Reframing Future Risks of Extreme Heat in the United States

The goal of this study is to reframe the analysis and discussion of extreme heat projections to improve communication of future extreme heat risks in the United States. We combine existing data from 31 of the Coupled Model Intercomparison Project Phase 5 models to examine future exposure to extreme heat for global average temperatures of 1.5, 2, 3, and 4 °C above a preindustrial baseline. We find that throughout the United States, historically rare extreme heat events become increasingly common in the future as global temperatures rise and that the depiction of exposure depends in large part on whether extreme heat is defined by absolute or relative metrics. For example, for a 4 °C global temperature rise, parts of the country may never see summertime temperatures in excess of 100 °F, but virtually all of the country is projected to experience more than 4 weeks per summer with temperatures exceeding their historical summertime maximum. All of the extreme temperature metrics we explored become more severe with increasing global average temperatures. However, a moderate climate scenario delays the impacts projected for a 3 °C world by almost a generation relative to the higher scenario and prevents the most extreme impacts projected for a 4 °C world.

Avoided climate impacts of urban and rural heat and cold waves over the U.S. using large climate model ensembles for RCP8.5 and RCP4.5

Previous studies examining future changes in heat/cold waves using climate model ensembles have been limited to grid cell-average quantities. Here, we make use of an urban parameterization in the Community Earth System Model (CESM) that represents the urban heat island effect, which can exacerbate extreme heat but may ameliorate extreme cold in urban relative to rural areas. Heat/cold wave characteristics are derived for U.S. regions from a bias-corrected CESM 30-member ensemble for climate outcomes driven by the RCP8.5 forcing scenario and a 15-member ensemble driven by RCP4.5. Significant differences are found between urban and grid cell-average heat/cold wave characteristics. Most notably, urban heat waves for 1981-2005 are more intense than grid cell-average by 2.1°C (southeast) to 4.6°C (southwest), while cold waves are less intense. We assess the avoided climate impacts of urban heat/cold waves in 2061-2080 when following the lower forcing scenario. Urban heat wave days per year increase from 6 in 1981-2005 to up to 92 (southeast) in RCP8.5. Following RCP4.5 reduces heat wave days by about 50%. Large avoided impacts are demonstrated for individual communities; e.g., the longest heat wave for Houston in RCP4.5 is 38 days while in RCP8.5 there is one heat wave per year that is longer than a month with some lasting the entire summer. Heat waves also start later in the season in RCP4.5 (earliest are in early May) than RCP8.5 (mid-April), compared to 1981-2005 (late May). In some communities, cold wave events decrease from 2 per year for 1981-2005 to one-in-five year events in RCP4.5 and one-in-ten year events in RCP8.5.

Reaching agreement for an Aboriginal e-health research agenda: the Aboriginal Telehealth Knowledge Circle consensus method

INTRODUCTION

In Canada, telehealth has been successfully implemented in a number of Aboriginal communities with subsequent improvements to access to health care and quality of life. However, there are many knowledge gaps that limit our understanding of the broad range of Aboriginal e-health issues; a research agenda is urgently required. The objective of this research was to develop an Aboriginal e-health research agenda designed to address the substantial knowledge gaps that impede e-health deployment and adoption particularly in rural and remote Aboriginal communities in Canada. A consensus method based on Aboriginal culture, values and approaches to consensus was developed to achieve this.

METHODS

In this consensus methodology, a core group of Aboriginal telehealth leaders, led by a research facilitator, engaged in an iterative process of individual and group review of research data. The reviewed data included stakeholder interview data, questionnaires, literature and other resources and was prioritized in order to develop recommendations for an Aboriginal e-health research agenda.

RESULTS

A total of 40 stakeholders including Aboriginal Telehealth Knowledge Circle (ATKC) members, communities of practice and regional, provincial and federal leaders and policy-makers participated in the consensus process. The research recommendations showed a high degree of consistency among stakeholders. Participants reached consensus on 6 areas: research ethics, internet-based e-health services data, educational resources, sustainability models, best practices and exploration of innovative applications.

