Causes of death and pathogen prevalence in bottlenose dolphins Tursiops truncatus stranded in Alabama, USA, between 2015 and 2020, following the Deepwater Horizon oil spill

Between 2010 and 2014, an unusual mortality event (UME) involving bottlenose dolphins Tursiops truncatus occurred in the northern Gulf of Mexico, associated with the Deepwater Horizon oil spill (DWHOS). Cause of death (COD) patterns in bottlenose dolphins since then have not been analyzed, and baseline prevalence data for Brucella ceti and cetacean morbillivirus, 2 pathogens previously reported in this region, are lacking. We analyzed records from bottlenose dolphins stranded in Alabama from 2015 to 2020 with necropsy and histological findings to determine COD (n = 108). This period included another UME in 2019 associated with prolonged freshwater exposure. A subset of individuals that stranded during this period were selected for molecular testing for Brucella spp. and Morbillivirus spp. Causes of death for all age classes were grouped into 6 categories, including (1) human interaction, (2) infectious disease, (3) noninfectious disease (prolonged freshwater exposure and degenerative), (4) trauma, (5) multifactorial, and (6) unknown. Two additional categories unique to perinates included fetal distress and in utero pneumonia. Human interaction was the most common primary COD (19.4%) followed closely by infectious disease (17.6%) and noninfectious disease (freshwater exposure; 13.9%). Brucella was detected in 18.4% of the 98 animals tested, but morbillivirus was not detected in any of the 66 animals tested. Brucella was detected in some moderately to severely decomposed carcasses, indicating that it may be beneficial to test a broad condition range of stranded animals. This study provides valuable information on COD in bottlenose dolphins in Alabama following the DWHOS and is the first to examine baseline prevalence of 2 common pathogens in stranded animals from this region.

Results of the California Healthy Homes Indoor Air Quality Study of 2011-2013: impact of natural gas appliances on air pollutant concentrations

This study was conducted to assess the current impact of natural gas appliances on air quality in California homes. Data were collected via telephone interviews and measurements inside and outside of 352 homes. Passive samplers measured time-resolved CO and time-integrated NOX , NO2 , formaldehyde, and acetaldehyde over ~6-day periods in November 2011 - April 2012 and October 2012 - March 2013. The fraction of indoor NOX and NO2 attributable to indoor sources was estimated. NOX , NO2 , and highest 1-h CO were higher in homes that cooked with gas and increased with amount of gas cooking. NOX and NO2 were higher in homes with cooktop pilot burners, relative to gas cooking without pilots. Homes with a pilot burner on a floor or wall furnace had higher kitchen and bedroom NOX and NO2 compared to homes without a furnace pilot. When scaled to account for varying home size and mixing volume, indoor-attributed bedroom and kitchen NOX and kitchen NO2 were not higher in homes with wall or floor furnace pilot burners, although bedroom NO2 was higher. In homes that cooked 4 h or more with gas, self-reported use of kitchen exhaust was associated with lower NOX , NO2 , and highest 1-h CO. Gas appliances were not associated with higher concentrations of formaldehyde or acetaldehyde.

Formaldehyde and acetaldehyde exposure mitigation in US residences: in-home measurements of ventilation control and source control

Measurements were taken in new US residences to assess the extent to which ventilation and source control can mitigate formaldehyde exposure. Increasing ventilation consistently lowered indoor formaldehyde concentrations. However, at a reference air exchange rate of 0.35 h(-1), increasing ventilation was up to 60% less effective than would be predicted if the emission rate were constant. This is consistent with formaldehyde emission rates decreasing as air concentrations increase, as observed in chamber studies. In contrast, measurements suggest acetaldehyde emission was independent of ventilation rate. To evaluate the effectiveness of source control, formaldehyde concentrations were measured in Leadership in Energy and Environmental Design (LEED)-certified/Indoor airPLUS homes constructed with materials certified to have low emission rates of volatile organic compounds (VOC). At a reference air exchange rate of 0.35 h(-1), and adjusting for home age, temperature and relative humidity, formaldehyde concentrations in homes built with low-VOC materials were 42% lower on average than in reference new homes with conventional building materials. Without adjustment, concentrations were 27% lower in the low-VOC homes. The mean and standard deviation of formaldehyde concentration was 33 μg/m(3) and 22 μg/m(3) for low-VOC homes and 45 μg/m(3) and 30 μg/m(3) for conventional.

Medical management of inflammatory bowel disease among Canadian gastroenterologists

BACKGROUND

Little is known about physician perceptions of and practices in using infliximab - a biological agent that was approved in Canada for the treatment of Crohn's disease in 2001, and for ulcerative colitis in 2006.

OBJECTIVES

To describe Canadian gastroenterologists' use and perceptions of infliximab in the treatment of refractory inflammatory bowel disease (IBD), and to identify factors that may influence a gastroenterologist's decision to initiate infliximab therapy.

METHODS

A postal questionnaire was distributed to all practicing clinicians captured in the 2007 membership of the Canadian Association of Gastroenterology. Each physician was contacted up to a maximum of three times.

