What can we do when the smoke rolls in? An exploratory qualitative analysis of the impacts of rural wildfire smoke on mental health and wellbeing, and opportunities for adaptation

BACKGROUND

Extreme, prolonged wildfire smoke (WFS) events are becoming increasingly frequent phenomena across the Western United States. Rural communities, dependent on contributions of nature to people's quality of life, are particularly hard hit. While prior research has explored the physical health impacts of WFS exposure, little work has been done to assess WFS impacts on mental health and wellbeing, or potential adaptation solutions.

METHODS

Using qualitative methods, we explore the mental health and wellbeing impacts experienced by community members in a rural Washington State community that has been particularly hard hit by WFS in recent years, as well as individual, family, and community adaptation solutions. We conducted focus groups with residents and key informant interviews with local health and social service providers.

RESULTS

Participants identified a variety of negative mental health and wellbeing impacts of WFS events, including heightened anxiety, depression, isolation, and a lack of motivation, as well as physical health impacts (e.g., respiratory issues and lack of exercise). Both positive and negative economic and social impacts, as well as temporary or permanent relocation impacts, were also described. The impacts were not equitably distributed; differential experiences based on income level, outdoor occupations, age (child or elderly), preexisting health conditions, housing status, and social isolation were described as making some residents more vulnerable to WFS-induced physical and mental health and wellbeing challenges than others. Proposed solutions included stress reduction (e.g., meditation and relaxation lessons), increased distribution of air filters, development of community clean air spaces, enhancing community response capacity, hosting social gatherings, increasing education, expanding and coordination risk communications, and identifying opportunities for volunteering. Findings were incorporated into a pamphlet for community distribution. We present a template version herein for adaptation and use in other communities.

CONCLUSIONS

Wildfire smoke events present significant mental health and wellbeing impacts for rural communities. Community-led solutions that promote stress reduction, physical protection, and community cohesion have the opportunity to bolster resilience amid this growing public health crisis.

Net Reclassification Index and Integrated Discrimination Index Are Not Appropriate for Testing Whether a Biomarker Improves Predictive Performance

One of the goals of the Critical Path Institute's Predictive Safety Testing Consortium (PSTC) is to promote best practices for evaluating novel markers of drug induced injury. This includes the use of sound statistical methods. For rat studies, these practices have centered around comparing the area under the receiver-operator characteristic curve for each novel injury biomarker to those for the standard markers. In addition, the PSTC has previously used the net reclassification index (NRI) and integrated discrimination index (IDI) to assess the increased certainty provided by each novel injury biomarker when added to the information already provided by the standard markers. Due to their relatively simple interpretations, NRI and IDI have generally been popular measures of predictive performance. However recent literature suggests that significance tests for NRI and IDI can have inflated false positive rates and thus, tests based on these metrics should not be relied upon. Instead, when parametric models are employed to assess the added predictive value of a new marker, following (Pepe, M. S., Kerr, K. F., Longton, G., and Wang, Z. (2013). Testing for improvement in prediction model performance. Stat. Med. 32, 1467-1482), the PSTC recommends that likelihood based methods be used for significance testing.

The Predictive Safety Testing Consortium: safety bio-markers, collaboration, and qualification

The Predictive Safety Testing Consortium (PSTC) is one of nine consortia comprising the Critical Path Institute (C-Path), a non-profit organisation launched in 2005 and dedicated to playing the role of a catalyst in the development of new approaches that advance medical innovation and regulatory science. C-Path achieves this by lead-ing teams that share data, knowledge and expertise resulting in sound, consensus-based science. PSTC is a unique, public-private partnership that brings pharmaceutical companies together to share and validate safety testing methods under the advisement of worldwide regulatory agencies, including the US Food and Drug Administration (FDA), the European Medicines Agency (EMA), and the Japanese Pharmaceuticals and Medical Devices Agency (PMDA). The eighteen corporate members of PSTC share a common goal: to find improved safety testing methods and approaches utilizing fluid-based safety biomarkers which accurately predict drug-induced tissue injury. Specifically, the primary goal of PSTC is the qualification of novel translational safety biomarkers for use in early clinical trials in order to ena-ble safer investigations and development of new drug candidates. This manuscript describes the critical importance of improved safety biomarkers to the drug development process and the present state of the biomarker qualification process with regulatory agencies. In addition, the work that the PSTC and its collaborative partners have done and con-tinue to do to identify and qualify more selective and specific safety biomarkers is highlighted. Finally, successes in-cluding the recently adopted regulatory Letter of Support and ongoing efforts to better define the regulatory qualifica-tion process and an integrated translational safety strategy are also discussed.

Increasing the number of trainees in general surgery residencies: is there capacity?

PURPOSE

General surgeons have decreased as a proportion of the total U.S. surgical workforce. Given the likelihood of increasing shortages of general surgeons, the authors evaluated available expansion capacity of existing general surgery residency programs.

METHOD

In November 2009, the authors e-mailed a Web-based questionnaire to the program directors and coordinators of the 246 U.S. general surgery residency programs that were then certified by the Accreditation Council for Graduate Medical Education.

RESULTS

Of the 246 programs the authors contacted, 123 (50%) completed the survey. Community hospital programs and academic programs had similar response rates (52% and 50%, respectively). Of the 115 program directors who responded to the relevant question, 92 (80%) reported sufficient existing case volume capacity to accommodate additional surgery residents. Both community and academic program directors reported modest expansion capacity: an average of 1.7 and 2.0 additional residents per year, respectively. Across all programs, the average additional capacity reported was 1.9 additional residents per year. An expansion of this size would increase the number of general surgery residency positions from 1,137 to 1,515 annually. After accounting for subspecialization, this increase of 378 residents would result in approximately 249 additional general surgeons entering the workforce per year after five years.

CONCLUSIONS

Expansion capacity within existing approved general surgery residency programs is insufficient to meet the expected demand for general surgeons in the United States. Strategies to alleviate shortages include developing new training programs, cultivating new medical education funding streams, and changing the surgical training paradigm.