high degree of heterogeneity (I2>99%). Qualitative synthesis revealed a range of reasons relating to attrition from app-based interventions, including social, demographic, and behavioral factors that could be addressed. CONCLUSIONS Dropout rates in mHealth interventions are high, but possible areas to minimize attrition exist. Reducing dropout rates will make these apps more effective for disease management in the long term. CLINICALTRIAL International Prospective Register of Systematic Reviews (PROSPERO) CRD42019128737; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019128737

In order of first author surname

Purpose Type 2 diabetes mellitus has become a major concern of Australian healthcare providers. From rates of barely more than 1 percent in the mid-90s, diabetes is now the leading cause of morbidity in the country. To combat the growing diabetes epidemic, Western Sydney Local Health District created the Western Sydney Diabetes (WSD) initiative. One of the key components of the WSD initiative since 2014 has been joint specialist case conferencing (JSCC). The purpose of this paper is to evaluate the JSCC service including both individual- and practice-based changes. Design/methodology/approach The authors evaluated the JSCC program by conducting an analysis of patient-level data in addition to a discrete practice-level study. The study aim was to examine both the effect on individual patients and the practice, as well as acceptability of the program for both doctors and their patients. The evaluation included data collection and analysis of primary patient outcomes, as well as a survey of GPs and patients. Patient data on primary outcomes were obtained by accessing and downloading them through GP practice management software by GP practice staff. Findings The authors found significant improvements at both the patient levels, with reductions in BMI, HbA1c and blood pressure sustained at three years, and at the practice level with improvements in markers of patient management. The authors also found high acceptability of the program from both patients and GPs. Originality/value This paper provides good evidence for the use of a JSCC program to improve diabetes management in primary care through capacity building with GPs.

Background Approximately two-thirds of individuals presenting to emergency departments in Western Sydney have glucose dysregulation, accelerating their risk of cardiovascular disease (CVD). We evaluated the prevalence and management of type 2 diabetes (T2D) in cardiology inpatients in Western Sydney. A novel model of care between diabetes and cardiology specialist hospital teams (joint specialist case conferencing, JSCC) is described herein and aimed at aligning clinical services and upskilling both teams in the management of the cardiology inpatient with comorbid T2D. Methods Cardiology inpatients at Blacktown-Mount Druitt Hospital were audited during a 1-month period. Results 233 patients were included, mean age 64 ± 16 years, 60% were male, 27% overweight and 35% obese. Known T2D comprised 36% (n = 84), whereas 6% (n = 15) had a new diagnosis of T2D, of which none of the latter were referred for inpatient/outpatient diabetes review. Approximately, 27% (n = 23) and 7% (n = 6) of known diabetes patients suffered hyper- and hypoglycaemia, respectively, and 51% (n = 43) had sub-optimally controlled T2D (i.e. HbA1c > 7.0%); over half (51%, n = 51) had coronary artery disease. Only two patients were treated with an SGLT2 inhibitor and no patients were on glucagon like peptide-1 receptor analogues. The majority were managed with metformin (62%) and therapies with high hypoglycaemic potential (e.g., sulfonylureas (29%)) and in those patients treated with insulin, premixed insulin was used in the majority of cases (47%). Conclusions Undiagnosed T2D is prevalent and neglected in cardiology inpatients. Few patients with comorbid T2D and CVD were managed with therapies of proven cardiac and mortality benefit. Novel models of care may be beneficial in this high-risk group of patients and discussed herein is the establishment of the diabetes-cardiology JSCC service delivery model which has been established at our institution.