RESULTS

Of 466 questionnaires mailed out, responses were received from 336 (72%), with 292 respondents (63%) returning fully completed surveys. For 80% of respondents, IBD patients comprised less than 30% of their clinical practice. Most prescribed infliximab at an initial dose of 5 mg⁄kg (97%), prescribed loading doses at 0, 2 and 6 weeks (88%), premedicated with corticosteroids (74%), administered maintenance infusions at eight-week intervals (89%), co-administered immunosuppressive agents (81%) and continued infliximab 'indefinitely' as long as it was effective and well tolerated (76%). Most gastroenterologists (>70%) identified lack of drug insurance coverage and provincial funding criteria as important barriers to prescribing infliximab.

CONCLUSIONS

Most Canadian gastroenterologists exhibited similar practice patterns with respect to the use of infliximab for induction and maintenance therapy of IBD. Common barriers to the initiation of infliximab therapy were identified.

Health disparities in chickenpox or shingles in Alberta?

OBJECTIVE

Exploring for evidence of socio-economic health disparities in chickenpox and shingles in Alberta, Canada.

METHODS

Chickenpox and shingles cases were identified from administrative data from Alberta's universal health care insurance system for 1994-2002. Incident cases were those with the earliest dated utilization of a health service (chickenpox: ICD9-CM 052/ICD10-CA B01; shingles: ICD9-CM 053/ ICD10-CA B02). Crude and age-specific rates were estimated for each year by an indicator of socio-demographic status based upon the nature of the payer and eligibility for health care premium subsidy (SES-proxy) for the provincial health care insurance system.

RESULTS

Among young children there is a gradient of disparity in chickenpox rates prior to the year in which publicly funded vaccination programs were implemented. After this point, disparities decline but less so for First Nations children than for others. There was no evidence of disparity by SES-proxy for shingles.

CONCLUSION

Publicly funded vaccination programs may effectively contribute to reduction in disease disparities for vaccine-preventable diseases. Further study is required to ascertain why disparities continue for First Nations children.

65. Concurrent pursuit of degrees and courses during community medicine residency: Challenges, policies and proceduress

We describe the policies and practices of Canadian Community Medicine (CM) residency programs regarding the Royal College requirement for one year of academic course work. We surveyed 10 Program Directors (PD) of the 11 Canadian CM residency programs (excluding our university) by either telephone interview or written completion of a structured interview guide. Questions addressed: what is currently allowed and/or encouraged; the policies in place; and the benefits and challenges to concurrent pursuit of degrees by CM residents. Of particular interest were policies regarding residents studying off-site and what actions PDs take if courses or degrees desired by a resident were not available at the home university. Seven of 10 PDs replied. Most programs did not have written policies to deal with requests to study off-site; decisions were made on a case-by-case basis. When approved, residents received salary support and bore all costs of off-site education. Several CM programs require degree acquisition during the academic year; others encourage degree acquisition. While CM program websites indicate degree completion is possible within one calendar year, often practicum placements run concurrently with resident clinical rotations or projects are competed during residency rotations. Most programs prefer residents to stay on campus for their contribution to rounds and on-call, socialization of the cohort, and continuity. It would be helpful to programs generally if PDs had policies to guide decisions; it would be particularly useful for the specialty if this were (to the degree possible) a common policy across universities. PDs and universities wish to make academic learning more readily accessible. We suggest a focus on the development of quality distance learning and innovative strategies to share course development and improve residents’ access to learning without the need to go off-site. Zweifler J, Evans R. Development of a residency/MPH Program. Fam Med 2001; 33(6):453-8. Tilak GS, Baker SR. Self-subsidization of educational expenses by senior radiology residents. Acad Radiol 2007; 14:105-9. Walter DA, Rosenquist PB, Bawtinhimer G. Distance learning technologies in the training of psychiatry residents; a critical assessment. Acad Psychiatry 2004; 28(10):60-5.

17. Boundaries or overlap: An examination of the community-oriented clinical practice of community medicine specialists and family/general practitioners

We compared the work settings and “community-oriented clinical practice” of Community Medicine (CM) specialists and family physicians/general practitioners (FP). We conducted secondary data analysis of the 2004 National Physician Survey (NPS) to examine main work setting and clinical activity reported by 154 CM (40% of eligible CM in Canada) and 11,041 FP (36% of eligible FP in Canada). Text data from the specialist questionnaire related to “most common conditions that you treat” were extracted from the Master database for CM specialists, and subjected to thematic analysis and coded. CM specialists were more likely than FP to engage in “community medicine/public health” (59.7% vs 15.3%); while the opposite was found for primary care (13% vs. 78.2%). CM specialists were less likely to indicate a main work setting of private office/clinic/community health centre/community hospital than were FP (13.6% vs. 75.6%). Forty-five percent of CM provided a response to “most common conditions treated” with the remainder either leaving the item blank or indicating that they did not treat individual patients. The most frequently named conditions in rank order were: psychiatric disorders; public health program/activity; respiratory problems; hypertension; and metabolic disorders (diabetes). There is some overlap in the professional activities and work settings of CM specialists and FP. The “most commonly treated conditions” suggest that some CM specialists may be practicing primary care as part of the Royal College career path of “community-oriented clinical practice.” However the “most commonly treated conditions” do not specifically indicate an orientation of that practice towards “an emphasis on health promotion and disease prevention” as also specified by the Royal College for that CM career path. This raises questions about the appropriateness of the current training requirements and career paths as delineated for CM specialists by the Royal College of Physicians & Surgeons of Canada. Bhopal R. Public health medicine and primary health care: convergent, divergent, or parallel paths? J Epidemiol Community Health 1995; 49:113-6. Pettersen BJ, Johnsen R. More physicians in public health: less public health work? Scan J Public Health 2005; 33:91-8. Stanwell-Smith R. Public health medicine in transition. J Royal Society of Medicine 2001; 94(7):319-21.

