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1.  The Founding of a Medical Service Bureau in King County, Washington, 1933 
Western Journal of Medicine  1976;124(1):67-69.
The events leading to the establishment of the King County Medical Service Corporation, now King County Medical-Blue Shield, were varied and complex. Under pressure, the King County Medical Society redefined its code of ethics, expanded its view of acceptable practice and gave birth to a major provider of prepaid health care services.
PMCID: PMC1129988  PMID: 766413
2.  Health sciences library building projects: 1994 survey. 
Designing and building new or renovated space is time consuming and requires politically sensitive discussions concerning a number of both long-term and immediate planning issues. The Medical Library Association's fourth annual survey of library building projects identified ten health sciences libraries that are planning, expanding, or constructing new facilities. Two projects are in predesign stages, four represent new construction, and four involve renovations to existing libraries. The Texas Medical Association Library, the King Faisal Specialist Hospital and Research Centre Library, and the Northwestern University Galter Health Sciences Library illustrate how these libraries are being designed for the future and take into account areas of change produced by new information technologies, curricular trends, and new ways to deliver library services.
Images
PMCID: PMC226028  PMID: 7599586
3.  Scope of resident ophthalmology consultation service and patient follow-up rates at a level 1 trauma center in Brooklyn, New York 
Background
The purpose of this study was to investigate the most common reasons for urgent ophthalmology consultations in both the emergency room and inpatient settings at a large public hospital served by a busy ophthalmology residency program, and to track patient follow-up rates.
Methods
We reviewed the medical records of all patients evaluated by the ophthalmology consultation service at Kings County Hospital Center from June 2003 to October 2005 using a retrospective hospital-based study design. We categorized emergency room patients and inpatients into traumatic and nontraumatic subgroups, and looked at diagnoses and patient demographics, as well as follow-up patterns for emergency room consultations.
Results
In total, 743 patients were evaluated; 436 (59%) were emergency room patients and 307 (41%) were inpatients. Consultation for traumatic eye injury was provided for 399 patients (54%), accounting for 284 (65%) of the emergency room consults and 115 (37.5%) of the inpatient consults. The most common reason for inpatient consultation was to rule out ocular manifestations of systemic disease (57 patients, 29.7%), while the most common final diagnosis for trauma inpatient consultation was orbital wall fracture (59 patients, 51.3%). In total, 262 patients (60%) in the emergency room consultation group returned for follow-up care; 162 (57%) of the trauma patients followed up and 100 (66%) of the nontrauma patients followed up.
Conclusion
This study provides a comprehensive analysis of the eye conditions and follow-up rates evaluated by the ophthalmology service at Kings County Hospital Center. By evaluating the follow-up patterns of these patients, we may be able to alter patient counseling to increase patient compliance.
doi:10.2147/OPTH.S43345
PMCID: PMC3617788  PMID: 23576862
ophthalmology; residency program; urgent consultation; inpatients; outpatients; follow-up
4.  Trauma among American Indians in an urban county. 
Public Health Reports  1996;111(4):321-327.
OBJECTIVE. To describe severe injury among American Indians in a large metropolitan county given that most previous studies of the high Indian injury morbidity and mortality rates have been conducted primarily in rural areas. METHODS. A retrospective analysis of a hospital trauma registry was conducted for the years 1986-92 at the Harborview Medical Center, the only Level I trauma center in King County, Washington, metropolitan county with the seventh largest number of urban American Indians in the United States. RESULTS. Of 14,851 King County residents included in the registry, 593 (4%) were classified as American Indian. With King County whites as the reference, the age-standardized incidence ratio for inclusion of American Indians in the registry was 4.4 (95% confidence interval 4.1, 4.8). The standardized incidence ratios and proportional incidence ratios showed significant differences in mechanism and whether it was intentional or unintentional among Indians compared with whites. Hospitalizations for stab wounds, bites, and other blunt trauma were all significantly more frequent among Indians. Trauma admissions among Indians were disproportionately associated with assaults. A high proportion (72.3%) of American Indians tested had blood alcohol levels exceeding 0.1%. CONCLUSION. Urban American Indians experience high rates of trauma, differing from those among whites. Efforts to reduce injury in urban areas should include collaboration with representative urban American Indian organizations.
PMCID: PMC1381875  PMID: 8711098
5.  Use of Rapid Genomic Deletion Typing To Monitor a Tuberculosis Outbreak within an Urban Homeless Population 
Journal of Clinical Microbiology  2005;43(11):5550-5554.
