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1.  Mortality of gasworkers—final report of a prospective study 
Doll, R., Vessey, M. P., Beasley, R. W. R., Buckley, A. R., Fear, E. C., Fisher, R. E. W., Gammon, E. J., Gunn, W., Hughes, G. O., Lee, K., and Norman-Smith, Beatrice (1972).Brit. J. industr. Med.,29, 394-406. Mortality of gasworkers—final report of a prospective study. The mortality experience of selected groups of gasworkers employed by four area Gas Boards and observed over a period of eight years was described by us in a report in 1965. The present paper adds a further four years' data to those previously collected for men having regular exposure in coal carbonizing plants and for men having exposure only to by-products of the gas-making process. To these we have added data relating to men employed by four additional area Gas Boards who have been observed over periods of seven to eight years.
The new data provide confirmation that exposure to the products of coal carbonization can give rise to cancer of the lung and leave little doubt that the risk of bladder cancer is also increased. Two additional deaths from scrotal cancer have been observed; there is evidently still a need for vigilance if this disease is to be treated at a stage early enough to prevent death. With respect to all these cancers, work as a topman appears to be particularly hazardous.
The additional data included in the present report fail to settle the question whether the risk of lung cancer is especially associated with the conditions of work in one particular type of retort house; if there are any differences, however, they are likely to be small.
In our original report, a highly significant association between death from bronchitis and exposure to the coal carbonizing process was described. The more recent data for the four original Gas Boards offer only limited support to the view that bronchitis is a specific occupational hazard of gasworkers, and the data for the four additional Gas Boards provide no further support whatsoever. The explanation for these discrepancies is obscure, but they may be due to the major changes that have been occurring in the industry during the last decade.
No evidence was obtained that by-products workers experience any risk of dying as a result of their occupation.
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PMCID: PMC1009455  PMID: 15625750
2.  Health and environmental impacts of increased generation of coal ash and FGD sludges. Report to the Committee on Health and Ecological Effects of Increased Coal Utilization. 
This paper focuses on the incremental impacts of coal ash and flue gas desulfurization (FGD) wastes associated with increased coal usage by utilities and industry under the National Energy Plan (NEP). In the paper, 1985 and 2000 are the assessment points using the baseline data taken from the Annual Environmental Analysis Report (AEAR, September 1977). In each EPA region, the potential mix of disposal options has been broadly estimated and impacts assessed therefrom. In addition, future use of advanced combustion techniques has been taken into account. The quantities of coal ash and FGD wastes depend on ash and sulfur content of the coal, emission regulations, the types of ash collection and FGD systems, and operating conditions of the systems and boiler. The disposal of these wastes is (or will be) subject to Federal and State regulations. The one key legal framework concerning environmental impact on land is the Resource Conservation and Recovery Act (RCRA). RCRA and related Federal and State laws provide a sufficient statutory basis for preventing significant adverse health and environmental impacts from coal ash and FGD waste disposal. However, much of the development and implementation of specific regulations lie ahead. FGD wastes and coal ash and FGD wastes are currently disposed of exclusively on land. The most common land disposal methods are inpoundments (ponds) and landfills, although some mine disposal is also practiced. The potential environmental impacts of this disposal are dependent on the characteristics of the disposal site, characteristics of the coal ash and FGD wastes, control method and the degree of control employed. In general, the major potential impacts are ground and surface water contamination and the "degradation" of large quantities of land. However, assuming land is available for disposal of these wastes, control technology exists for environmentally sound disposal. Because of existing increases in coal use, the possibility of significant environmental impacts, both regionally and nationally, exists regardless of whether the NEP scenario develops or not. Existing baseline data indicate that with sound control technology and successful development and implementation of existing regulatory framework, regional scale impacts are likely to be small; however, site-specific impacts could be significant and need to be evaluated on a case-by-case basis. Both Federal and privately-funded programs are developing additional data and information on disposal of FGD sludges and coal ash. Continuation of these programs will provide additional vital information in the future. However, further information in several areas if desirable: further data on levels of radionuclides and trace metals in these wastes: studies on biological impacts of trace metals; and completion of current and planned studies on disposal problems associated with advanced combustion techniques like fluid bed combustion.