Secular trends in the epidemiology of shingles in Alberta

Varicella vaccine was licensed in Canada in 1998, and a publicly funded vaccination programme introduced in the province of Alberta in 2001. In theory the vaccination programme might increase the burden of disease from shingles, making it important to develop baseline data against which future comparisons can be made. The study's aim was to describe the epidemiology of non-fatal cases of shingles for which publicly funded health services were utilized for the period 1986-2002. Shingles cases were identified from the records of Alberta's universal, publicly funded health-care insurance system for 1986-2002. The earliest dated health service utilizations for ICD-9-CM codes of 053 or ICD-10-CA codes of B02 were classified as incident. Diagnostic codes at least 180 days after the first were classified as recurrent episodes. Denominators for rates were estimated using mid-year population estimates from the Alberta Health Care Insurance Plan Registry. Annual age- and sex-specific rates were estimated. We explored the pattern of rates for sex, age and year effects and their interactions. Shingles rates increased between 1986 and 2002. There was a sex effect and evidence of an age-sex interaction. Females had higher rates than males at every age; however, the difference between females and males was greatest for the 50-54 years age group and declined for older age groups. The increased rate of shingles in Alberta began before varicella vaccine was licensed or publicly funded in Alberta, and thus cannot be attributed to vaccination.

The changing epidemiology of chickenpox in Alberta

BACKGROUND

Varicella vaccine was licensed in Canada in 1998. The province of Alberta introduced a universal publicly funded varicella vaccination program in 2001.

PURPOSE

To describe the epidemiology of non-fatal cases of chickenpox for which publicly funded health services were utilized for the period 1986-2002.

METHODS

We used the records of Alberta's universal, publicly funded health care insurance system to identify cases of chickenpox for the period 1986-2002. The earliest dated utilization of a health service for which there was an ICD9-CM code of 052.xx or an IC10-CA code of B01.xx was used as the date of illness onset. Denominators for rates were estimated using mid-year population estimates from the Alberta Health Care Insurance Registry. Age-specific rates were estimated for each year.

RESULTS

The crude incidence of chickenpox significantly declined over the period 1994-2002, most steeply after the year 2000. The incidence of chickenpox varied by age group and year and there was evidence of age-group-year interaction. Among those aged 5-19 years, chickenpox incidence began to decline prior to vaccine licensure in Canada. Among those aged less than one year and those aged 1-4 years, the incidence increased until 1999 when a decline began. Over the period 0.8% of cases were hospitalized.

CONCLUSION

Chickenpox rates began to decline prior to the introduction of the publicly funded vaccination program; however the declines in rates among the youngest age-groups are consistent with a vaccination program effect.

Doctors, patients and influenza-like illness: clinicians or patients at risk?

BACKGROUND

Healthcare providers can transmit influenza and influenza-like illness (ILI) to patients and vice versa. However, the magnitude of this problem in the healthcare system as a whole is unknown. Using population-based administrative health data, we tested the hypothesis of a temporal association of ILI diagnosis among clinicians and their patients.

METHODS

Healthcare providers under study included physicians (85%) and a variety of other medical professionals (such as chiropractors, dentists and optometrists). Cases of ILI were defined as having an ICD-9 code of influenza (487), pneumonia (480-486) or bronchitis (466 and 490) in a province-wide healthcare-provider billing system. Rates of ILI among persons who saw a sick (case) and non-sick (control) doctor were calculated and compared.

RESULTS

The rate of ILI was lower among providers than among patients for every year of the study. The mean number of exposures to patients diagnosed with ILI was higher among case providers than among control providers (P = 0.044). However, exposure to case providers did not significantly increase the risk of ILI diagnosis among patients (OR=1.11; 95% confidence intervals 0.85-1.36).

INTERPRETATION

Our findings are consistent with the hypothesis of patient-to-provider transmission. However, we may have underestimated the association and magnitude of this effect. Our results do not support the hypothesis that infectious doctors transmit disease to their patients, although this may be partly accounted for by the lower rates of ILI among the provider population in general.

Response rates for surveys of chiropractors

BACKGROUND

Survey response rates may vary by type of practitioner studied and may have declined over time. Response rates for surveys of complementary practitioners have not been studied.

OBJECTIVE

To describe the response rates in published surveys of chiropractors and explore for secular trends in response rates and for methodologic and geographic correlates of response rates.

METHODS

Secondary analysis of data extracted from published English language reports of surveys of chiropractors. Response rates were calculated as the total number of persons from whom a questionnaire was returned divided by the total number of persons who were sent a questionnaire.

RESULTS

Sixty-two surveys represented by 79 articles published in the interval 1980 to 2000 met inclusion criteria for analysis. We were able to calculate a response rate for 46 postal surveys. The mean response rate was 52.7%. There was no significant association between geographic setting and response rate, and there was no evidence of secular trend in response rates. None of the studies employed incentives. The strongest predictor of response rate was number of contacts with the target population.