CONCLUSIONS

An ATKC consensus process was successfully applied to reach consensus on an Aboriginal e-health research agenda, demonstrating the potential of Indigenous research approaches for defining levels of agreement on complex topics. The resulting conceptual map for e-health research can be used as a springboard for partnership-based research initiatives involving Aboriginal communities, governments and researchers, and may be of interest to Indigenous e-health researchers at an international level.

Delayed ultraviolet erythema not suppressed by oral prednisolone: a randomized crossover study

BACKGROUND

The anti-inflammatory potency of topical dermatological corticosteroids in suppressing ultraviolet (UV) erythema is routinely measured. No such model exists to assess the potency of systemically administered steroids.

OBJECTIVE

To determine whether or not suppression of delayed UV erythema by a systemic corticosteroid could provide a useful model for assessing the anti-inflammatory potency of systemic corticosteroids.

METHODS

We conducted a randomized, placebo-controlled, patient and assessor blinded, crossover study of oral prednisolone effects on the delayed UV-induced erythemal response in normal subjects. Six healthy volunteers were phototested with a xenon arc monochromator and then dosed with 30 mg of oral prednisolone or matching placebo daily for 4 days. Repeat phototesting was performed on the 4th day of dosing. The minimal erythema dose (MED) was assessed immediately after test UV doses were administered and 24 h later. After a 2-week washout period, the dosing and testing were repeated in a crossover fashion.

RESULTS

A suppression index (SI) [1/(baseline MED value divided by on prednisolone/placebo value)] allowed comparison of the degree of suppression on and off prednisolone. Oral prednisolone did not significantly suppress the threshold UV erythema response (MED). We may have missed small effects in this study and possibly a larger dose or a longer duration of corticosteroid would have had an effect. Possibly, assessment of corticosteroid potency in suppressing established UV erythema rather than on the development of threshold erythema would have yielded different results.

CONCLUSION

The threshold UV erythema suppression model assessed in this study could not distinguish between oral prednisolone and placebo. This UV-erythema suppression test system is not promising as a model to test the anti-inflammatory potency of systemic steroids.

Standardized Mini-Mental State Examination. Use and interpretation

OBJECTIVE

To review administration of the Standardized Mini-Mental State Examination (SMMSE) for dementia and depression and to evaluate how well it interprets older people's cognitive function.

QUALITY OF EVIDENCE

Literature from January 1990 to December 1999 was searched via MEDLINE using the MeSH headings Alzheimer Disease, Vascular Dementia, Lewy Bodies, and Depression. Several studies have described the reliability and validity of the SMMSE.

MAIN MESSAGE

The SMMSE, a standardized approach to scoring and interpreting older people's cognitive function, provides a global score of cognitive ability that correlates with daily function. Careful interpretation of results of the SMMSE, together with history and physical assessment, can assist in differential diagnosis of cognitive impairment resulting from Alzheimer's disease, vascular dementia, dementia with Lewy bodies, or depression. Repeated measurements can be used to assess change over time and response to treatment.

CONCLUSION

The SMMSE is a valuable tool for family doctors who are often the first medical professionals to identify changes in patients' cognitive function. The SMMSE requires little time to complete and is a key component of a comprehensive dementia workup. Determining whether a patient has dementia is important because there are now effective medications that are most beneficial if started early.

Chronic obstructive pulmonary disease stage and 6-minute walk outcome

PURPOSE

Although physicians generally reserve pulmonary rehabilitation (PR) referral for patients in later stages of chronic obstructive pulmonary disease (COPD), there is no evidence to suggest that PR programs are more effective for these persons than for those in earlier stages of the disease. This study examined the relationship between 6-minute walk change and COPD stage in patients completing PR.

METHODS

The sample consisted of 76 patients who enrolled in the University of Alabama at Birmingham's Cardiopulmonary Rehabilitation Program with a primary diagnosis of COPD between January 1996 and June 2000. Data was collected on 6-minute walk upon entry into the program and upon program completion. Patients were stratified according to COPD stage using the American Thoracic Society staging system.

RESULTS

There were significant differences among the three stages with regard to initial and ending 6-minute walk distances such that persons in later stages of the disease have shorter initial and ending 6-minute walk distances. However, all three stages show significant improvements in the 6-minute walk after PR. There were no significant differences in the median change among groups indicating that the median change was not better (or worse) for patients in any particular COPD stage.