PMCID: PMC1638118  PMID: 540614
3.  Asthma related hospital treatment in Finland: 1972-86. 
Thorax  1993;48(1):44-47.
BACKGROUND: The number of asthma related treatment periods in hospital has increased in many countries, particularly among children. The aim of the present investigation was to describe the use made of hospital services by asthmatic patients over a wide range in Finland. METHODS: A total of 255,387 treatment periods for asthma that had occurred between 1972 and 1986 was collected from the discharge register maintained by the National Board of Health (diagnosis 493, International Classification of Diseases). The numbers of admissions, days in hospital, and new occurrences of asthma were calculated by sex and age in relation to the total population at the end of each year. RESULTS: Asthma induced treatment periods in hospital in Finland were 12,860 (277 treatment periods per 100,000 inhabitants) in 1972 and 20,000 (406 per 100,000 inhabitants) in 1986. The annual increase in the number of such periods was 4.7% for men (95% confidence interval (95% CI) 3.5 to 5.9%) and 3.4% for women (2.1 to 4.7%) in relation to population. The most pronounced change was found in those aged 65 years and over, in which the number of treatment periods was found to increase annually by 7.5% (6.0 to 9.0%) for men and 4.9% (3.4 to 6.5%) for women, whereas the smallest increase was found among persons under 15 years with an annual change of 1.3% (0.2 to 2.3%) for boys and 1.1% (-0.1 to 2.4%) for girls. Although the number of asthma related treatment periods increased, that of new patients with asthma did not. An average of 114 new male asthmatic patients per 100,000 men were treated in hospitals annually between 1977 and 1986, whereas the figure for women was 115; the annual change during this 10 year period was 0.2% (-0.8 to 1.2%) for men and -0.8% (-1.8 to 0.2%) for women. CONCLUSIONS: The increase in the number of asthma related hospital treatment periods seemed attributable to the frequent treatment of the same patients. Treatment periods for persons aged 40 years or over were found to increase most, suggesting that the treatment of these asthmatic patients should be optimised and its organisation improved.
PMCID: PMC464239  PMID: 8434352
4.  Correlation of the Emergency Medicine Resident In-Service Examination with the American Osteopathic Board of Emergency Medicine Part I 
Introduction: Eligible residents during their fourth postgraduate year (PGY-4) of emergency medicine (EM) residency training who seek specialty board certification in emergency medicine may take the American Osteopathic Board of Emergency Medicine (AOBEM) Part 1 Board Certifying Examination (AOBEM Part 1). All residents enrolled in an osteopathic EM residency training program are required to take the EM Resident In-service Examination (RISE) annually. Our aim was to correlate resident performance on the RISE with performance on the AOBEM Part 1. The study group consisted of osteopathic EM residents in their PGY-4 year of training who took both examinations during that same year.
Methods: We examined data from 2009 to 2012 from the National Board of Osteopathic Medical Examiners (NBOME). The NBOME grades and performs statistical analyses on both the RISE and the AOBEM Part 1. We used the RISE exam scores, as reported by percentile rank, and compared them to both the score on the AOBEM Part 1 and the dichotomous outcome of passing or failing. A receiver operating characteristic (ROC) curve was generated to depict the relationship.
Results: We studied a total of 409 residents over the 4-year period. The RISE percentile score correlated strongly with the AOBEM Part 1 score for residents who took both exams in the same year (r=0.61, 95% confidence interval [CI] 0.54 to 0.66). Pass percentage on the AOBEM Part 1 increased by resident percent decile on the RISE from 0% in the bottom decile to 100% in the top decile. ROC analysis also showed that the best cutoff for determining pass or fail on the AOBEM Part 1 was a 65th percentile score on the RISE.