Beginning in mid-2002, a large tuberculosis outbreak occurred among homeless persons in King County, Washington. In order to further monitor the outbreak following its peak in 2003, Mycobacterium tuberculosis isolates from all new King County tuberculosis (TB) patients in 2004 and the first half of 2005 (n = 220) were genotyped by using a rapid comparative genomics-based (genomic deletion-typing) approach, with confirmation by mycobacterial interspersed repetitive units and repetitive-sequence-based PCR (rep-PCR). Results were compared to retrospective genotypic data from 1995 to 2003. The outbreak strain SBRI9, which was not seen among King County homeless persons prior to 2002, accounted for 16 out of 30 TB cases (53%) within this population in 2002. This trend continued with 27 out of 35 cases (77%) caused by the outbreak strain in 2003, 11 out of 13 cases (85%) caused by the outbreak strain in 2004, and 4 out of 10 cases (40%) caused by the outbreak strain in the first 5 months of 2005. Thus, the outbreak strain remained well established within this homeless population throughout the study period. At least four SBRI9 cases were in people who had previously been infected by other strains. The novel PCR-based strain-typing approach used in this investigation proved to be cost-effective and very rapid. In most cases, it was possible to analyze DNA extracted directly from primary isolation (Mycobacterium growth indicator tube) cultures submitted by clinical laboratories, a feature that markedly reduced the delay between diagnosis and strain typing results. This rapid turnaround facilitated public health efforts to prevent new outbreaks involving this strain.
doi:10.1128/JCM.43.11.5550-5554.2005
PMCID: PMC1287805  PMID: 16272485
6.  Asthma and the home environment of low-income urban children: Preliminary findings from the seattle-king county healthy homes project 
Objectives
Childhood asthma is a growing public health concern in low-income urban communities. Indoor exposure to asthma triggers has emerged as an important cause of asthma exacerbations. We describe indoor environmental conditions related to asthma triggers among a low-income urban population in Seattle/King County, Washington, as well as caregiver knowledge and resources related to control of these triggers.
Methods
Data are obtained from in-person, structured, closed-end interviews with the caretakers of children aged 4–12 years with persistent asthma living in households with incomes less than 200% of poverty. Additional information is collected during a home inspection. The children and their caregivers are participants in the ongoing Seattle-King County Healthy Homes Project, a randomized controlled trial of an intervention to empower low-income families to reduce exposure to indoor asthma triggers. We report findings on the conditions of the homes prior to this intervention among the first 112 enrolled households.
Results
A smoker was present in 37.5% of homes. Mold was visible in 26.8% of homes, water damage was present in 18.6% of homes, and damp conditions occurred in 64.8% of households, while 39.6% of caregivers were aware that excessive moisture can increase exposures to allergens. Dust-trapping reservoirs were common; 76.8% of children's bedrooms had carpeting. Cockroach infestation in the past 3 months was reported by 23.4% of caregivers, while 57.1% were unaware of the association of roaches and asthma. Only 19.8% of the children had allergy-control mattress covers.
Conclusions
Many low-income urban children with asthma in King County live in indoor environments that place them at substantial risk of ongoing exposure to asthma triggers. Substandard housing and lack of resources often underlie these exposures. Initiatives involving health educators, outreach workers, medical providers, health care insurers, housing agencies, and elected officials are needed to reduce these exposures.
doi:10.1007/BF02350962
PMCID: PMC3456608  PMID: 10741842
Asthma; Child; Indoor Air Pollution; Indoor Environment; Knowledge/Behaviors; Low-Income Populations
7.  Nutrition-Labeling Regulation Impacts on Restaurant Environments 
Background
Recent attempts to improve the healthfulness of away-from-home eating include regulations requiring restaurants to post nutrition information. The impact of such regulations on restaurant environments is unknown.
Purpose
To examine changes in restaurant environments from before to after nutrition-labeling regulation in a newly regulated county versus a nonregulated county.
Methods
Using the Nutrition Environment Measures Surveys–Restaurant version audit, environments within the same quick-service chain restaurants were evaluated in King County (regulated) before and 6 and 18 months after regulation enforcement and in Multnomah County (nonregulated) restaurants over a 6-month period. Data were collected in 2008–2010 and analyses conducted in 2011.
Results
Overall availability of healthy options and facilitation of healthy eating did not differentially increase in King County versus Multnomah County restaurants aside from the substantial increase in onsite nutrition information posting in King County restaurants required by the new regulation. Barriers to healthful eating decreased in King County relative to Multnomah County restaurants, particularly in food-oriented establishments. King County restaurants demonstrated modest increases in signage that promotes healthy eating, although the frequency of such promotion remained low, and the availability of reduced portions decreased in these restaurants. The healthfulness of children’s menus improved modestly over time, but not differentially by county.
