GP perceptions of workforce shortage in a rural setting

INTRODUCTION

Currently Australia is experiencing a rural medical workforce shortage, especially among GPs. Strategies aimed at improving this shortage have generally been directed at small and remote rural communities (RRMA 4-7); however, longstanding GP shortages also continue in large (RRMA 3) rural communities. The key to the understanding the rural workforce is the perceptions of GPs themselves. This article compared GP perceptions of workforce shortages in Tamworth, New South Wales, Australia (an RRMA 3 town) with actual levels of workforce participation.

METHODS

A survey of 31/33 GPs working in the New South Wales town of Tamworth was conducted in 2005. Participating GPs were individually interviewed and were asked to estimate local GP workforce needs, calculate their weekly consulting time sessions and advise if they were accepting new patients. The survey was repeated 12 months later with the same cohort to track workforce change.

RESULTS

In May 2005 there were 27.8 full time equivalent (FTE) GPs working in Tamworth (population 42 000). In May 2006 this had risen to 31.5 FTE practitioners. Initially, all practitioners surveyed believed there was a workforce shortage, with no practice accepting new patients. This shortage was perceived to be >10 FTE GPs (6.5%), between 5-9 GPs (64.5%) and between 1-4 GPs by 29% of surveyed GPs. In June 2006 there were 31.5 FTE GPs working in Tamworth. The follow-up survey of 29 GPs revealed a significant shift in their perceptions with only 41.4% of GPs perceiving the shortage as 1-4 FTE GPs (p = 0.2), 17.2% between 5-9 GPs and 41.4% nil. No GPs in the follow-up survey perceived the shortage as >10. At the end of the 12 month study period, 8 of 17 practices were accepting new patients.

CONCLUSION

GP perceptions of shortage largely reflected concurrent workforce changes that occurred during the study period where there was a 12% improvement after a prolonged period of workforce stagnation. This change drove improvements in patient access and in many GPs' minds ameliorated much of the perceived shortage. Many factors may be involved, including the increased use of practice nurses, private billing and start-up capacity. General practitioner perceptions appear to be sensitive to workforce changes, with sampled GPs working with higher patient ratios than those seen as acceptable in metropolitan areas.

Evidence-based implementation of adult asthma guidelines in the emergency department: a controlled trial

OBJECTIVE

To determine if an evidence-based implementation (EBI) strategy could lead to the successful implementation of guidelines for the management of adult asthma in a large rural ED.

METHODS

This was a pre- and post-intervention trial, comparing data for seven clinical indicators from a study hospital and a control hospital. Retrospective pre-intervention audits were conducted at the study hospital for 3 months (1 April-30 June 2004) and the control hospital for 4 months (1 March-30 June 2004). The effect of an EBI to implement established guidelines for the management of asthma at the study hospital was compared with the effect of a mail-out of guideline booklets and wall charts to the control hospital. Post-intervention audits were then performed at both hospitals. Sustainability of the EBI was gauged by 12 month follow-up data at the study hospital.

RESULTS

There were 55 presentations of adult asthma at the study hospital in the pre-intervention phase and 67 post-intervention. The corresponding numbers for the control hospital were 51 and 42, respectively. Following the EBI there were significant improvements at the study hospital for the documentation of severity (27-99%, P < 0.01), use of spirometry (38-84%, P < 0.01), medication delivery via spacer device (0-26%, P < 0.01), use of systemic steroids (66-84%P < 0.05), use of written short-term asthma plans (14-82%, P < 0.01), reduction of ipratropium use in mild asthma (43-16%, P < 0.05) and reduction in antibiotic use in afebrile asthmatics (37-6%, P < 0.01). For the control hospital there was a significant increase in spirometry use from 2% to 40% (P < 0.01). For seven clinical indicators combined, compliance with the guideline increased from 38% to 79.1% (P < 0.01) at the study hospital, whereas there was no change at the control hospital, 44.3% to 43% (P = 0.75) There were 68 presentations at 12 month follow up at the study hospital and compliance with the seven clinical indicators was 78.2%.