CONCLUSION

Response rates for surveys of chiropractors are similar to those observed for surveys of medical doctors. The key to obtaining high response rates is the use of evidence-based methods in design and conduct of the surveys.

Alternative medicine use by individuals with major depression

OBJECTIVE

To describe the use of alternative medicine (AM) by persons with major depression and to examine the factors associated with AM use among these individuals.

METHODS

We used data from the 1994-1995 and 1996-1997 National Population Health Surveys. We selected subjects who had major depression according to the Composite International Diagnostic Interview Short Form for Major Depression (CIDI-SFMD). The prevalence of AM and conventional health service use by the subjects was calculated for each survey and was stratified by province. We employed logistic regression to examine the factors associated with AM use.

RESULTS

There was a temporal trend toward increasing use of AM among persons with major depression. The prevalence of AM use among subjects with major depression was 7.8% in 1994-1995 and 12.9% in 1996-1997. Female sex, having more than 12 years' education, and having 1 or more long-term medical conditions were associated with an increased likelihood of using AM. The sex difference in AM use depended on subjects' age in 1996-1997.

CONCLUSION

General practitioners, mental health specialists, and AM providers should be aware of their patients' use of both conventional medical services and AM because there may be interactions between conventional and alternative treatments. Communication and, if possible, cooperation may lead to improved outcomes in the management of depressive disorders.

Using epidemiology to target staff influenza vaccination programs

We examined staff influenza vaccination rates in rural hospitals that had both acute- and long-term-care (LTC) units. After controlling for hospital, acute-care staff were less likely to be vaccinated than LTC staff. There was no consistent association between type of worker and vaccination after controlling for both hospital and type of care.

Influenza vaccination in Alberta long-term care facilities

BACKGROUND

Canada's National Advisory Committee on Immunization recommends that both staff and residents of long-term care facilities be vaccinated against influenza. This paper describes the influenza vaccination policies and programs, as well as vaccination rates, for staff and residents of long-term care institutions in Alberta. Such data have not previously been reported.

METHODS

Data were collected by means of an anonymous mail survey (with 2 reminders) sent to Alberta nursing homes and auxiliary hospitals in spring 1999.

RESULTS

Of 160 facilities providing long-term care during the study period, 136 responded to the survey (85%). Of these, only 85 provided data on staff vaccination rates, whereas 118 provided data on resident vaccination rates. For institutions reporting this information, the median proportion of staff vaccinated was 29.9% and the median proportion of residents vaccinated was 91.0%. Only 2 facilities reported that staff vaccination was mandatory; however, only one of these had a written policy consistent with the self-report period. Using a travelling vaccination cart, offering vaccination on night shift, and monitoring and providing feedback about staff vaccination rates were infrequently employed as elements of staff vaccination programs, although all were positively correlated with staff vaccination rates. Standing orders for resident vaccination were reported by only 84 facilities. Fourteen institutions required written consent for vaccination from the resident or a relative. Facility requirements for consent to vaccinate from the resident or a relative were significantly associated with mean vaccine coverage: 90.5% coverage for institutions requiring verbal consent, 86.5% coverage for institutions requiring written consent and 95.0% for institutions not requiring written or verbal consent.

INTERPRETATION

Staff vaccination rates in Alberta long-term care facilities are unacceptably low. Changes in staff vaccination programs may improve the situation even in the absence of mandatory vaccination or work exclusion rules. Requirements for written consent for vaccination of residents of long-term care facilities may be a barrier to immunization.

Major depression: prevalence, treatment utilization and age in Canada

OBJECTIVE

To determine the relationships between age, prevalence of major depression and antidepressant treatment in Canadian populations by using data from three health surveys.

BACKGROUND

Major depression is an important disorder, and there is a concern that treatment for it may be underutilized. Age may have an impact on treatment use.

METHODS

Two of the surveys incorporated into the present analysis were random digit dial telephone surveys, with sample sizes of 2542 subjects and 796 subjects, respectively. The third data source was the National Population Health Survey (n=73,402), which used some face to face and some telephone-based data collection methods. In each of these studies, major depression was evaluated using a short form version of the Composite International Diagnostic Interview for Major Depression. Diagnostic status was evaluated in relation to current use of antidepressant medications, age and other relevant factors. All analyses accounted for unequal selection probabilities and clustering inherent in the sampling procedures.

RESULTS

The prevalence of major depression was consistently found to be highest in subjects under the age of 45 years. However, older subjects were more likely to report having depression diagnosed. Antidepressant treatment was found to be less frequent in young subjects, despite these subjects being in the group with the highest prevalence of depression. Younger respondents were less likely to see a physician about their depressive symptoms, and when they did they were less likely to be told that they had a depressive disorder.

CONCLUSIONS

The data presented indicate that antidepressant medications tend to be used less frequently in younger than older age groups in Canada. Additional studies are needed to confirm optimal use rates in relation to age.

The prevalence and correlates of influenza vaccination among a home care population

OBJECTIVE

To estimate the prevalence and correlates of influenza vaccination in a Home Care population.