Conclusions
A restaurant nutrition-labeling regulation was accompanied by some, but not uniform, improvements in other aspects of restaurant environments in the regulated compared to the nonregulated county. Additional opportunities exist for improving the healthfulness of awayfrom- home eating beyond menu labeling.
doi:10.1016/j.amepre.2012.07.025
PMCID: PMC3479434  PMID: 23079173
8.  Shut out of medicine in Canada, Dr. Leonora Howard King blazed a trail in China. 
After being denied the opportunity to study medicine and work at home, Dr. Leonora Howard King became Canada's first female medical missionary to China. Although she attempted to wear both the religious and secular hats handed her by the Women's Foreign Missionary Society, Howard King found that she was too busy meeting the medical needs of destitute women and children to proselytize. She won the favour of Chinese royalty, and after treating hundreds of wounded soldiers during the 1894-95 war with Japan became the first Western woman to become a mandarin, an honour bestowed by her adopted country.
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PMCID: PMC1335511  PMID: 8976342
9.  The story of the condom 
Condoms have been a subject of curiosity throughout history. The idea of safer sex has been explored in ancient and modern history, and has been used to prevent venereal diseases. We conducted a historical and medical review of condoms using primary and secondary sources as well as using the RSM library and the internet. These resources show that the first use of a condom was that of King Minos of Crete. Pasiphae, his wife, employed a goat's bladder in the vagina so that King Minos would not be able to harm her as his semen was said to contain “scorpions and serpents” that killed his mistresses. To Egyptians, condom-like glans caps were dyed in different colours to distinguish between different classes of people and to protect themselves against bilharzia. The Ancient Romans used the bladders of animals to protect the woman; they were worn not to prevent pregnancy but to prevent contraction of venereal diseases. Charles Goodyear, the inventor, utilized vulcanization, the process of transforming rubber into malleable structures, to produce latex condoms. The greater use of condoms all over the world in the 20th and 21st centuries has been related to HIV. This account of the use of condoms demonstrates how a primitive idea turned into an object that is used globally with a forecast estimated at 18 billion condoms to be used in 2015 alone.
doi:10.4103/0970-1591.109976
PMCID: PMC3649591  PMID: 23671357
Bilharzia; condom; Fromm; Kabuta-Gata; Minos; vulcanization
10.  Injuries and their relation to potential hazards in child day care. 
Injury Prevention  1996;2(2):105-108.
OBJECTIVES: To prospectively determine the incidence rate of injuries that required medical attention among children in day care and to identify possible hazards related to these injuries. SETTING: King County, Washington. METHODS: Prospective cohort study of children in a sample of licensed day care facilities. RESULTS: From 1 July 1992 to 30 June 1993, 53 medically attended injuries were reported by 133 day care sites; incidence rate 1.9 per 100,000 hours of day care attendance. The rate of injury in 91 small family day care homes was essentially the same as that in 42 larger day care centers; relative rate 1.0 (95% confidence interval 0.6 to 1.9). Injuries that required sutures accounted for 39% of the cases, while 17% required a cast, splint, or sling. No child was hospitalized. Sixty nine sites were inspected and all had potentially correctable physical hazards, with a median of 15 hazards per site (range 7 to 26). These potential hazards had little relationship to the risk of injury and a case-by-case review identified only two injuries that might have been prevented by a more energy absorbent playground surface. CONCLUSIONS: The incidence of medically attended injuries found in this study is consistent with other studies from the United States. Most injuries were minor and had little relation to physical hazards at day care locations.
PMCID: PMC1067670  PMID: 9346070
11.  GRATEFUL MED-LOANSOME DOC outreach project in central Pennsylvania. 
The Geisinger Medical Center Library implemented a GRATEFUL MED outreach project in rural north-central Pennsylvania directed at providing physicians access to current medical literature. A total of 1,327 physicians affiliated with twenty-three hospitals practice in a thirteen-county area the size of the state of New Jersey. Of these hospitals, only four have hospital libraries, which vary in size and in staff abilities to meet the information needs of their affiliated physicians. The outreach project encompassed two stages--demonstrations of GRATEFUL MED and LOANSOME DOC at county medical society or hospital meetings, and installation and training in individual offices. The eighteen-month project ended in March 1992. Statistics were collected for the number of GRATEFUL MED software packages loaded (sixty-two), the number of document delivery items supplied by Geisinger Medical Center Library to project participants (367), and the number of physicians attending introductory demonstrations or follow-up training programs (455 at sixty-eight sessions). By the end of the project, 147 (32%) of those who had attended a seminar had access to GRATEFUL MED.
PMCID: PMC225899  PMID: 8004026
12.  Arterial roads and area socioeconomic status are predictors of fast food restaurant density in King County, WA 
Background
Fast food restaurants reportedly target specific populations by locating in lower-income and in minority neighborhoods. Physical proximity to fast food restaurants has been associated with higher obesity rates.
Objective
To examine possible associations, at the census tract level, between area demographics, arterial road density, and fast food restaurant density in King County, WA, USA.