Conclusion: We have shown there is a strong correlation between a resident's percentile score on the RISE during their PGY-4 year of residency training and first-time success on the AOBEM Part 1 taken during the same year. This information may be useful for osteopathic EM residents as an indicator as to how well prepared they are for the AOBEM Part 1 Board Certifying Examination.
doi:10.5811/westjem.2013.7.17904
PMCID: PMC3952889  PMID: 24696749
5.  A Survey of the Methods Developed in the National Coal Board's Pneumoconiosis Field Research for Correlating Environmental Exposure with Medical Condition 
The correlation of the medical and environmental data (i.e. the derivation of the dosage-response relationship) in a study such as the National Coal Board's Pneumoconiosis Field Research (P.F.R.) is subject to many complicating factors compared with the more conventional types of biological assay. Several methods have been developed within the Research to overcome these difficulties, and the new procedures are described. Each is concerned with the estimation of the direct relation between the radiological abnormality associated with simple pneumoconiosis and some single measure of the past hazard, but the basic techniques are sufficiently general to be applicable in other fields of study.
The first development involves the definition of an underlying continuous scale of radiological abnormality. This prepares the way for the derivation of the “quantitative” relation between exposure and response, to replace the “semi-quantal” relation which is inherent in the use of a small number of discrete categories of radiological abnormality. The effect of errors of observation of dosage and response on the corresponding quantitative and quantal relationships is then determined.
The second development concerns the use of a “multi-dimensional” representation of past hazard. Most of the men under observation had worked in a number of different mining occupations before their first chest radiograph was taken, but this exposure cannot be assessed in terms of dust concentrations, for which reliable data are not available. Nevertheless, it is shown that past hazard can usefully be represented by three “dimensions” corresponding to the periods spent in three main types of environment—(a) the coal-face (coal-getting shift), (b) the coal-face (preparation shift) and (c) elsewhere underground. Each man's past exposure up to the time of his first chest radiograph can be expressed in terms of these three dimensions and the effect of each environment separately can be determined.
The third development extends the multi-dimensional approach to cover not only the working history before the first medical examination, but also the recorded exposure (in terms of measured dust concentrations), to which each man has been subject between the first and subsequent “follow-up” surveys. This measured exposure is regarded as one dimension of the man's total exposure up to the time of his second (or later) examination, and it is possible in this way to determine the direct relation between radiological abnormality and measured exposure, even when this component represents only part of the total hazard to which the man has been subject.
The application of the methods is illustrated by the analysis of some of the data which have been obtained in the Pneumoconiosis Field Research.
PMCID: PMC1038147  PMID: 13698432
6.  Hospital cost control in Norway: a decade's experience with prospective payment. 
Public Health Reports  1985;100(4):406-417.
Under Norway's prospective payment system, which was in existence from 1972 to 1980, hospital costs increased 15.8 percent annually, compared with 15.3 percent in the United States. In 1980 the Norwegian national government started paying for all institutional services according to a population-based, morbidity-adjusted formula. Norway's prospective payment system provides important insights into problems of controlling hospital costs despite significant differences, including ownership of medical facilities and payment and spending as a percent of GNP. Yet striking similarities exist. Annual real growth in health expenditures from 1972 to 1980 in Norway was 2.2 percent, compared with 2.4 percent in the United States. In both countries, public demands for cost control were accompanied by demands for more services. And problems of geographic dispersion of new technology and distribution of resources were similar. Norway's experience in the 1970s demonstrates that prospective payment is no panacea. The annual budget process created disincentives to hospitals to control costs. But Norway's changes in 1980 to a population-based methodology suggest a useful approach to achieve a more equitable distribution of resources. This method of payment provides incentives to control variations in both admissions and cost per case. In contrast, the Medicare approach based on Diagnostic Related Groups (DRGs) is limited, and it does not affect variations in admissions and capital costs. Population-based methodologies can be used in adjusting DRG rates to control both problems. In addition, the DRG system only applies to Medicare payments; the Norwegian experience demonstrates that this system may result in significant shifting of costs onto other payors.