BackgroundThe health burden of type 2 diabetes can be mitigated by engaging patients in two key aspects of diabetes care: self-management and regular contact with health professionals. There is a clear benefit to integrating these aspects of care into a single clinical tool, and as mobile phone ownership increases, apps become a more feasible platform. However, the effectiveness of online health interventions is contingent on uptake by health care providers, which is typically low. There has been little research that focuses specifically on barriers and facilitators to health care provider uptake for interventions that link self-management apps to the user’s primary care physician (PCP). ObjectiveThis study aimed to explore PCP perspectives on proposed features for a self-management app for patients with diabetes that would link to primary care services. MethodsResearchers conducted 25 semistructured interviews. The interviewer discussed potential features that would link in with the patient’s primary care services. Interviews were audio-recorded, transcribed, and coded. Framework analysis and the Consolidated Criteria for Reporting Qualitative Research checklist were employed to ensure rigor. ResultsOur analysis indicated that PCP attitudes toward proposed features for an app were underpinned by perceived roles of (1) diabetes self-management, (2) face-to-face care, and (3) the anticipated burden of new technologies on their practice. Theme 1 explored PCP perceptions about how an app could foster patient independence for self-management behaviors but could also increase responsibility and liability for the PCP. Theme 2 identified beliefs underpinning a commonly expressed preference for face-to-face care. PCPs perceived information was more motivating, better understood, and presented with greater empathy when delivered face to face rather than online. Theme 3 described how most PCPs anticipated an initial increase in workload while they learned to use a new clinical tool. Some PCPs accepted this burden on the basis that the change was inevitable as health care became more integrated. Others reported potential benefits were outweighed by effort to implement an app. This study also identified how app features can be positively framed, highlighting potential benefits for PCPs to maximize PCP engagement, buy-in, and uptake. For example, PCPs were more positive when they perceived that an app could facilitate communication and motivation between consultations, focus on building capacity for patient independence, and reinforce rather than replace in-person care. They were also more positive about app features that were automated, integrated with existing software, flexible for different patients, and included secondary benefits such as improved documentation. ConclusionsThis study provided insight into PCP perspectives on a diabetes app integrated with primary care services. This was observed as more than a technological change; PCPs were concerned about changes in workload, their role in self-management, and the nature of consultations. Our research highlighted potential facilitators and barriers to engaging PCPs in the implementation process.

BACKGROUND The health burden of type 2 diabetes can be mitigated by engaging patients in two key aspects of diabetes care: self-management and regular contact with health professionals. There is a clear benefit to integrating these aspects of care into a single clinical tool, and as mobile phone ownership increases, apps become a more feasible platform. However, the effectiveness of online health interventions is contingent on uptake by health care providers, which is typically low. There has been little research that focuses specifically on barriers and facilitators to health care provider uptake for interventions that link self-management apps to the user’s primary care physician (PCP). OBJECTIVE This study aimed to explore PCP perspectives on proposed features for a self-management app for patients with diabetes that would link to primary care services. METHODS Researchers conducted 25 semistructured interviews. The interviewer discussed potential features that would link in with the patient’s primary care services. Interviews were audio-recorded, transcribed, and coded. Framework analysis and the Consolidated Criteria for Reporting Qualitative Research checklist were employed to ensure rigor. RESULTS Our analysis indicated that PCP attitudes toward proposed features for an app were underpinned by perceived roles of (1) diabetes self-management, (2) face-to-face care, and (3) the anticipated burden of new technologies on their practice. Theme 1 explored PCP perceptions about how an app could foster patient independence for self-management behaviors but could also increase responsibility and liability for the PCP. Theme 2 identified beliefs underpinning a commonly expressed preference for face-to-face care. PCPs perceived information was more motivating, better understood, and presented with greater empathy when delivered face to face rather than online. Theme 3 described how most PCPs anticipated an initial increase in workload while they learned to use a new clinical tool. Some PCPs accepted this burden on the basis that the change was inevitable as health care became more integrated. Others reported potential benefits were outweighed by effort to implement an app. This study also identified how app features can be positively framed, highlighting potential benefits for PCPs to maximize PCP engagement, buy-in, and uptake. For example, PCPs were more positive when they perceived that an app could facilitate communication and motivation between consultations, focus on building capacity for patient independence, and reinforce rather than replace in-person care. They were also more positive about app features that were automated, integrated with existing software, flexible for different patients, and included secondary benefits such as improved documentation. CONCLUSIONS This study provided insight into PCP perspectives on a diabetes app integrated with primary care services. This was observed as more than a technological change; PCPs were concerned about changes in workload, their role in self-management, and the nature of consultations. Our research highlighted potential facilitators and barriers to engaging PCPs in the implementation process.