Methods
Data on median household incomes, property values, and race/ethnicity were obtained from King County and from US Census data. Fast food restaurant addresses were obtained from Public Health-Seattle & King County and were geocoded. Fast food density was expressed per tract unit area and per capita. Arterial road density was a measure of vehicular and pedestrian access. Multivariate logistic regression models containing both socioeconomic status and road density were used in data analyses.
Results
Over one half (53.1%) of King County census tracts had at least one fast food restaurant. Mean network distance from dwelling units to a fast food restaurant countywide was 1.40 km, and 1.07 km for census tracts containing at least one fast food restaurant. Fast food restaurant density was significantly associated in regression models with low median household income (p < 0.001) and high arterial road density (p < 0.001) but not with percent of residents who were nonwhite.
Conclusion
No significant association was observed between census tract minority status and fast food density in King County. Although restaurant density was linked to low household incomes, that effect was attenuated by arterial road density. Fast food restaurants in King County are more likely to be located in lower income neighborhoods and higher traffic areas.
doi:10.1186/1479-5868-6-46
PMCID: PMC2724491  PMID: 19630979
13.  A pilot study of the King LT supralaryngeal airway use in a rural Iowa EMS system 
Introduction
In 2003, the King Laryngeal Tube (LT) received FDA approval for US sales. Prehospital systems in urban setting have begun evaluating and adopting the LT for clinical airway management. However, it is not routinely approved by State EMS Boards for use by all prehospital providers. Given the LT’s simple design there may be benefit to using this tool for airway management in all levels of prehospital providers. This pilot study reviews cases where the King LT was used in a rural Iowa county EMS system.
Methods
In 2006, the Iowa Department of Public Health / Bureau of EMS approved a 12 month pilot evaluating the King LT by all levels of EMS providers in a rural county EMS system. Following a didactic and competency training session on using the King LT, the providers were instructed to continue airway management per usual protocol but were allowed to use the King LT as a first line airway tool if they felt indicated. Successful placement of airway devices used were determined by colourimetric end-tidal CO2, chest auscultation and rise as well as vital sign and skin colour improvement. Review of the data was approved by the University of Iowa Institution Review Board (IRB).
Results
During the 12-month pilot period, the King LT was used in 13 patients with a mean age of 60.7 years (24–81). All patients had cardiopulmonary or traumatic arrest. The King LT was successfully placed on the first attempt in all but one case. The King LT was placed following endotracheal intubation failure in 6/13 (46.1%) cases and in 3/13 (23.1%) of cases of Combitube attempt / failure.
Conclusions
This small pilot project emphasizes the need for additional rapid airway management tools given the demonstrated ETI failures. The authors believe the King LT has significant potential to impact prehospital airway management as a primary airway device or backup to other failed strategies. Further study is necessary to evaluate the LT’s efficacy compared to current strategies.
doi:10.1007/s12245-008-0023-5
PMCID: PMC2657251  PMID: 19384666
Prehospital; Airway
14.  The role of the academic medical center library in training public librarians*† 
Purpose: This project enhanced access to and awareness of health information resources on the part of public libraries in western Pennsylvania.
Setting/Participants/Resources: The Health Sciences Library System (HSLS), University of Pittsburgh, conducted a needs assessment and offered a series of workshops to 298 public librarians.
Brief Description: The National Library of Medicine–funded project “Access to Electronic Health Information” at the HSLS, University of Pittsburgh, provided Internet health information training to public libraries and librarians in sixteen counties in western Pennsylvania. Through this project, this academic medical center library identified the challenges for public librarians in providing health-related reference service, developed a training program to address those challenges, and evaluated the impact of this training on public librarians' ability to provide health information.
Results/Outcome: The HSLS experience indicates academic medical center libraries can have a positive impact on their communities by providing health information instruction to public librarians. The success of this project—demonstrated by the number of participants, positive course evaluations, increased comfort level with health-related reference questions, and increased use of MEDLINEplus and other quality information resources—has been a catalyst for continuation of this programming, not only for public librarians but also for the public in general.
Evaluation Method: A training needs assessment, course evaluation, and impact training survey were used in developing the curriculum and evaluating the impact of this training on public librarians' professional activities.
PMCID: PMC164399  PMID: 12883558
15.  Feasibility of Partnering with Emergency Medical Services to Identify People at Risk for Uncontrolled High Blood Pressure 
Introduction
Uncontrolled high blood pressure (HBP) is a significant health problem and often goes undetected. In the prehospital care-delivery system of 9-1-1 emergency medical services (EMS) calls, emergency medical technicians (EMTs) routinely collect medical information, including blood pressure values, that may indicate the presence of chronic disease. This information is usually archived without any further follow-up. We conducted several planning activities during the fall of 2006 to determine if a partnership between researchers at the Health Marketing Research Center at the University of Washington, Public Health Seattle King County EMS division, and several large fire departments could be developed to help identify community residents with uncontrolled HBP and determine the most effective way to communicate HBP information to them.