METHODS

This was a cross-sectional investigation involving linkage of three population-based databases from a rural Alberta Regional Health Authority, i.e., the Regional immunization and the Regional home oxygen information systems to the Regional home care information system. The sample comprised 649 persons who had been admitted or discharged from the Regional Home Care Program in the period Oct. 1-Dec. 31, 1998. An anonymous data file was released to the investigators. We estimated the proportion ever vaccinated against influenza, the proportion vaccinated in the period Oct. 1-Dec. 31, 1998 ("currently vaccinated"); and explored sociodemographic and program correlates of current vaccination.

RESULTS

67% had ever been vaccinated against influenza; 60.7% were currently vaccinated. Factors associated with current vaccination (multivariate analysis) include older age, being married, not receiving nursing services, district of residence and program status.

CONCLUSIONS

Influenza vaccination rates were suboptimal. The correlates of vaccination suggest systems-level impediments to influenza vaccination.

The incidence of pulmonary embolism in unexplained sudden cardiac arrest with pulseless electrical activity

PURPOSE

The cause of many cases of sudden cardiac arrest from pulseless electrical activity is unknown. We hypothesized that pulmonary embolism was responsible for a substantial proportion of these cases and used transesophageal echocardiography to identify pulmonary embolism among patients with sudden cardiac arrest.

SUBJECTS AND METHODS

We performed a prospective study at a tertiary care, university-operated county hospital, with a level 1 trauma center. Consecutive patients (n = 36) who were admitted with (n = 20) or unexpectedly developed (n = 16) sudden cardiac arrest of unknown cause were studied with transesophageal echocardiography during cardiopulmonary resuscitation. We determined the presence of central pulmonary embolism, right ventricular enlargement, and other causes of sudden cardiac arrest (such as myocardial infarction and aortic dissection) using prospectively defined criteria.

RESULTS

Of the 25 patients with pulseless electrical activity as the initial event, 9 (36%) had pulmonary emboli (8 seen with transesophageal echocardiography and 1 diagnosed at autopsy) compared with none of the 11 patients with other rhythms, such as asystole or ventricular tachycardia or fibrillation (P = 0.02). Of the 8 patients who had pulmonary embolism diagnosed by transesophageal echocardiography, 2 survived to hospital discharge.

CONCLUSIONS

Mortality from massive pulmonary embolism is high, particularly if patients present with sudden cardiac arrest. Earlier diagnosis of pulmonary embolus may permit wider use of thrombolytic agents or other interventions and may potentially increase survival.

Crystallographic, X-ray absorption, and IR studies of solid- and solution-state structures of tris(nitrato) N,N,N',N'-tetraethylmalonamide complexes of lanthanides. Comparison with the Americium complex

To fine-tune the design of optimized donor ligands for nuclear waste actinide selective extraction, both electronic and molecular structures of the actinide complexes that are formed must be investigated. In particular, to achieve the selective complexation of transplutonium 3+ ions versus lanthanide 3+ ions is one of the major challenges, given the chemical similarities between these two f-element families. In this work, the structure of solvent-phase M(NO3)3(TEMA)2 complexes (Ln = Nd, Eu, Ho, Yb, Lu, Am; TEMA = N,N,N',N'-tetraethylmalonamide) was investigated by liquid-phase spectroscopic methods among which extended X-ray absorption fine structure played a major role. In addition, the crystal structures of the species Nd(NO3)3(TEMA)2 and Yb(NO3)3(TEMA)2 have been determined by X-ray diffraction. Nd(NO3)3(C11N2O2H22)2 crystallizes in the monoclinic system (P2(1) space group; a = 11.2627(4) A, b = 20.5992(8) A, c = 22.2126(8) A; alpha = gamma = 90 degrees, beta = 102.572(1) degrees; Z = 6), and Yb(NO3)3(C11N2O2H22)2 crystallizes in the orthorhombic system (P2(1)2(1)2(1) space group; a = 9.3542(1) A, b = 18.1148(2) A, c = 19.7675(2) A; alpha = beta = gamma = 90 degrees; Z = 4). In the solvent phase, the metal polyhedron was found to be similar to that of the solid-state complex Nd(NO3)3(TEMA)2 for M = Nd to Ho. For M = Yb and Lu, a significant elongation of one nitrate oxygen bond was observed. Comparison with measurements on the Am(NO3)3(TEMA)2 complex in ethanol has shown the similarities between the Nd3+ and Am3+ coordination spheres.

Paying research subjects: participants' perspectives

OBJECTIVE

To explore the opinions of unpaid healthy volunteers on the payment of research subjects.

DESIGN

Prospective cohort.

SETTING

Southern Alberta, Canada.

PARTICIPANTS

Medically eligible persons responding to recruiting advertisements for a randomised vaccine trial were invited to take part in a study of informed consent at the point at which they formally consented or refused trial participation. Of 72 invited, 67 (62 trial consenters, 5 trial refusers) returned questionnaires at baseline and 54 at follow-up.

OUTCOME MEASURES

Proportions of persons who agreed or disagreed with three close-ended statements on the payment of research subjects; themes and categories identified by content analysis of responses to an open-ended question.