Introduction: Type 2 diabetes is the leading burden of disease in Australia, particularly in Western Sydney, with 960,000 people and one of the fastest growing populations. Approximately 15% of the population have diabetes, 35% are at high risk of diabetes and 50% are overweight/obese. Western Sydney Diabetes (WSD) initiative was established in 2012 by Western Sydney Local Health District (hospital care) and Western Sydney Primary Health Network (primary healthcare) with a range of partners. Aim, theory, targeted population and timeline: The business case identified support to primary care through a hospital-led Joint-Specialist Case-Conference (JSCC) service with a focus on prevention and management of patients with diabetes at an individual and practice level. WSD has run a JSCC service since 2014. A diabetes specialist, resident medical staff, and diabetes nurse educator attend General Practice (GP) to conference with the GP and the patient to develop a management plan. In a session, we see up to 12 patients, 30 minutes each. With four teams doing six sessions a week, JSCC has seen over 1000 patients, and over 150 GPs. JSCC aims to keep people with diabetes well, with fewer complications and reduce the demand on hospitals. It achieves this by empowering GPs to develop their capacity to manage their patients in the long term after 10 sessions with JSCC. Highlights: We demonstrated significant benefits for the patient, including (at 3-6 month follow-up) an average HbA1c concentration reduction of 0.87% (95% CI -1.31, -0.44), mean reduction in systolic blood pressure of 6.45mmHg (95% CI -11.48, -1.41) and non-significant reductions in mean weight, total cholesterol and diastolic blood pressure. We also found a significant reduction in hospital waiting times for specialist services, from 12 to 2.5 weeks. These investigations are repeated at the 18 month follow-up. The JSCC program has high acceptance among GPs. Over 90% of GPs agree/strongly agree that JSCC was useful to their practice to build their capacity to manage patients with diabetes and would recommend it to their colleagues. The PEN Clinical Audit Tool (PENCAT) was used to track the management of patients with diabetes. Early results indicate that GP practices experienced significant reductions in mean HbA1c of all patients with diabetes (not only those who had been case conferenced) and reductions in BMI, blood pressure and indicators of care integration. Looking forward; conclusions, sustainability, and transferability: A cost-benefit analysis found that for every dollar spent on JSCC, we would see a return of over A$3. More broadly, across a number of interventions targeting diabetes prevention and management, it found that, over seven years, a $68m investment would deliver a net benefit of $124m. The flexibility of JSCC and the cultural diversity of Western Sydney (50% of the population born overseas) means the program will be easily transferrable to other primary/tertiary care environs. Discussion and lessons learned: JSCC is a cost-effective method to empower GPs to provide enhanced management of chronic diabetes care, across healthcare and community settings at a low cost to the healthcare system. We have identified a successful business model that can easily be exported to different locales and across differing types of chronic disease to better support care integration and practice.

Although many diabetes self-management apps exist, these are not tailored for people from culturally and linguistically diverse (CALD) backgrounds. This study aimed to explore GP perceptions of how diabetes app features could help GPs better support their patients from CALD backgrounds. Twenty-five semi-structured interviews with GPs in Western Sydney explored attitudes towards a proposed app’s suitability for CALD patients. Interviews were audio-recorded, transcribed and coded using Framework Analysis. Theme 1 explored the implications of perceptions that patients’ health literacy is dependent on the language used. Theme 2 explored the influence of messaging from sources that share the patient’s language and culture (including misinformation from community sources). Theme 3 described the suitability of the app platform for CALD patients, and its potential challenges in this group. GPs perceived that a diabetes app could be useful for providing support to patients from CALD backgrounds. Findings suggest app features should be optimised to address existing challenges that GPs face and carefully consider strategies for recruiting CALD patients. It is important that GPs feel comfortable promoting an app to their CALD patients to help increase participation rates by people in the CALD community.