Methods
We partnered with 4 King County, Washington, fire departments that provide 9-1-1 EMS to develop an intervention for people with uncontrolled HBP who were attended by EMTs in response to a 9-1-1 call for assistance. On the basis of discussions with EMS personnel at all levels, we developed a system by which we could identify at-risk community residents by using medical incident report forms that EMS personnel completed; we consulted with EMS personnel to determine the most effective means of reaching these people. In addition we developed a survey to assess community residents' beliefs about blood pressure control, the role of EMTs as health care providers, and the convenience of fire stations as places to have blood pressure checked. Using contact information that EMS personnel obtained, we surveyed 282 community residents from a total of 794 people whom EMTs had identified as at risk for uncontrolled HBP to help us understand our target audience.
Results
In consultation with EMS personnel, we determined that direct mail was the most effective way to reach people with uncontrolled HBP identified from EMS records to advise them of their risk. On the basis of the number with a known response to each question, 67% (n = 180/269) of the respondents reported that a doctor or other health professional had told them they had HBP, 95% (246/259) believed that regular screening for HBP was important, 65% (166/254) said that EMTs were highly credible health care providers, and 82% (136/165) said that they would feel comfortable receiving blood pressure screening at a local fire station.
Conclusion
Partnering with local EMS may be an effective way to identify and reach community residents with uncontrolled HBP with information on their medical condition and to encourage them to have follow-up screening.
PMCID: PMC3340291  PMID: 22300868
16.  Factors Associated With the Adoption of a Patient Education Intervention Among First Responders, King County, Washington, 2010–2011 
Introduction
This study investigated facilitators and barriers to adoption of an at-scene patient education program by firefighter emergency medical technicians (EMTs) in King County, Washington.
Methods
We consulted providers of emergency medical services (EMS) to develop a patient education pamphlet in the form of a tear-off sheet that could be attached to the EMT medical incident report. The pamphlet included resources for at-scene patient education on high blood pressure, blood glucose, falls, and social services. The program was launched in 29 fire departments in King County, Washington, on January 1, 2010, and a formal evaluation was conducted in late 2011. We developed a survey based on diffusion theory to assess 1) awareness of the pamphlet, 2) evaluation of the pamphlet attributes, 3) encouragement by peers and superiors for handing out the pamphlet, 4) perceived behavioral norms, and 5) demographic variables associated with self-reported adoption of the at-scene patient education program. The survey was completed by 822 (40.1%) of 2,047 firefighter emergency medical technicians. We conducted bivariate and multivariable analyses to assess associations between independent variables and self-reported adoption of the program.
Results
Adoption of the at-scene patient education intervention was significantly associated with positive evaluation of the pamphlet, encouragement from peers and superiors, and perceived behavioral norms. EMS providers reported they were most likely to hand out the pamphlet to patients in private residences who were treated and left at the scene.
Conclusion
Attributes of chronic disease prevention programs and encouragement from peers and supervisors are necessary in diffusion of patient education interventions in the prehospital care setting.
doi:10.5888/pcd11.130221
PMCID: PMC3917608  PMID: 24480631
17.  MED14/381: A New Internet Service for a Medical Society and Library (Billrothhaus) in Vienna 
Since 1997, the "Gesellschaft der Ärzte in Wien", the oldest medical society in Austria, has been using the possibilities of the Internet to improve the communication with its members. It developed a modern dynamic Web site with different kinds of services: Having one of the largest medical libraries in Austria, it offers remote access to medical databases, full text electronic journals, medical news services like Reuters Medical News and has established a document supply service. Being one of Austria's most traditional platforms where latest developments in medicine are being presented on a very high scientific level, the Internet activities of the society also focus on web-casting projects including live-broadcasting of lectures held in the society as well as on-demand services of these lectures. The modern technological infrastructure built up in the last two years also enables the society to act as an Internet Service Provider for its members and for other medical societies, offering them useful services like unlimited Internet access, Email-accounts, Web space for homepages, virtual servers or server housing. By organising Internet -Workshops for physicians, the society tries to train them how to communicate over the Internet and how to use databases, electronic journals or how to follow online-presentations of congresses and lectures. This paper intends to outline these new possibilities by referring to the Web site of the "Gesellschaft der Ärzte in Wien", making evident how the Internet changes the way medical societies can communicate with their members.
doi:10.2196/jmir.1.suppl1.e57
PMCID: PMC1761839
Medical Informatics Applications; Information Systems; Online Systems; Databases
18.  Medical Image Resource Center 2002: An Update on the RSNA's Medical Image Resource Center 
Journal of Digital Imaging  2002;15(1):2-4.