CONCLUSION

An EBI significantly improved compliance at the study hospital with no improvement noted in the control hospital. These improvements were maintained at 12 month follow up. An EBI can lead to significant improvements in the management of asthma at a large rural referral hospital ED and might have implications for hospitals with similar roles and profiles.

Outcome after complete percutaneous removal of infected pacemaker systems and implantable cardiac defibrillators

The mortality of retained, infected pacemaker systems is high. We assessed the safety and rate of relapse of infection after complete percutaneous removal of leads of infected pacemaker systems. None of the 40 subjects experienced procedure-related mortality and there were no cases of relapse after a median duration of follow up of 8 years (range, 3 months to 12 years). Procedure-related complications and other adverse events during therapy are reported. Percutaneous removal of infected pacemakers in conjunction with appropriate antibiotic therapy is safe and effective.

Sediment TCDD-EQs and EROD and MROD activities in Ranid frogs from agricultural and nonagricultural sites in Michigan (USA)

In vitro studies have demonstrated atrazine-mediated induction of 7-ethoxyresorufin O-deethylase (EROD) activity. EROD is an enzyme active in the metabolism of many compounds, including many xenobiotics. These studies have suggested that atrazine may affect reproductive function by altering steroid metabolism. The goal of this study was to determine whether relationships could be detected between measured atrazine concentrations in surface waters and the liver-somatic index (LSI) and EROD and 7-methoxyresorufin O-deethylase (MROD) activities in the livers of ranid frogs. In addition, sediment dioxin toxic equivalents (TCDD-EQs) were determined using the H4IIE-luc cell bioassay. Adult and juvenile green frogs (Rana clamitans), bullfrogs (R. catesbeiana), and Northern leopard frogs (R. pipiens) were collected from areas with extensive corn cultivation and areas where there was little agricultural activity in south central Michigan in the summer of 2003. Atrazine concentrations at nonagricultural sites ranged from less than the limit of quantification (0.17 microg atrazine/L) to 0.23 microg atrazine/L and did not exceed 1.2 microg atrazine/L at agricultural sites. Sediment TCDD-EQs were measurable only at one agricultural site. Of the measured parameters, only LSI values in adult male frogs differed significantly between agricultural and nonagricultural sites, with greater values observed at agricultural sites. In green frogs, EROD and MROD activities were measurable in both adult and juvenile frogs and were similar among sites. Median EROD activities ranged from 13 to 21 pmol/min/mg protein in adult male green frogs and from 5 to 13 pmol/min/mg protein in adult female green frogs. Juvenile frogs had greater EROD and MROD activities than adult frogs. Bullfrogs and leopard frogs had greater activities than did green frogs. Atrazine concentrations were significantly and negatively correlated with MROD activity in adult male green frogs (Spearman R = -0.800). LSI and EROD and MROD activities of adult female or juvenile green frogs were not significantly correlated with atrazine concentrations. These results suggest that atrazine does not appear to have a consistent association with EROD or MROD activities in wild-caught green frogs.

The role of transthoracic echocardiography in excluding left sided infective endocarditis in Staphylococcus aureus bacteraemia

In all patients with Staphylococcus aureus bacteraemia a transoesophageal echocardiogram is recommended to exclude infective endocarditis. We determined that a finding of normal to trivial valvular regurgitation on transthoracic echocardiogram in these patients significantly reduced the probability of infective endocarditis. Furthermore, in the absence of embolic phenomena the likelihood of infective endocarditis was less than 2%. This probability could be further reduced if the echocardiogram was performed greater than 5 days after the bacteraemia. Therefore, in the assessment of patients with S. aureus bacteraemia a transoesophageal echocardiogram is not always required to exclude infective endocarditis.