CONCLUSIONS

This study suggests that PR is equally effective in increasing physical performance for all patients regardless of COPD stage. This type of information can be used to support the recommendation of PR for patients early in the disease process.

Advance directives in cardiac and pulmonary rehabilitation patients

PURPOSE

Advance directives have been available in parts of the United States for more than 20 years, but research shows that only a small percentage of adults (5-25%) have some form of written advance directive. The purose of this study was to examine the presence of advance directives among persons entering cardiac and pulmonary rehabilitation, and identify characteristics of persons most likely to have advance directives.

METHODS

The sample consisted of 336 cardiac patients and 181 pulmonary patients who enrolled in the University of Alabama at Birmingham's Cardiopulmonary Rehabilitation Program between January 1996 and December 1999. As part of the initial program assessment, patients were asked two questions: (1) Do you have a living will? (2) Do you have any advance directives? For the purposes of this study, the two questions were combined to examine the presence of either a living will or other type of advance directive.

RESULTS

Results indicate that 25% of both subgroups (cardiac and pulmonary patients) report having written advance directives. Logistic regression analysis indicates that among cardiac patients whites and older persons were more likely to have advance directives. Among pulmonary patients, females and whites were more likely to have advance directives.

CONCLUSIONS

These results indicate that only a minority of cardiopulmonary rehabilitation patients have advance directives upon entry into the program, and that the prevalence differs among gender, racial, and age groups. Cardiac and pulmonary rehabilitation programs may be valuable sites for educating patients about advance directives and efforts by rehabilitation personnel may increase the prevalence of advance directives among patients.

Referral patterns to a University-based cardiac rehabilitation program

Referral rates to our cardiac rehabilitation program among patients hospitalized for coronary heart disease were computed over an 18-month period. Only 8.7% of eligible patients were referred, suggesting that more education targeting physicians, patients, and insurers is needed and barriers to participation must be systematically addressed.

The place of bigamy in the pantheon of crime?

Bigamy is officially classified as a 'sex offence'. The offence is rare and attracts little criminological attention, and the reaction of the courts has become more lenient in recent years, yet the media coverage of bigamy remains quite pervasive. An analysis of the criminal career profile over 32 years (1963-94) of the 42 bigamists convicted in 1973 indicates that they had no other convictions for bigamy and only two had convictions for a sex offence. Among the 25 persons with other convictions, the crimes of theft/handling stolen goods and fraud and forgery predominate. In fact, the criminal careers of these bigamists are more similar to the criminal careers of white collar offenders than of other sex offenders. It is suggested that by looking at convicted bigamists' criminal careers one can more appropriately categorize the crime as deception, and in this context we need to consider how to respond to its perpetrators and victims.

Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators

Data from a national registry of myocardial infarction patients from June 1994 to April 1996 were analyzed to compare the presenting characteristics, acute reperfusion strategies, treatment patterns, and clinical outcomes among black and white patients. Blacks presented much later to the hospital after the onset of symptoms (median 145 vs 122 minutes, p <0.001), were more likely to have atypical cardiac symptoms (28% vs 24%, p <0.001), and nondiagnostic electrocardiograms during the initial evaluation period compared with whites (37% vs 31%, p <0.001). Also, blacks were less likely to receive intravenous thrombolytic therapy (adjusted odds ratio [OR] 0.76, 95% confidence intervals [CI] 0.71 to 0.80), coronary arteriography (adjusted OR 0.85, 95% CI 0.77 to 0.95), other elective catheter-based procedures (adjusted OR 0.87, 95% CI 0.78 to 0.96), and coronary artery bypass surgery (adjusted OR 0.66, 95% CI 0.58 to 0.75) than their white counterparts. Despite these differences in treatment, there were no significant differences in hospital mortality between blacks and whites.