RESULTS

A minority (43.3%) agreed with paying either patient or healthy volunteer participants. Opinions did not change over time. Participants' comments addressed: benefits and drawbacks to research participation; benefits and drawbacks to paying research participants; conditions under which payment of research subjects would be acceptable, and the nature of acceptable recognition. Acceptable conditions were to improve problematic recruitment, to reimburse costs, and to recognise participants, particularly for their time investment. Both non-monetary and monetary recognition of volunteers were thought to be appropriate.

CONCLUSIONS

Most unpaid volunteers disagreed with paying research participants. The themes arising from their comments are similar to those that have been raised by ethicists and suggest that recognising the time and effort of participants should receive greater emphasis than presently occurs.

Cellular and connective tissue changes in alveolar septal walls in emphysema

Emphysema is commonly defined as enlargement of airspaces distal to terminal bronchioles accompanied by destruction of alveolar walls, but without obvious fibrosis. Morphometric techniques were used to correlate changes in components of the alveolar septa surrounding enlarged airspaces in human emphysema with the mean linear intercept (Lm) of those airspaces. Alveolar and capillary surface density decreased with increased Lm, but the ratio of these surface densities to each other remained close to normal for mild to moderate increases in Lm. This suggests that the decreased gas exchange observed in emphysema is initiated by a total loss of septa and not by selective pathological changes of the microvasculature. Increases in septal wall thickness directly correlated with increases in Lm. For the mild to moderate emphysema lesions included in this study, an increase of 100% in Lm correlated with a 130% increase in the relative volume of the alveolar septal interstitium. Significant increases occurred in both elastin (0.14 to 0.56 microm(3)/microm(2) basement membrane [BM]) and collagen (0.49 to 1. 63 microm(3)/microm(2) BM). The increase in elastin and collagen raises the possibility of a remodeling process in the connective matrix in alveolar walls. Whether or not the new connective tissue represents a disordered, nonfunctional regional response needs to be determined.

A disease severity scale for systemic sclerosis: development and testing

OBJECTIVE

To develop and test a severity scale for individual organ involvements in systemic sclerosis (SSc, scleroderma).

METHODS

An international study group completed the following tasks: (1) developed a glossary of terms including all pertinent variables for 9 potentially affected organ systems; (2) collected prospective data to determine the feasibility and practicality of each proposed variable; (3) revised the initial list of variables; (4) determined the association of each variable with mortality (a proxy for morbidity) using 579 patients in an existing comprehensive longitudinal scleroderma databank; (5) developed a severity grading scale for each organ system by discussion and consensus; and (6) externally validated the scale using an independent group of 680 patients from the same databank.

RESULTS

Nine organ-specific severity scales were developed from 0 (no documented involvement) to 4 (endstage disease). The data required for scale completion are relatively easy and practical for all physicians to obtain.

CONCLUSION

This preliminary severity scale will be useful for assessing disease severity status in individual patients both at one point in time and longitudinally. The severity scale will assist in the design and conduct of clinical trials and the comparison of study populations with one another. The scale will serve as a framework for developing a scleroderma disease activity index.

Physician specialty is associated with differences in warfarin use for atrial fibrillation

OBJECTIVE

To determine whether physician specialty is associated with prescription of warfarin to elderly persons with atrial fibrillation.

DESIGN

Cross-sectional survey.

SETTING

One hundred and thirty-eight randomly selected general practitioners--all 58 internists and all 27 cardiologists in southern Alberta were surveyed by mail.

INTERVENTION

Physicians identified their preferred drug for stroke prevention generally and in response to two hypothetical cases.

MAIN RESULTS

Response rates were 66% (general practitioners), 76% (internists) and 89% (cardiologists). Specialists (92%) were more likely than general practitioners (76%) to choose warfarin (P = 0.007). Findings were similar for questions related to case scenarios; however, the magnitude of differences between specialists and general practitioners was less pronounced. Specialists were more likely (77%) to prescribe warfarin for elderly females than were general practitioners (62%, P = 0.08). Similar proportions of specialists (77%) and general practitioners (67%) would prescribe warfarin to elderly males.

CONCLUSION

Physician specialty is associated with warfarin prescription for elderly persons with atrial fibrillation.

Monte Carlo analysis of multi-layer targets for production of 15O

A Monte Carlo simulation code was written to analyze multi-layer targets for production of 15O. The code models beam-particle transport through the target and production and transport of generated radionuclides; it can be used to assess the effects on radionuclide production of several beam and target design variables. A pathlength correction feature is included that relaxes restrictions inherent in previous ion transport codes and a variance reduction procedure is implemented that significantly improves code efficiency.

Outbreaks can be disasters: a guide to developing your plan

Disaster can strike at any time. Most hospitals have a contingency plan for attack from without, but it can also happen from within as one small rural hospital discovered. The authors share practical tips for prevention, detection crisis management, and post-crisis follow-up based on principles of disaster planning. Experience is a great teacher and we can benefit from the authors' helpful tips for creating a more complete plan.

Influenza and tetanus immunization. Are adults up-to-date in rural Alberta?

PURPOSE

To discover what proportion of adults residing within the boundaries of a rural health district were up-to-date with influenza and tetanus vaccinations.

METHODS

A directory-seeded, random digit dial telephone survey of health knowledge, attitudes, and practices was conducted in summer 1993. Eligible subjects were aged 16 or older, lived within health district boundaries, and spoke English.