PMCID: PMC1424928  PMID: 3927385
7.  Mortality in Appalachian Coal Mining Regions: The Value of Statistical Life Lost 
Public Health Reports  2009;124(4):541-550.
SYNOPSIS
Objectives
We examined elevated mortality rates in Appalachian coal mining areas for 1979–2005, and estimated the corresponding value of statistical life (VSL) lost relative to the economic benefits of the coal mining industry.
Methods
We compared age-adjusted mortality rates and socioeconomic conditions across four county groups: Appalachia with high levels of coal mining, Appalachia with lower mining levels, Appalachia without coal mining, and other counties in the nation. We converted mortality estimates to VSL estimates and compared the results with the economic contribution of coal mining. We also conducted a discount analysis to estimate current benefits relative to future mortality costs.
Results
The heaviest coal mining areas of Appalachia had the poorest socioeconomic conditions. Before adjusting for covariates, the number of excess annual age-adjusted deaths in coal mining areas ranged from 3,975 to 10,923, depending on years studied and comparison group. Corresponding VSL estimates ranged from $18.563 billion to $84.544 billion, with a point estimate of $50.010 billion, greater than the $8.088 billion economic contribution of coal mining. After adjusting for covariates, the number of excess annual deaths in mining areas ranged from 1,736 to 2,889, and VSL costs continued to exceed the benefits of mining. Discounting VSL costs into the future resulted in excess costs relative to benefits in seven of eight conditions, with a point estimate of $41.846 billion.
Conclusions
Research priorities to reduce Appalachian health disparities should focus on reducing disparities in the coalfields. The human cost of the Appalachian coal mining economy outweighs its economic benefits.
PMCID: PMC2693168  PMID: 19618791
8.  MORTALITY OF GASWORKERS WITH SPECIAL REFERENCE TO CANCERS OF THE LUNG AND BLADDER, CHRONIC BRONCHITIS, AND PNEUMOCONIOSIS 
The mortality of selected groups of gasworkers has been observed over a period of eight years, and a comparison has been made of the mortality from different causes among different occupational groups. Men were included in the study if they had been employed by the industry for more than five years and were between 40 and 65 years of age when the observations began. All employees and pensioners of four area Gas Boards who met these conditions were initially included; but the number was subsequently reduced to 11,499 by excluding many of the occupations which did not involve entry into the carbonizing plants or involved this only irregularly. All but 0·4% of the men were followed successfully throughout the study. Mortality rates, standardized for age, were calculated for 10 diseases, or groups of diseases, for each of three broad occupational classes, i.e., those having heavy exposure in carbonizing plants (class A), intermittent exposure or exposure to conditions in other gas-producing plants (class B), and such exposure (class C).
The results showed that the annual death rate was highest in class A (17·2 per 1,000), intermediate in class B (14·6 per 1,000), and lowest in class C (13·7 per 1,000), the corresponding mortallity for all men in England and Wales over the same period being slightly lower than the rate for class A (16·3 per 1,000). The differences between the three classes were largely accounted for by two diseases, cancer of the lung and bronchitis. For cancer of the lung the death rate (3·06 per 1,000) was 69% higher in class A than in class C; for bronchitis (2·89 per 1,000) it was 126% higher. For both diseases the mortality in class B was only slightly higher than in class C, and in both these categories the mortality was close to that observed in the country as a whole.
Three other causes of death showed higher death rates in the exposed classes than in the unexposed or in the country as a whole, but the numbers of deaths attributed to them were very small. The death rate from cancer of the bladder in class A was four times that in class C, but the total number of deaths was only 14. Five deaths were attributed to pneumoconiosis, four of which occurred in bricklayers (class B). One death from cancer of the scrotum occurred in a retort house worker.