Presenting characteristics, treatment patterns, and clinical outcomes of non-black minorities in the National Registry of Myocardial Infarction 2

Data from a national registry (cohort) of myocardial infarction, which has enrolled 275,046 patients from June 1994 to April 1996, were analyzed to compare the baseline demographic and clinical characteristics, treatment patterns, and clinical outcomes among Hispanics, Asian-Pacific islanders, and native Americans with those of white Americans presenting to the hospital with acute myocardial infarction. Non-black minorities were younger, had a higher proportion of men, used the emergency medical services less frequently, and presented later to the hospital after the onset of symptoms (135 vs 122 minutes, p <0.001) than whites. Also, non-black minorities were less likely to receive beta-blocker therapy at discharge (crude odds ratio 0.86, confidence interval 0.82 to 0.90) than whites, but they were generally as likely to receive intravenous thrombolytic therapy (with the exception of Asian-Pacific islanders) and undergo both coronary arteriography and revascularization procedures as their white counterparts. There were no significant differences in hospital mortality for non-black minorities compared with whites.

Analysis of loss of heterozygosity and KRAS2 mutations in ovarian neoplasms: clinicopathological correlations

The molecular events that give rise to ovarian epithelial neoplasms are not well understood. In particular, it is not known whether adenocarcinomas arise from benign or low malignant potential (LMP) precursors. We have examined a large series of benign (25) and LMP (31) ovarian tumors for loss of heterozygosity (LOH) at multiple loci on 17 chromosomes. LOH was observed in benign tumors on chromosomes 6 (14%) and 9 (5%) and on the X chromosome (33%) only. LOH on these chromosomes was also detected in a small number of LMP neoplasms, suggesting that these may derive sometimes from benign precursors. In addition, we examined LOH in 93 adenocarcinomas. Analysis of associations between LOH events showed that LOH on chromosomes 5 and 17 (P = 0.0002) and on chromosomes 17 and 18 (P = 0.00007) were associated significantly with each other, which suggests that these may represent cooperative, progressive events. No novel significant associations were identified between LOH events and stage, grade, or histology, which would indicate the existence of genetic heterogeneity in ovarian neoplasms. KRAS2 mutations were detected more often in LMP neoplasms than in malignant tumors (P = 0.004) and were detected more often in Stage I/II malignant tumors than in Stage III/IV malignant tumors (P = 0.033), suggesting that LMP tumors with KRAS2 mutations are unlikely to progress to frank malignancy. Univariate (but not multivariate) survival analysis showed that LOH of chromosomes 11 (P = 0.039) and 17 (P = 0.04) was associated with a significantly worse prognosis. Replication of these novel findings is necessary, and the identification, isolation, and characterization of the critical genes affected by LOH will determine their importance in the pathogenesis of ovarian malignancies.

Selective expression of CD44 cell-adhesion molecule in thyroid papillary carcinoma fine-needle aspirates

Recent descriptions of numerous pitfalls in the cytologic diagnosis of thyroid papillary carcinoma on fine-needle aspiration biopsy specimens have prompted studies of new ancillary diagnostic methods. We evaluated the potential use of immunocytochemical staining of thyroid fine-needle aspiration biopsy specimens for CD44, a glycosylated cartilage link protein associated with extracellular matrix adhesion and lymphocyte homing. Fourteen of 16 (88%) classic, surgically confirmed, thyroid aspiration biopsies stained intensely positive for this marker, whereas 0 of 30 (0%) similarly-processed benign aspirates from colloid nodules showed immunoreactivity for CD44 antigen. From this study, we conclude that most papillary carcinomas of the thyroid express the celladhesion molecule CD44, which may be of clinical value in confirming the diagnosis on borderline fine-needle aspiration specimens. Further study of CD44 expression may prove of significant interest in explaining the unusual mode of spread and clinical course of this disease.

Homozygous deletions on the short arm of chromosome 9 in ovarian adenocarcinoma cell lines and loss of heterozygosity in sporadic tumors

Rat ovarian surface epithelial cells transformed spontaneously in vitro have been found to have homozygous deletions of the interferon alpha (IFNA) gene. This suggests that inactivation of a tumor-suppressor gene in this region may be crucial for the development of ovarian cancer. We therefore used microsatellite markers and Southern analysis to examine the homologous region in humans--the short arm of chromosome 9--for deletions in sporadic ovarian adenocarcinomas and ovarian tumor cell lines. Loss of heterozygosity occurred in 34 (37%) of 91 informative sporadic tumors, including some benign, low-malignant-potential and early-stage tumors, suggesting that it is an early event in the development of ovarian adenocarcinoma. Furthermore, homozygous deletions on 9p were found in 2 of 10 independent cell lines. Deletion mapping of the tumors and lines indicates that the candidate suppressor gene inactivated as a consequence lies between D9S171 and the IFNA locus, a region that is also deleted in several other tumors and that contains the melanoma predisposition gene, MLM.