RESULTS

Just over half (57.5%) of people aged 65 and older had received influenza vaccine in the previous 12 months, and 55.4% of people 16 years and older had received tetanus vaccine in the last 10 years (93% of people aged 16 to 24 were covered, but only 20.5% of people aged 65 or older). Most (89.8%) of those 65 and older knew that influenza vaccine was recommended for people their age. Only 59% of respondents knew that influenza vaccine was recommended for people with chronic health conditions, regardless of age.

CONCLUSION

Among adults, coverage with influenza and tetanus vaccines varies with age, but is generally unsatisfactory. Rates in this rural area of Alberta were similar to Canadian rates for tetanus vaccine coverage but higher for influenza vaccine coverage.

A strategy to improve communication between health care professionals and people living with cancer: II. Follow-up of a workshop on the teaching and assessment of communication skills in Canadian Medical Schools

BACKGROUND AND METHODS

Follow-up questionnaires were sent to all Canadian medical schools in 1994 and 1996 in order to evaluate changes that had taken place in the teaching of physician-patient communication skills since recommendations were made by a national "Workshop on the Teaching and Assessment of Communication Skills in Canadian Medical Schools" in 1992.

RESULTS AND CONCLUSIONS

Fifteen of 16 schools responded. All 15 reported major changes in the teaching of physician-patient communication over the preceding four years or planned changes in the very near future. However, barriers to improving the communications curriculum still existed. The most frequently cited barrier was the lack of trained faculty to teach communication skills; this was followed in frequency by poor coordination over the four years of medical school with lack of scheduled time in the clerkship years. There were identified needs to train faculty to teach communication skills and to extend formal teaching of the subject into the clerkship. Concurrent with these changes, the accreditation process for Canadian medical schools now requires the teaching and evaluation of communication skills.

Disease-specific quality of life: the Gallstone Impact Checklist

OBJECTIVE

To develop a disease-specific quality-of-life scale for symptomatic cholelithiasis for use in clinical trials, and to evaluate its reliability, construct validity and responsiveness.

DESIGN

Questionnaire.

PARTICIPANTS

Health care professionals, patients with symptomatic cholelithiasis and their significant others.

INTERVENTIONS

A 114-item questionnaire was developed from open-ended questions completed by the participants. Questions dealt with physical symptoms, activities of daily living, job performance, leisure activities, emotional factors, marital and sexual relations, support networks and financial situation. The questionnaire was administered by an interviewer to 50 subjects booked for elective cholecystectomy: frequency-importance products were calculated for each of the 114 items. A final shortened scale (the Gallstone Impact Checklist [GIC]) contained 41 items and was completed by patients with symptomatic cholelithiasis on two occasions, 4 to 6 weeks apart.

RESULTS

The checklist requires 10 to 15 minutes to complete. Reliability of the questionnaire and its four subscales was assessed by Cronbach's alpha (overall questionnaire 0.88, pain 0.60, dyspepsia 0.73, emotional impact 0.78 and food and eating 0.84). Construct validity was established by comparison of questionnaire subscales with global ratings of physical and emotional health. Among subjects who reported a difference in their symptoms attributed to gallstones, there was a significant change in total GIC score and in each of the four subscales. Among patients who had undergone cholecystectomy, the absolute value of the effect size was 1.63.

CONCLUSIONS

The GIC has content validity and appears to be a reliable, responsive measure of within-person change for subjects with symptomatic cholelithiasis.

Denominators for estimation of influenza vaccine coverage among high risk persons aged 15 to 64 years

PURPOSE

To propose and demonstrate a method for the estimation of the denominators required for the calculation of vaccine coverage for persons aged 15 to 64 years who are recommended to receive influenza vaccine.

METHODS

The age-sex-specific proportions of persons aged 15 to 64 years who self reported having relevant chronic health conditions were estimated from Cycle 6 of the General Social Survey, and applied to 1996 Alberta census estimates to calculate a denominator for the calculation of vaccine coverage for Alberta for 1996.

RESULTS

For the province of Alberta for 1996, it was estimated that about 281,000 persons aged 15 to 64 had a health condition that was an indication for influenza vaccination.

CONCLUSION

The application of age-sex-specific Canadian proportions to provincial census data will provide denominators for the estimation and comparison of vaccine coverage among high risk adults from year to year.

Needs for CME in geriatrics. Part 2: Physician priorities and perceptions of community representatives

OBJECTIVE

To explore physicians' responses to the needs for education in geriatrics identified by a community needs survey.

DESIGN

Interviews conducted during a cross-sectional survey.

SETTING

Private family practices in Calgary.

PARTICIPANTS

Randomly selected family physicians in Calgary who had previously recruited patients for a community needs survey. Thirty of 60 volunteer physicians randomly selected for phase 1 of the study were interviewed. One physician recruited patients for phase 1 but declined to be interviewed.

MAIN OUTCOME MEASURES

Demographic variables, practice characteristics, and opinions on urgency of potential topics for continuing medical education.

RESULTS

Physicians agreed with community informants that they need more education about medication for the elderly, medical management, and mental health issues. Physicians did not perceive pressing needs for education in communication skills with patients, in compassion, or in health promotion for patients. Physicians identified many barriers to meeting needs identified by the community. Among the most notable obstacles were inadequate time, inadequate remuneration, and lack of accessible community resources.