The Radiological Society of North America has launched a project called the Medical Image Resource Center (MIRC) to establish a community of Webbased libraries of imaging information, including teaching files, other educational materials, and research data. This system would enable radiologic professionals to create and publish such materials more easily and to gain more convenient access to new and existing materials. An overview of the project, a brief summary of the overall requirements and objectives, and a brief description of the progress and ongoing plans for MIRC are presented.
doi:10.1007/s10278-002-1000-9
PMCID: PMC3946082  PMID: 12134208
19.  The geographic distribution of obesity by census tract among 59 767 insured adults in King County, WA 
Objective
To evaluate the geographic concentration of adult obesity prevalence by census tract (CT) in King County, WA, in relation to social and economic factors.
Methods and Design
Measured heights and weights from 59 767 adult men and women enrolled in the Group Health (GH) health care system were used to estimate obesity prevalence at the CT level. CT-level measures of socioeconomic status (SES) were median home values of owner-occupied housing units, percent of residents with a college degree, and median household incomes, all drawn from the 2000 Census. Spatial regression models were used to assess the relation between CT-level obesity prevalence and socio-economic variables.
Results
Smoothed CT obesity prevalence, obtained using an Empirical Bayes tool, ranged from 16.2% to 43.7% (a 2.7-fold difference). The spatial pattern of obesity was non-random, showing a concentration in south and southeast King County. In spatial regression models, CT-level home values and college education were more strongly associated with obesity than household incomes. For each additional $100 000 in median home values, CT obesity prevalence was 2.3% lower. The three SES factors together explained 70% of the variance in CT obesity prevalence after accounting for population density, race/ethnicity, age and spatial dependence.
Conclusions
To our knowledge, this is the first report to show major social disparities in adult obesity prevalence at the CT scale that is based, moreover, on measured heights and weights. Analyses of data at sufficiently fine geographic scale are needed to guide targeted local interventions to stem the obesity epidemic.
doi:10.1038/ijo.2013.179
PMCID: PMC3955743  PMID: 24037278
obesity; health status disparities; geography; socioeconomic factors; cross-sectional studies
20.  “A Good Personal Scientific Relationship”: Philip Morris Scientists and the Chulabhorn Research Institute, Bangkok 
PLoS Medicine  2008;5(12):e238.
Background
This paper examines the efforts of consultants affiliated with Philip Morris (PM), the world's leading transnational tobacco corporation, to influence scientific research and training in Thailand via the Chulabhorn Research Institute (CRI). A leading Southeast Asian institute for environmental health science, the CRI is headed by Professor Dr. Her Royal Highness Princess Chulabhorn, the daughter of the King of Thailand, and it has assumed international significance via its designation as a World Health Organization (WHO) Collaborating Centre in December 2005.
Methods and Findings
This paper analyses previously confidential tobacco industry documents that were made publicly available following litigation in the United States. PM documents reveal that ostensibly independent overseas scientists, now identified as industry consultants, were able to gain access to the Thai scientific community. Most significantly, PM scientist Roger Walk has established close connections with the CRI. Documents indicate that Walk was able to use such links to influence the study and teaching of environmental toxicology in the institute and to develop relations with key officials and local scientists so as to advance the interests of PM within Thailand and across Asia. While sensitivities surrounding royal patronage of the CRI make public criticism extremely difficult, indications of ongoing involvement by tobacco industry consultants suggest the need for detailed scrutiny of such relationships.
Conclusions
The establishment of close links with the CRI advances industry strategies to influence scientific research and debate around tobacco and health, particularly regarding secondhand smoke, to link with academic institutions, and to build relationships with national elites. Such strategies assume particular significance in the national and regional contexts presented here amid the globalisation of the tobacco pandemic. From an international perspective, particular concern is raised by the CRI's recently awarded status as a WHO Collaborating Centre. Since the network of WHO Collaborating Centres rests on the principle of “using national institutions for international purposes,” the documents presented below suggest that more rigorous safeguards are required to ensure that such use advances public health goals rather than the objectives of transnational corporations.
Jeff Collin and Ross MacKenzie analyze tobacco industry documents and find that Philip Morris consultants were able to gain access to a Thai research institute that is a WHO Collaborating Centre.
Editors' Summary
Background.
Tobacco use kills 5.4 million people a year (one person every six seconds) and accounts for one in ten adult deaths worldwide. Globally, the use of tobacco is on the rise, especially in developing countries, which have become a major target for tobacco industry marketing. The tobacco industry has worked hard to try and influence public perceptions about the risks of smoking and the risk of inhaling secondhand smoke (passive smoking). The industry has used a variety of tactics to downplay the health hazards of smoking or inhaling secondhand smoke—two examples are publishing articles casting doubts about the health hazards of tobacco and funding research that is biased toward giving pro-industry results. Another tactic is for tobacco industry consultants to try and gain entry to universities and other academic centers to see if they can influence research and teaching activities.