Plasma steroid hormone concentrations, aromatase activities and GSI in ranid frogs collected from agricultural and non-agricultural sites in Michigan (USA)

The triazine herbicide atrazine has been hypothesized to disrupt sexual development in frogs by up-regulating aromatase activity, resulting in greater estradiol (E2) concentrations and causing feminization in males. The goal of this study was to collect native ranid frogs from atrazine-exposed ponds and determine whether relationships exist between measured atrazine concentrations and the gonadosomatic index (GSI), plasma concentrations of testosterone (T), E2 or 11-ketotestosterone (KT), or with aromatase activity. In the summer of 2002 and 2003, adult and juvenile green frogs (Rana clamitans), bullfrogs (R. catesbeiana) and Northern leopard frogs (R. pipiens) were collected from areas with extensive corn cultivation and areas where there was little agricultural activity in south-central Michigan. Atrazine concentrations were below the limit of quantification at non-agricultural sites. Atrazine concentrations did not exceed 2 microg/L at most agricultural sites, but a concentration of 250 microg atrazine/L was measured in one sample from one site in 2002. Plasma steroid concentrations varied among locations. Aromatase activity was measurable in less than 11% of testes in adult males, and in less than 4% of testes in juvenile males. Median aromatase activities in ovaries of adult females ranged from 3 to 245 pmol/h/mg protein, and maximum activities were 2.5-fold greater in juveniles than in adults. Atrazine concentrations were not significantly correlated with any of the parameters measured in this study. These results indicate that atrazine does not up-regulate aromatase in green frogs in the wild, and does not appear to affect plasma steroid hormone concentrations.

Atrazine concentrations, gonadal gross morphology and histology in ranid frogs collected in Michigan agricultural areas

The triazine herbicide atrazine has been suggested to be a potential disruptor of normal sexual development in male frogs. The goals of this study were to collect native ranid frogs from sites in agricultural and non-agricultural areas and determine whether hypothesised atrazine effects on the gonads could be observed at the gross morphological and histological levels. Juvenile and adult green frogs (Rana clamitans), bullfrogs (R. catesbeiana) and leopard frogs (R. pipiens) were collected in the summers of 2002 and 2003. Atrazine concentrations were below the limit of quantification at non-agricultural sites, and concentrations did not exceed 2 microg/L at most agricultural sites. One concentration greater than 200 microg atrazine/L was measured once at one site in 2002. Hermaphroditic individuals with both male and female gonad tissue in either one or both gonads, were found at a low incidence at both non-agricultural and agricultural sites, and in both adults and juveniles. Testicular oocytes (TO) were found in male frogs at most of the sites, with the greatest incidence occurring in juvenile leopard frogs. TO incidence was not significantly different between agricultural and non-agricultural sites with the exception of juveniles collected in 2003. Atrazine concentrations were not significantly correlated with the incidence of hermaphroditism, but maximum atrazine concentrations were correlated with TO incidence in juvenile frogs in 2003. However, given the lack of a consistent relationship between atrazine concentrations and TO incidence, it is more likely the TOs observed in this study result from natural processes in development rather than atrazine exposure.

Modelling the fate and transport of nickel in the mersey estuary

Modelling heavy metals in estuarine environments is extremely complex for various reasons; one of the primary complicating factors is that metals exist in two phases, dissolved and particulate bound. Dynamic changes in water chemistry, and in particular salinity, affect the partitioning of metals between the two phases and hence make it difficult to determine the relative fractions of each phase. A relatively simple approach was developed to relate variations in partition coefficient for Ni to salinity fluctuations in the Mersey Estuary. The functional relationship developed between partition coefficient and salinity departs from the traditional exponential type curve, providing a more realistic relationship.A numerical model was then developed for predicting the transport and distribution of Ni about the Mersey Estuary. The model couples transport of metals throughout the water along with incorporating the chemical processes controlling how nickel is fractioned between dissolved and particulate phases through the newly developed partition coefficient relationship. Model predictions of dissolved Ni along the longitudinal axis of the estuary were compared with measurements of Ni for two events; very good correlation was obtained between the model results and the data.