For other causes of death the mortality rates were similar to or lower than the corresponding national rates.
Examination of the data separately for each area Board showed that the excess mortality from lung cancer and chronic bronchitis in retort house workers persisted in each area. For two Boards the mortality from other causes was close to that recorded for other men living in the same region; in the other two Boards it was substantially lower.
A comparison between the mortality of men who worked in horizontal retort houses and of those who worked in vertical houses suggested that the risk of lung cancer was greater in the horizontal houses and the risk of bronchitis was greater in the vertical houses, the differences being, however, not statistically significant.
In the light of these and other data, it is concluded that exposure to products of coal carbonization can give rise to cancer of the lung and to bronchitis, and probably also to cancer of the bladder. A risk of pneumoconiosis from work on the repair and setting of retorts is confirmed.
PMCID: PMC1008209  PMID: 14261702
9.  Recurrent Dislocation of the Shoulder Joint 
Dr. Anthony F. DePalma is shown. Photograph provided with kind permission of the Art Committee of Thomas Jefferson University, Philadelphia, PA.
Dr. DePalma was the first editor of Clinical Orthopaedics and Related Research, established by the recently formed Association of Bone and Joint Surgeons. The idea of forming the Association of Bone and Joint surgeons had been conceived by Dr. Earl McBride of Oklahoma City in 1947, and organized by a group of twelve individuals (Drs. Earl McBride, Garrett Pipkin, Duncan McKeever, Judson Wilson, Fritz Teal, Louis Breck, Henry Louis Green, Howard Shorbe, Theodore Vinke, Paul Williams, Eugene Secord, and Frank Hand) [9]. The first organizational meeting was held in conjunction with the 1949 Annual Meeting of the AAOS [9] and the first annual meeting held April 1–2, 1949 in Oklahoma City. Drs. McBride and McKeever invited Dr. DePalma to attend that meeting and join the society. According to DePalma, “Even at this small gathering, there were whisperings of the need of another journal to provide an outlet for the many worthy papers written on clinical and basic science subjects” [7]. The decision to form a new journal was finalized in 1951, and Drs. DePalma and McBride signed a contract with J.B. Lippincott Company. Dr. DePalma was designated Editor-in-Chief, and the journal became a reality in 1953 with the publication of the first volume. From the outset he established the “symposium” as a unique feature, in which part of the articles were devoted to a particular topic. Dr. DePalma served as Editor for 13 years until 1966, when he resigned the position and recommended the appointment of Dr. Marshall R. Urist. At his retirement, Clinical Orthopaedics and Related Research was well established as a major journal.
Dr. Anthony F. DePalma was born in Philadelphia in 1904, the son of immigrants from Alberona in central Foggia, Italy [1]. He attended the University of Maryland for his premedical education, then Jefferson Medical College, from which he graduated in 1929. He then served a two-year internship (common at the time) at Philadelphia General Hospital. Jobs were scarce owing to the Depression, and he felt fortunate to obtain in 1931 a position as assistant surgeon at the Coaldale State Hospital, in Coaldale, Pennsylvania, a mining town. However, he became attracted to orthopaedics and looked for a preceptorship (postgraduate training in specialties was not well developed at this time before the establishments of Boards). In the fall of 1932, he was appointed as a preceptor at the New Jersey Orthopaedic Hospital, an extension of the New York Orthopaedic Hospital. In 1939 he acquired Board certification (the first board examination was offered in 1935 for a fee of $25.00 [2]) and was appointed to the NJOH staff [1].
Dr. DePalma volunteered for military service in 1942, and served first at the Parris Island Naval Hospital in South Carolina, then on the Rixey, a hospital ship. In addition to serving to evacuate casualties to New Zealand, his ship was involved in several of the Pacific island assaults (Guam, Leyte, Okinawa). In 1945, he was assigned to the Naval Hospital in Philadelphia [1].