Introduction: In Western Sydney, over 50% of the residents are overweight and at high risk of developing diet-related chronic disease. It is a diabetes ‘hotspot’ with a rate 1.5 times higher than the Sydney average. At a cost of $14.6 billion per annum and at current population growth rates, by 2019, diabetes will be the most costly disease in Australia and a debilitating burden on the health system. Health cannot solve the problem alone. The solution lies in prevention through a multi-sectoral, transformational, long-term prevention strategy with scaled up investment. Policy context/ objective: Western Sydney Local Health District, NSW Health and the NSW Department of Premier and Cabinet have partnered with over 50 organisations including the three levels of government, non-government organisations and the private sector to form the Western Sydney Diabetes Prevention Alliance. The Alliance aims to produce a paradigm shift in the local environment to allow residents to purchase and prepare healthy food, have access to safe areas for physical exercise and reduce dependency on car travel, through local and governmental interventions and improved urban design. Targeted population: The Alliance has consulted with a number of consumers and experts in their field over a 9-month period, and analysed the most effective local and international interventions to produce a prevention strategy. The strategy is supported by 15 individual initiatives. The strategy aims to prevent 10,000 new cases of diabetes by targeting 270,000 people within a population of 870,000. The target populations include 220,000 children, 44,000 people at high risk and 6,000 ‘healthy’ adults. Highlights: An economic case cost-benefit analysis produced by PwC predicts an investment of $124.27m would realise total net benefits of $577.00m to 2030. Ten of the proposed initiatives are included in this model, but the number and content may alter over time. The benefits will be achieved through savings in healthcare costs, government subsidies and lost productivity. The costs and benefits have been modelled on running each initiative over 14 years from 2017 to 2030. The costing model is based on the average annual cost of the treatment of a person with diabetes, includes a decay rate of the efficacy of interventions, as well as the inclusion of the direct costs of setting up and running each program on an annual basis. Costs of the initiatives have been based on data from existing programs and commercial data provided by Alliance members. The establishment of a Prevention Hub has also been included for sustainability. This cost-benefit analysis has been developed to attract financial support from both government and the private sector. Transferability: The objectives are to improve the overall health of western Sydney residents, as well as to become an exemplar that can be adopted by other health districts throughout Australia Conclusion: The benefits of the Alliance lie in the ongoing collaboration of previously disparate organisations to address a major health and societal issue, the shared vision to reach the majority of residents and the goal to halt a relentless progression toward diabetes within the local community.

Introduction: Chronic Heart Failure (CHF) is a complex and disabling disease with increasing prevalence in Australia, affecting 10% of people over the age of 65 and estimated cost of $1 billion per annum. CHF hospitalisations are potentially preventable when patients have timely access to healthcare services; receive evidence based, co-ordinated care across the continuum of primary, secondary and tertiary services. Background: Data analysis at Blacktown and Mount Druitt Hospital (BMDH) Western Sydney Local Health District (WSLHD), identified 84% of 2012/13 CHF admissions were Potentially Preventable Admissions (PPA), including 28 day re-admission rate of 28%. A team was established in February 2014 with the goal to reduce PPA from 84% to 70% by October 2015, developing strategies to support patients to live well at home, improve their health outcomes and experience of care over the lifetime of their disease. Methodology: The New South Wales Agency for Clinical Innovation (ACI) Healthcare Redesign Methodology was utilised. Five phases including initiation, diagnostics, solution design, implementation and evaluation; the methodology emphasises partnership with patients and stakeholders. Over 5 months, 35 stakeholders including patients and staff from BMDH, Community, General Practice and Medicare Locals participated in workshops, interviews, forums and data collection. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116642– http://www.ijic.org/