Why Was This Study Done?
The researchers were concerned that consultants from the tobacco company Philip Morris had gained access to an academic research center in Thailand called the Chulabhorn Research Institute (CRI). The CRI is an internationally renowned teaching institution for a variety of scientific disciplines, including environmental toxicology (the study of how chemicals in the environment, such as tobacco smoke, can affect human health), biomedicine, and biotechnology. The institute has secured funding from the Thai government, the Association of Southeast Nations and the United Nations Development Programme. In 2005 the institute's environmental toxicology unit was designated a World Health Organization (WHO) Collaborating Centre. WHO Collaborating Centres are “institutions such as research institutes, parts of universities or academies, that are designated by the Director-General of the WHO to carry out activities in support of the WHO's programs” (http://www.who.int/collaboratingcentres/en/). The researchers were concerned that Philip Morris consultants had been able to develop relationships with the CRI to help advance the company's interests.
What Did the Researchers Do and Find?
The researchers analyzed previously confidential tobacco industry documents that were made publicly available online following litigation in the United States. They searched two online collections of industry documents—the Legacy Tobacco Documents Library and Tobacco Documents Online—as well as the online collections operated by US-based tobacco companies. They found that consultants to Philip Morris were able to gain access to the scientific community in Thailand. A Philip Morris scientist named Roger Walk was able to establish close connections to the CRI, and he used these connections to influence research and teaching activities at the CRI on environmental toxicology. Walk was also able to build relationships with government officials and scientists in Thailand to help advance the interests of Philip Morris in the country and across Asia.
What Do these Findings Mean?
This study provides evidence that the tobacco industry has established close links with a research institute in Thailand that collaborates with the WHO, and has been able to influence the institute's teaching curriculum and research. Such links are of great concern to the public health community, which is working hard to reduce deaths and disease due to tobacco. These links raise the possibility that the tobacco industry is managing to influence medical research and teaching at academic institutions. The WHO has stated that a firewall is in place between itself and the tobacco industry—but the study authors argue, based on their findings, that “this firewall is not impenetrable.” The study findings, they conclude, highlight a challenge posed to international tobacco control efforts, especially with respect to Article 5.3 of an international treaty called the WHO Framework Convention on Tobacco Control; Article 5.3 addresses the need to protect public health policies from the vested interests of the tobacco industry. The authors say that better safeguards must be put in place to prevent tobacco companies from thwarting public health goals.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050238.
The Legacy Tobacco Documents Library contains over 9.7 million documents created by tobacco companies
Tobacco Documents Online contains over 4 million tobacco industry documents
Over 900 WHO Collaborating Centres are at work in 99 Member States on many health disciplines
The WHO held an inquiry in 2000 into possible tobacco industry influence over the organization (and over other UN agencies), and has published its recommendations in response to this inquiry
The WHO Framework Convention on Tobacco Control is an international treaty on controlling tobacco
doi:10.1371/journal.pmed.0050238
PMCID: PMC2605886  PMID: 19108600
21.  Prediction of Critical Illness During Out-of-Hospital Emergency Care 
Context
Early identification of nontrauma patients in need of critical care services in the emergency setting may improve triage decisions and facilitate regionalization of critical care.
Objectives
To determine the out-of-hospital clinical predictors of critical illness and to characterize the performance of a simple score for out-of-hospital prediction of development of critical illness during hospitalization.
Design and Setting
Population-based cohort study of an emergency medical services (EMS) system in greater King County, Washington (excluding metropolitan Seattle), that transports to 16 receiving facilities.
Patients
Nontrauma, non–cardiac arrest adult patients transported to a hospital by King County EMS from 2002 through 2006. Eligible records with complete data (N=144 913) were linked to hospital discharge data and randomly split into development (n=87 266 [60%]) and validation (n=57 647 [40%]) cohorts.
Main Outcome Measure
Development of critical illness, defined as severe sepsis, delivery of mechanical ventilation, or death during hospitalization.
Results
Critical illness occurred during hospitalization in 5% of the development (n=4835) and validation (n=3121) cohorts. Multivariable predictors of critical illness included older age, lower systolic blood pressure, abnormal respiratory rate, lower Glasgow Coma Scale score, lower pulse oximetry, and nursing home residence during out-of-hospital care (P<.01 for all). When applying a summary critical illness prediction score to the validation cohort (range, 0-8), the area under the receiver operating characteristic curve was 0.77 (95% confidence interval [CI], 0.76-0.78), with satisfactory calibration slope (1.0). Using a score threshold of 4 or higher, sensitivity was 0.22 (95% CI, 0.20-0.23), specificity was 0.98 (95% CI, 0.98-0.98), positive likelihood ratio was 9.8 (95% CI, 8.9-10.6), and negative likelihood ratio was 0.80 (95% CI, 0.79-0.82). A threshold of 1 or greater for critical illness improved sensitivity (0.98; 95% CI, 0.97-0.98) but reduced specificity (0.17; 95% CI, 0.17-0.17).