On his return to Philadelphia, he contacted staff members at Jefferson Medical College, including the Chair, Dr. James Martin, and became good friends with Dr. Bruce Gill (a professor of Orthopaedics at the University of Pennsylvania, and one of the earliest Presidents of the AAOS). After he was discharged from the service, he joined the staff of the Department of Orthopaedic Surgery at Jefferson, where he remained the rest of his career. He succeeded Dr. Martin as Chair in 1950, a position he held until 1970 when he reached the mandatory retirement age of 65. He closed his practice and moved briefly to Pompano Beach, Florida, but the lure of academia proved too powerful, and in January, 1971, he accepted the offer to develop a Division of Orthopaedics at the New Jersey College of Medicine and became their Chair. He committed to a five-year period, and then again moved to Pompano Beach, only to take the Florida State Boards and open a private practice in 1977. His practice grew, and he continued that practice until 1983 at the age of nearly 79. Even then he continued to travel and lecture [1].
We reproduce here four of his many contributions on the shoulder. The first comes from his classic monograph, “Surgery of the Shoulder,” published by J. B. Lippincott in 1950 [2]. In this article he describes the evolutionary development of the shoulder, focusing on the distinction between various primates, and relates the anatomic changes to upright posture and prehensile requirements. The remaining three are journal articles related to frozen shoulder [1], recurrent dislocation [3], and surgical anatomy of the rotator cuff [6], three of the most common shoulder problems then and now. He documented the histologic inflammation and degeneration in various tissues including the coracohumeral ligaments, supraspinatus tendon, bursal wall, subscapularis musculotendinous junction, and biceps tendon. Thus, the problem was rather more global than localized. He emphasized, “Manipulation of frozen shoulders is a dangerous and futile procedure.” For recurrent dislocation he advocated the Magnuson procedure (transfer of the subscapularis tendon to the greater tuberosity) to create a musculotendinous sling. All but two of 23 patients he treated with this approach were satisfied with this relatively simple procedure. (Readers will note the absence of contemporary approaches to ascertain outcomes and satisfaction. The earliest outcome musculoskeletal measures were introduced in the 60s by Larson [11] and then by Harris [10], but these instruments were physician-generated and do not reflect the rather more rigorously validated patient-generated outcome measures we use today. Nonetheless, the approach used by Dr. DePalma reflected the best existing standards of reporting results.) Dr. DePalma’s classic article, “Surgical Anatomy of the Rotator Cuff and the Natural History of Degenerative Periarthritis,” [6] reflected his literature review and dissections of 96 shoulders from 50 individuals “unaware of any (shoulder) disability” and mostly over the age of 40. By the fifth decade, most specimens began to show signs of rotator cuff tearing and he found complete tears in nine specimens from “the late decades.” He concluded,
“Based on the…observations, one can reasonably construct the natural history of periarthritis of the shoulder. It is apparent that aging is an important etiological factor, and with aging certain changes take place in the connective tissue elements of the musculotendinous cuff…it is also apparent that in slowly developing lesions of this nature compensating adjustments in the mechanics of the joint take place so that severe alterations in the mechanics of the joint do not appear. However, one must admit that such a joint is very vulnerable and, if subjected to minor trauma, the existing degenerative lesion would be extended and aggravated.”
Thus, he clearly defined the benign effects of rotator cuff tear in many aging individuals, but also the potential to create substantial pain and disability.
Dr. DePalma was a prolific researcher and writer. In addition to his “Surgery of the Shoulder,” he wrote three other books, “Diseases of the Knee: Management in Medicine and Surgery” (published by J.B. Lippincott in 1954) [4], “The Management of Fractures and Dislocations” (a large and comprehensive two volume work published by W.B. Saunders in 1959, and going through 5 reprintings) [5], and “The Intervertebral Disc” (published by W.B. Saunders in 1970, and written with his colleague, Dr. Richard Rothman) [8]. PubMed lists 62 articles he published from 1948 until 1992.