The prognostic value of clinical, pathologic, and biologic parameters in ovarian cancer

BACKGROUND

The prognosis in ovarian cancer remains poor, and there is a need to identify patients who are less likely to respond to treatment.

METHODS

In a study of 133 unselected patients with ovarian adenocarcinoma treated by a standard protocol, variables such as age, tumor type, International Federation of Gynecology and Obstetrics stage, cellular differentiation, amount of residual disease after surgery, and results from flow cytometry were correlated with survival and relapse at 24 months.

RESULTS

Although stage and cellular differentiation were found to be significant associations with survival and relapse, multivariate analyses identified only residual disease and ploidy status (and the related DNA index and percentage of aneuploid cells) as independent prognostic variables. The magnitude of the effect of ploidy depended on the amount of residual disease; among patients with less disease (< 2 cm), the mortality rate was nearly fourfold higher for those with aneuploid tumors than for those with diploid tumors.

CONCLUSIONS

Routine use of ploidy determination in ovarian cancer is an important prognostic indicator, especially for a subgroup of patients with minimal residual disease.

The management of ovarian carcinoma is improved by the use of cancer-associated serum antigen and CA 125 assays

BACKGROUND

The new tumor-associated mucin assay, cancer-associated serum antigen (CASA), was assessed with the CA 125 assay for use in the management of patients with epithelial ovarian cancer.

METHODS

CASA and CA 125 were assessed retrospectively for use in (1) monitoring 28 patients with Stage 3 or 4 ovarian carcinoma during therapy, (2) predicting the outcome of 41 second-look laparotomies (SLL), and (3) predicting the survival outcome by measuring these levels after surgery but before chemotherapy in 65 patients with Stage 3 disease.

RESULTS

Of 20 patients with recurrence after an initial response, the presence of CASA levels detected recurrence in 65% before clinical detection; CA 125, 50%; and the combination of CASA and CA 125, 80%. Six patients whose disease was in long-term remission did not have elevations of either marker. When used to predict the results of SLL, the positive predictive values of CASA and CA 125 were 77% and 100%, respectively. The negative predictive values for CASA and CA 125 were 71% and 66%, respectively. CASA detected 50% of positive SLL where microscopic disease only was found; the CA 125 test did not. Multivariate analysis of survival rates using levels of CASA and CA 125, age, residual disease, tumor type and grade, or the presence or absence of cisplatin in the chemotherapeutic regimen found that postoperative CASA levels ranked above all prognostic factors except age. CASA levels may be more accurate than surgical reporting of residual disease or they may define a subset of patients with biologically more aggressive ovarian carcinoma.

CONCLUSIONS

The CASA test is sensitive to ovarian carcinoma, and both CASA and CA 125 are more useful when used in conjunction.

Towards optimizing rowing technique

An equation is developed (and solved) to describe the speed of a rowing boat as a function of the movement of the sculler's center of mass relative to the boat and the force applied. A method is presented to determine the degree to which fluctuations in boat speed through the rowing cycle affect the amount of power necessary to propel the boat at some mean speed. By changing technique, it is possible to modify these fluctuations in order to achieve the higher mean speed for a given amount of propulsive power. An approximate calculation of the ratio of the power put into the boat's motion to the power lost as water movement in the oar "puddle" suggests that increasing the blade area of the oar will result in improved efficiency. A similarity analysis is undertaken to see if large rowers have an advantage over small rowers in races. Dependence of drag coefficients on scale suggest they do; however, this advantage is very small and would be largely compensated for if boats were made optimally light (in which case the ratio of boat mass to body mass decreases as body mass decreases). Regulations of international rowing fix a minimum boat mass regardless of the rowers mass, thereby discriminating against smaller rowers. Equations are developed to show how stroke rate should scale with body mass for geometrically similar rowers. The ratio of power expended in internal motions to power expended propelling the boat is investigated.