CONCLUSIONS

Continuing medical education should help physicians recognize the community's needs and design programs that will address them.

Needs for CME in geriatrics. Part 1: Perceptions of patients and community informants

OBJECTIVE

To describe the needs of physicians for continuing education in geriatrics as perceived by patients and community informants.

DESIGN

Cross-sectional survey by mail and in-person interviews.

SETTING

Organizations working with the elderly in the community and patients in a primary care population in Calgary.

PARTICIPANTS

Key informants working with the elderly in the community, including managers and providers of physical, psychosocial, educational, or mental health services to the elderly, and the first two geriatric patients visiting physicians after telephone contact from study investigators were surveyed. Twenty-five of 27 key community informants and 32 of 61 geriatric patients responded.

MAIN OUTCOME MEASURE

Potential topics for continuing medical education.

RESULTS

The 10 most frequently identified topics were communication, time management, attitudes to the elderly, medication, continuity of care, mental health, medical management of complicated cases, knowledge of community resources, health promotion, and compassion. Patients were more concerned than key informants about the process of care. Key informants were concerned about the technical aspects of care.

CONCLUSIONS

The process of care as well as technical aspects of care must be addressed in continuing education in geriatrics for physicians.

Alveolar septal structure in different species

Because the retractive forces due to surface tension decrease with increasing radius of curvature, there should be a greater contribution to lung recoil attributable to the stress-bearing role of elastic elements in the lung parenchyma of species with larger alveoli. To examine alterations in lung structure that may relate to this stress-bearing role, the lungs of mice, hamsters, rats, rabbits, rhesus monkeys, baboons, and humans were preserved by vascular perfusion of fixative. The number of alveoli per lung, alveolar radius of curvature, surface area, and volume were measured by serial section reconstruction. Electron-microscopic determinations were made of the volume fraction and thickness of the epithelium, interstitium, and endothelium and of the connective tissue fibers of the alveolar septa and the portions of alveolar septa that form the alveolar ducts. The thickness of the alveolar septal interstitium increased linearly with the increase in radius of curvature of alveoli. The increase in interstitial thickness in lungs with larger alveoli was paralleled by large increases in the volume of collagen and elastin fibers present in this space. Comparable changes in the thickness of connective tissue fibers in alveolar duct walls were also found. This study demonstrates species-related changes in the structure of alveolar septa and in lung collagen and elastin fibers that are consistent with connective tissue fibers having a greater stress-bearing role in both the alveolar septa and alveolar ducts of species with larger alveoli.

Cell number and distribution in human and rat airways

Morphometric procedures were used to determine the number of cells, cell volume, cell diameter, and surface areas of the airways in human and rat lungs. Nuclear sizes of epithelial cells from human bronchi were significantly larger than other lung cell nuclei. The average volume of human ciliated cell nuclei was 310 +/- 30 microns 3 and 167 +/- 12 microns 3 in bronchi and bronchioles, respectively. The smaller nuclei of human bronchioles were comparable to those of alveolar cells. In the pseudostratified epithelium of human bronchi, basal cells had a large surface area in contact with the basement membrane (51.3 +/- 4.6 microns 2 per cell) when compared with ciliated (1.1 +/- 0.1 microns 2), goblet (7.6 +/- 1.2 microns 2), or other secretory cells (12.0 +/- 2.1 microns 2). In the first four airway generations distal to the trachea, basal cells account for 30% of the cells in human airway epithelium and 2% of the cells in rat airway epithelium. Total airway surface area from trachea to bronchioles was 2,471 +/- 320 and 27.2 +/- 1.7 cm2 in human and rat lungs, respectively. These direct measurements of airway surface area are less than half of the estimates based on current lung models. The total number of airway epithelial cells were 10.5 x 10(9) for human and 0.05 x 10(9) for rat lungs. For both species, there were 18 times more alveolar cells than bronchial epithelial cells.

Pelvic inflammatory disease: cumulative incidence in primary care

The cumulative incidence of pelvic inflammatory disease (PID) among 2749 women aged 14-50 making contraception-related visits to 186 randomly selected Calgary family physicians participating in a 1986-1987 cross-sectional survey of physician attitudes and contraceptive prescribing was estimated to be 6.5%. For 10 consecutive working days after the doctors were interviewed, they completed a one-page checklist on every woman making a visit in which contraception was discussed beyond taking a history, including visits where the topic was opened by either the doctor or the patient, or where symptoms were suspected to be related to the use of contraception. Contraception-related visits accounted for 34.7% of all visits to the physicians by women aged 14-50. No definition of PID was provided to the physicians. The history of PID could have been elicited from the patient given or documented by the physician, or diagnosed at the time of the visit. A history of PID was more common among smokers than nonsmokers (11.0% vs 4.3%), and parous than nonparous women (8.8% vs 4.4%). Among women of Caucasian race/ethnicity, 6.2% vs 9.1% of women of other ethnicities had a history of PID. A larger proportion of low income than high income women (8.0% vs 5.3%) had a history of PID. The proportions of women with a PID history did not vary with marital status or age. The estimated 6.5% cumulative incidence is probably an underestimation of the true rate.