We wish to pay tribute to Dr. DePalma for his vision in establishing Clinical Orthopaedics and Related Research as a unique journal and for his many contributions to orthopaedic surgery.
References
DePalma A. Loss of scapulohumeral motion (frozen shoulder). Ann Surg. 1952;135:193–204.DePalma AF. Origin and comparative anatomy of the pectoral limb. In: DePalma AF, ed. Surgery of the Shoulder. Philadelphia: JB Lippincott; 1950:1–14.DePalma AF. Recurrent dislocation of the shoulder joint. Ann Surg. 1950;132:1052–1065.DePalma AF. Diseases of the Knee: Management in Medicine and Surgery. Philadelphia, PA: JB Lippincott Company; 1954.DePalma AF. The Management of Fractures and Dislocations—An Atlas. Philadelphia: WB Saunders Company; 1959.DePalma AF. Surgical anatomy of the rotator cuff and the natural history of degenerative periarthritis. Surg Clin North Am. 1963;43:1507–1520.DePalma AF. A lifetime of devotion to the Janus of orthopedics. Bridging the gap between the clinic and laboratory. Clin Orthop Relat Res. 1991;265:146–169.DePalma AF, Rothman RH. The Intervertebral Disc. Philadelphia: WB Saunders Company; 1970.Derkash RS. History of the Association of Bone and Joint Surgeons. Clin Orthop Relat Res. 1997;337:306–309.Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.Larson CB. Rating scale for hip disabilities. Clin Orthop Relat Res. 1963;31:85–93.
doi:10.1007/s11999-007-0105-3
PMCID: PMC2505210  PMID: 18264840
10.  Influenza Excess Mortality from 1950–2000 in Tropical Singapore 
PLoS ONE  2009;4(12):e8096.
Introduction
Tropical regions have been shown to exhibit different influenza seasonal patterns compared to their temperate counterparts. However, there is little information about the burden of annual tropical influenza epidemics across time, and the relationship between tropical influenza epidemics compared with other regions.
Methods
Data on monthly national mortality and population was obtained from 1947 to 2003 in Singapore. To determine excess mortality for each month, we used a moving average analysis for each month from 1950 to 2000. From 1972, influenza viral surveillance data was available. Before 1972, information was obtained from serial annual government reports, peer-reviewed journal articles and press articles.
Results
The influenza pandemics of 1957 and 1968 resulted in substantial mortality. In addition, there were 20 other time points with significant excess mortality. Of the 12 periods with significant excess mortality post-1972, only one point (1988) did not correspond to a recorded influenza activity. For the 8 periods with significant excess mortality periods before 1972 excluding the pandemic years, 2 years (1951 and 1953) had newspaper reports of increased pneumonia deaths. Excess mortality could be observed in almost all periods with recorded influenza outbreaks but did not always exceed the 95% confidence limits of the baseline mortality rate.
Conclusion
Influenza epidemics were the likely cause of most excess mortality periods in post-war tropical Singapore, although not every epidemic resulted in high mortality. It is therefore important to have good influenza surveillance systems in place to detect influenza activity.
doi:10.1371/journal.pone.0008096
PMCID: PMC2779490  PMID: 19956611
11.  Mortality of British coal miners in 1961 
Liddell, F. D. K. (1973).Brit. J. industr. Med.,30, 15-24. Mortality of British coal miners in 1961. In an earlier enquiry, a sizeable proportion of deaths officially ascribed to coalmining occupations was shown to have been in men who had worked in the industry but not in jobs specific to coalmining, or who had left the mines and taken up other employment. This led to overstatement of mortality among miners, and particularly among face workers.