Water quality and fisheries in the Mersey estuary, England: A historical perspective

The Mersey estuary, NW England, once had a prolific fishery but in the aftermath of the industrial revolution water quality and fisheries declined and the Mersey became infamous as one of the most polluted rivers in Europe. Until relatively recently, almost all industrial and domestic effluents were discharged without treatment resulting in abominable fouling of the shoreline, and long anoxic reaches in the upper estuary during the summer. In addition, there were unknown biological impacts resulting from a complex mixture of dangerous substances present in the river. Over 1000 million pound has been spent to remedy this situation and there is unequivocal evidence that this has had the desired effect. Dissolved oxygen is now generally >60% saturation, salmon are now found at the tidal-limit and the estuary is becoming ever more popular for sea angling. The river is no longer an embarrassing liability but is now perceived as an important asset in the economic regeneration of this region of the United Kingdom.

Use of an 'evidence-based implementation' strategy to implement evidence-based care of asthma into rural district hospital emergency departments

INTRODUCTION

To determine if an evidence-based implementation (EBI) could lead to the successful implementation of evidence based care for adult asthma in small rural district hospitals.

METHODS

A controlled trial involving eight small rural hospitals (four each in the study and control groups) was conducted. Retrospective pre-intervention audits were conducted at all eight hospitals for 7 months (1 January 2004 to 31 July 2004) and evidence-practice gaps identified. An EBI was then used to implement established guidelines for the management of asthma in the study hospitals. Post-intervention audits were then performed over a period of 7 months (1 October 2004 to 31 April 2005).

RESULTS

There were 52 presentations of asthma in the study hospitals in the pre-implementation phase and 47 post-implementation. The corresponding numbers for the control hospitals were 46 and 42 respectively. There were no statistically significant differences in the severity between the groups. Following the EBI there were significant improvements at the study hospitals for the documentation of severity (8% to 62%, p <0.001), use of spirometry (12% to 62%, p <0.001) and the use of written short-term asthma plans (9% to 26%, p = 0.05). There was a decrease in use of ipratropium in mild asthma (44% to 30%, p = 0.228), an increase in the use of systemic steroids (61% to 72%, p = 0.255) and no change in prescribing antibiotics for afebrile patients with asthma (21% to 21% p = 0.956). There was no significant change in practice at the control hospitals except for a decrease in the use of systemic steroids (48% to 21%, p = 0.011). For the six clinical indicators aggregate there was a significant increase in compliance with guidelines at the study hospitals (36% to 62%, p < 0.001) but no change at the control hospitals (31% to 31%, p = 0.970).

CONCLUSION

The pre-intervention audits demonstrated low levels of compliance with asthma guidelines across six clinical indicators. An EBI significantly improved compliance across these six indicators, and no improvement was noted in the control hospitals. This study demonstrates that an EBI can alter clinical practice in small rural district hospitals.

Interleukin-10 gene expression in acute virus-induced asthma

RATIONALE

Virus-induced asthma is characterized by marked neutrophil influx and eosinophil degranulation, suggesting a mode of immunopathogenesis different from that of allergen-induced asthma.

OBJECTIVES

This study compared induced sputum cytokine responses in subjects with severe asthma exacerbation and respiratory virus infection with those of patients with stable asthma, healthy control subjects, and virus-infected nonasthmatic subjects.

METHODS

Subject infection status and pulmonary history were established on the basis of common cold and asthma questionnaires, and lung function and atopy tests were performed. Respiratory virus infection was diagnosed by cell culture and direct polymerase chain reaction, using induced sputum. The induced sputum cellular profile was examined and cytokine gene expression was assessed by quantitative real-time polymerase chain reaction.