Conclusions
In a population-based cohort, the score on a prediction rule using out-of-hospital factors was significantly associated with the development of critical illness during hospitalization. This score requires external validation in an independent population.
doi:10.1001/jama.2010.1140
PMCID: PMC3949007  PMID: 20716737
22.  Analysis of fatal pedestrian injuries in King County, WA, and prospects for prevention. 
Public Health Reports  1989;104(3):293-297.
Pedestrian fatalities caused by motor vehicles in King County, WA, over a 12-month period were reviewed to examine the potential for prevention by various strategies. Cases were identified through the King County Medical Examiner's Office. Between April 1, 1985, and March 31, 1986, a total of 38 pedestrians died of motor vehicle injuries. The victims were generally children (N = 11), the elderly (N = 13), or intoxicated adults (N = 9). Supervision of the child was inadequate in 64 percent of the children's deaths. The driver was at fault in deaths of seven children, five adults, and three elderly persons. None of the children and only one of the elderly victims was injured at night. The majority of injuries occurred on major thorough-fares; only 16 percent occurred on residential streets. Possible strategies for prevention appear to include improved enforcement of pedestrian right-of-way laws, changes in vehicle design, modification of the environment (particularly in urban areas), and improved training programs for children.
PMCID: PMC1579918  PMID: 2498980
23.  Effect of Intensive Care Unit Organizational Model and Structure on Outcomes in Patients with Acute Lung Injury 
Rationale: Prior studies supported an association between intensive care unit (ICU) organizational model or staffing patterns and outcome in critically ill patients.
Objectives: To examine the association of closed versus open models with patient mortality across adult ICUs in King County (WA).
Methods: Cohort study of patients with acute lung injury (ALI).
Measurements and Main Results: ICU structure, organization, and patient care practices were assessed using self-administered mail questionnaires completed by the medical director and nurse manager. We defined closed ICUs as units that required patient transfer to or mandatory patient comanagement by an intensivist and open ICUs as those relying on other organizational models. Outcomes were obtained from the King County Lung Injury Project, a population-based cohort of patients with ALI. The main endpoint was hospital mortality. Of 24 eligible ICUs, 13 ICUs were designated closed and 11 open. Complete survey data were available for 23 (96%) ICUs. Higher physician and nurse availability was reported in closed versus open ICUs. A total of 684 of 1,075 (63%) of patients with ALI were cared for in closed ICUs. After adjusting for potential confounders, patients with ALI cared for in closed ICUs had reduced hospital mortality (adjusted odds ratio, 0.68; 95% confidence interval, 0.53, 0.89; P = 0.004). Consultation by a pulmonologist in open ICUs was not associated with improved mortality (adjusted odds ratio, 0.94; 95% confidence interval, 0.74, 1.20; P = 0.62). These findings were robust for varying assumptions about the study population definition.
Conclusions: Patients with ALI cared for in a closed-model ICU have reduced mortality. These data support recommendations to implement structured intensive care in the United States.
doi:10.1164/rccm.200701-165OC
PMCID: PMC1994237  PMID: 17556721
intensive care unit; intensivist; outcome; practice patterns; Leapfrog Group
24.  The Radiological Society of North America’s medical image resource center: An update 
Journal of Digital Imaging  2001;14(Suppl 1):77-79.
The Radiological Society of North America (RSNA) has initiated a long-term project called the Medical Image Resource Center (MIRC). The overall goal of the effort is to create an on-line library of medical images and related information and to maintain and index a number of other medical image resources. The rationale for the project, a summary of the overall requirements and objectives, and a finally a brief description of the future plans for MIRC are presented.
doi:10.1007/BF03190302
PMCID: PMC3452689  PMID: 11442128
25.  CNS toxoplasmosis in acquired immune deficiency syndrome: a clinical-pathological-radiological review of 12 cases. 
From January 1981 to January 1983 acquired immune deficiency syndrome (AIDS) was diagnosed in 90 patients admitted to Kings County Hospital-Downstate Medical Center. CNS involvement occurred in 18 patients of whom 12 had toxoplasmosis confirmed by biopsy or necropsy. Pathological specimens from these 12 patients were notable for a marked diminution or absence of cellular inflammation. Each patient had elevated serological studies for toxoplasma. AIDS presented with symptoms referable to CNS toxoplasma in eight patients. In the remaining four patients, toxoplasma was found late in the course of the illness. CT showed either ring enhancing lesions or solid nodules. The course was uniformly fatal, though patients treated continuously with pyrimethamine and sulfadiazine survived longer.
Images
PMCID: PMC1028896  PMID: 3746305

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