RESULTS

A respiratory virus was detected in 78% of subjects with acute asthma. Specific viruses detected were rhinovirus (83%), influenza (15%), enterovirus (4%), and respiratory syncytial virus (2%). Virus-infected subjects with acute asthma or no asthma had increased RANTES (regulated on activation, normal T cell expressed and secreted) and macrophage inflammatory protein-1alpha messenger RNAs compared with other groups. Interleukin (IL)-10 mRNA was significantly increased in virus-infected acute asthma and reduced on recovery from acute asthma. IL-5, eotaxin, and IL-8 mRNA transcripts were similar across groups.

CONCLUSIONS

Asthma exacerbation triggered by respiratory virus infection is characterized by increased IL-10 gene expression that may explain the suppressed eosinophil influx in acute asthma. Airway neutrophilia due to respiratory virus infection is associated with chemokine gene expression involving RANTES and macrophage inflammatory protein-1alpha.

Effect of pancreatic and leukocyte elastase on hydraulic conductivity in lung interstitial segments

Elastase-induced changes in flow were used to quantify the degradation of lung interstitial elastin. Degassed rabbit lungs were inflated with silicon rubber via airways and vessels. The lungs were cut into 1-cm-thick sections. Two chambers were bonded to each section to enclose the interstitium surrounding an arterial segment. Flow of albumin solution (0-5 g/dl) between the chambers was followed by that of the albumin solution with 0.25 g/dl pancreatic elastase solution. Driving pressure was 5 cmH(2)0, and mean interstitial pressure was either 0 or 10 cmH(2)O. Elastase caused an increase in flow in approximately 70% of the interstitial segments and a reduction in flow in the remaining segments. The elastase-induced response in flow was independent of both albumin concentration and mean interstitial pressure. Leukocyte elastase (5 units/dl) produced flow responses similar to those of 0.25 g/dl pancreatic elastase. The increased flow of leukocyte elastase was reduced by a subsequent flow with 0.25 g/dl pancreatic elastase but enhanced by a subsequent flow with a 10-fold lower concentration. A change in the order of the elastase flows reversed the concentration-dependent responses. This behavior suggests a complex interaction among the interstitial fibers after degradation by pancreatic and leukocyte elastase. Endogenous elastase-induced increases in interstitial permeability might affect blood-lymph barrier permeability, whereas elastase-induced cessation of flow might be related to the alveolar septal wall destruction observed in emphysema.

Delivery of the clinical components of the Newcastle University medical course in a multidisciplinary academic unit in Tamworth

The University Department of Rural Health (UDRH), northern New South Wales, Australia, was established in late 2001 by the University of Newcastle in Tamworth, New South Wales (NSW). The UDRH is part of the Commonwealth Department of Health and Ageing's Health Workforce Undergraduate Initiative and was the eighth UDRH to be established in Australia. The UDRH northern NSW delivers medical education as part of a multidisciplinary academic unit. At the end of 2003, six medical students graduated having completed all of their clinical training based in Tamworth. Over 60% of the local medical community were teachers in the program. These students studied with final year dietetic, occupational therapy and radiography students co-located in Tamworth during 2002 and 2003. In 2004, ten new graduates from the program have chosen to commence employment in the New England Area Health Service, including two medical students completing their internship in 2004. This represents the first time that the full clinical curriculum of an Australian medical school has been delivered entirely in a single rural setting. It demonstrates a new way of funding medical education which embraces local clinicians as 'faculty' and provides a way for regional centres to develop their own future medical workforce.

Assessing the elimination of estrogenic activity in advanced wastewater treatment with a reporter gene-based bioassay

Estrogen-like chemicals, so-called xenoestrogens, have become a topic of concern because they are potentially capable of disturbing the hormonal balance of wildlife and humans. Effluents of wastewater treatment plants (WWTPs) are presumably the major source of xenoestrogens in the aquatic environment. In this study, we investigated eight WWTPs with respect to their input, elimination efficiency, and output of estrogenic activity by means of a reporter gene-based bioassay. All WWTPs employed activated sludge treatment with nitrification/denitrification and tertiary treatment (second nitrification and/or filtration). Estradiol equivalents (EEQs) in the influents of the WWTPs were between 5.7 and 65.8 ng/L. The greatest inputs were found in plants treating pure domestic sewage and in samples collected in winter. Process waters either had no estrogenic activity or EEQs in the range of raw sewage, depending on the source of the process water. EEQs of effluents ranged from mostly below quantification limit (0.8 ng/L) to a maximum of 5.4 ng/L in secondary and 1.4 ng/L in tertiary effluents. These findings demonstrate the elimination efficiency of the activated sludge treatment and the further improvement by additional tertiary treatment. However, several concentrated effluents elicited little, but detectable estrogenic responses in the bioassay.

Acute Q fever and brachial neuritis: case report and literature review

Peripheral nervous system complications of Q fever are uncommon. A case of electrophysiologically documented brachial neuritis occurring during acute Coxiella burnetii infection is reported. The relevant literature is reviewed.

Cell bioassays for detection of aryl hydrocarbon (AhR) and estrogen receptor (ER) mediated activity in environmental samples

In vitro cell bioassays are useful techniques for the determination of receptor-mediated activities in environmental samples containing complex mixtures of contaminants. The cell bioassays determine contamination by pollutants that act through specific modes of action. This article presents strategies for the evaluation of aryl hydrocarbon receptor (hereafter referred as dioxin-like) or estrogen receptor mediated activities of potential endocrine disrupting compounds in complex environmental mixtures. Extracts from various types of environmental or food matrices can be tested by this technique to evaluate their 2,3,7,8-tetrachlorodibenzo-p-dioxin equivalents or estrogenic equivalents and to identify contaminated samples that need further investigation using resource-intensive instrumental analyses. Fractionation of sample extracts exhibiting significant activities, and subsequent reanalysis with the bioassays can identify important classes of contaminants that are responsible for the observed activity. Effect-directed chemical analysis is performed only for the active fractions to determine the responsible compounds. Potency-balance estimates of all major compounds contributing to the observed effects can be calculated to determine if all of the activity has been identified, and to assess the potential for interactions such as synergism or antagonism among contaminants present in the complex mixtures. The bioassay approach is an efficient (fast and cost effective) screening system to identify the samples of interest and to provide basic information for further analysis and risk evaluation.

2,3,7,8-Tetrachlorodibenzo-p-dioxin equivalents in tissue samples from three species in the Denver, Colorado, USA, metropolitan area

The Rocky Mountain Arsenal (RMA), a Superfund site near Denver, Colorado, USA, has a history of various industrial processes that may have led to the release of polychlorinated dibenzo-p-dioxins (PCDDs), polychlorinated dibenzofurans (PCDFs), and polychlorinated biphenyls (PCBs). The PCDDs, PCDFs, and non-ortho- and mono-ortho-substituted PCBs cause a common set of toxic effects that are mediated through the aryl hydrocarbon receptor (AhR). The total AhR-mediated activity of complex mixtures in biota samples from the RMA and surrounding reference areas was determined by both instrumental and bioanalytical techniques. Mean concentrations of bioassay-derived 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) equivalents (TCDD-EQ) in carp eggs, owl livers, and kestrel eggs ranged from 0 to 8.5, 17 to 130, and 2.4 to 18 pg/g, respectively. For most samples analyzed, concentrations of TCDD-EQ and instrumentally derived TCDD equivalents (TEQs) were not significantly different. In a few tissue samples, concentrations of TEQs and TCDD-EQs were not equivalent. This can indicate the presence of AhR-active compounds that were not identified or quantified by instrumental techniques or the existence of nonadditive interactions among congeners when samples are analyzed by the bioassay. Overall, mean concentrations of TCDD-EQs in extracts of carp and kestrel eggs were not significantly different between groups of samples collected on and off the RMA, whereas concentrations of TCDD-EQs in several owl livers collected on the RMA were significantly greater than concentrations in owl livers from off the RMA.

The pathology of human and murine pulmonary infection with Cryptococcus neoformans var. gattii

Human infection by Cryptococcus neoformans var. neoformans is well characterised and usually occurs in immunocompromised patients. Less is known about infection by Cryptococcus neoformans var. gattii, which usually produces disease in previously normal individuals. In two cases of human pulmonary infection by Cryptococcus neoformans var. gattii, we observed a mixed inflammatory pattern, including granulomas associated with numerous T lymphocytes and a lymphocytic interstitial pneumonitis with B lymphocytes and formation of follicles. We also established a murine model of pulmonary infection by Cryptococcus neoformans var. gattii, which reproduced most of these features. This model is likely to prove useful in studies of the pathogenesis of this infection.

The tolerability, safety, and success of sputum induction and combined hypertonic saline challenge in children

Induced sputum using hypertonic saline (HS) is a useful research tool to study airway inflammation (AI). HS provocation testing can also be used to measure airway hyperresponsiveness (AHR). A combined HS challenge and sputum induction procedure has been developed to permit assessment of AI and AHR in a single test. The aim of this study is to report the success and tolerability of sputum induction alone, and in combination with a HS bronchial provocation challenge. Sputum induction alone was performed with beta2-agonist pretreatment. In the combined challenge, no beta2-agonist pretreatment was used. A high-output ultrasonic nebulizer with valve box and tubing were used to deliver 4.5% saline in doubling time periods from 0.5 s to 4 min. Outcomes assessed were completion of the test protocol, adequacy of sputum samples, decrease in FEV1, and adverse effects during the procedure. Fifty-three children who underwent a sputum induction alone, and 182 children who underwent a combined sputum induction and bronchial provocation using HS. Sputum induction alone was well tolerated, with 98% of children completing the procedure and only 4% experiencing a significant (> 15%) fall in FEV1. An adequate sample of sputum was obtained in 92% of children. The combined challenge was completed by 90% of children. A distressing cough occurred in 13% of children and irritation of the mucosa in 1% of children. In the combined challenge an adequate sample of sputum was obtained in significantly fewer children than with sputum induction alone (70% versus 92%, p < 0.05). Sputum cellular changes reflected the shorter nebulization time with sputum induction alone. We conclude that induction of sputum using HS after pretreatment with bronchodilator is well tolerated with a high success rate in children. Combining the HS challenge with sputum induction provides additional information and is a useful means of comparing AHR and AI simultaneously, but at the expense of having a reduced success rate in obtaining an adequate sample of sputum, as well as increased side effects.

Perfluorooctane sulfonate in fish-eating water birds including bald eagles and albatrosses

Perfluorooctane sulfonate (PFOS) was measured in 161 samples of liver, kidney, blood, or egg yolk from 21 species of fish-eating water birds collected in the United States including albatrosses from Sand Island, Midway Atoll, in the central North Pacific Ocean. Concentrations of PFOS in the blood plasma of bald eagles collected fromthe midwestern United States ranged from 13 to 2,220 ng/mL (mean: 330 ng/mL), except one sample that did not contain quantifiable concentrations of PFOS. Concentrations of PFOS were greater in blood plasma than in whole blood. Among 82 livers from various species of birds from inland or coastal U.S. locations, Brandt's cormorant from San Diego, CA, contained the greatest concentration of PFOS (1,780 ng/g, wet wt). PFOS was also found in the sera of albatrosses from the central North Pacific Ocean at concentrations ranging from 3 to 34 ng/mL. Occurrence of PFOS in birds from remote marine locations suggests widespread distribution of PFOS and related fluorochemicals in the environment.