A new coding of occupations was introduced in 1960, and the present investigation was concerned with all 5 362 men aged 20 to 64 who died in 1961 and were recorded as having last worked in a coalmining occupation or for the National Coal Board. The occupation at the time of last employment was determined from colliery records or after special enquiry by medical officers of health, and again was found to be at considerable variance with that on the death certificate. `Promotion' into coalmining occupations existed in all coalfields and depended on age at death and year of last appearance at work. `Promotion' to the face was particularly marked; however, more men had been working in the industry than were recorded as in specifically coalmining occupations. The effect of retirement from the coalface to other mining work was investigated.
In occupied miners underground, mortality was less than in all occupied and retired males, substantially so at the face. Miners generally had high rates of deaths from accidents and pneumoconiosis, and low rates for lung cancer. For most other causes, face workers had very low rates, while other underground workers and surface workers had rates below and above the national rates for occupied and retired males. Death rates were higher in Scotland than in the other British coalfields.
PMCID: PMC1009473  PMID: 4685295
12.  Pediatric Residents' Learning Styles and Temperaments and Their Relationships to Standardized Test Scores 
Background
Board certification is an important professional qualification and a prerequisite for credentialing, and the Accreditation Council for Graduate Medical Education (ACGME) assesses board certification rates as a component of residency program effectiveness. To date, research has shown that preresidency measures, including National Board of Medical Examiners scores, Alpha Omega Alpha Honor Medical Society membership, or medical school grades poorly predict postresidency board examination scores. However, learning styles and temperament have been identified as factors that 5 affect test-taking performance. The purpose of this study is to characterize the learning styles and temperaments of pediatric residents and to evaluate their relationships to yearly in-service and postresidency board examination scores.
Methods
This cross-sectional study analyzed the learning styles and temperaments of current and past pediatric residents by administration of 3 validated tools: the Kolb Learning Style Inventory, the Keirsey Temperament Sorter, and the Felder-Silverman Learning Style test. These results were compared with known, normative, general and medical population data and evaluated for correlation to in-service examination and postresidency board examination scores.
Results
The predominant learning style for pediatric residents was converging 44% (33 of 75 residents) and the predominant temperament was guardian 61% (34 of 56 residents). The learning style and temperament distribution of the residents was significantly different from published population data (P  =  .002 and .04, respectively). Learning styles, with one exception, were found to be unrelated to standardized test scores.
Conclusions
The predominant learning style and temperament of pediatric residents is significantly different than that of the populations of general and medical trainees. However, learning styles and temperament do not predict outcomes on standardized in-service and board examinations in pediatric residents.
doi:10.4300/JGME-D-10-00147.1
PMCID: PMC3244328  PMID: 23205211
13.  The relationship between coal rank and the prevalence of pneumoconiosis. 
As part of the Periodic X-ray Scheme of the National Coal Board (NCB), a comparison is made between the previous and new films of all miners who were face-workers on the former occasion, five years earlier. This assessment is made by distributing the films randomly to all the NCB readers. This paper compares the rank of coal mined in each colliery with each colliery's percentage prevalence of pneumoconiosis of at least ILO category 1 in the films of previous face-workers obtained during the third survey round (1969-73). Of the NCB's 291 collieries in Britain, information enabling a rank classification to be made was available for 250, employing 62 362 face-workers. In these 250 mines a progressive and five-fold increase in prevalence was observed from collieries mining low-rank (bituminous) coal to those mining coal of high ranks (anthracite and high-grade steam and coking coal). A possible reason for this is that, in the past, high-rank collieries may have had the highest mass-concentrations of respirable dust.
PMCID: PMC1008565  PMID: 500778
14.  Implementation of a High-Alert Medication Program 
The Permanente Journal  2008;12(2):15-22.
Introduction: Greater than 500,000 doses of high-alert medications are administered throughout the Kaiser Permanente Northern California (KPNC) Program on an annual basis. High-alert medications (HAM) carry a higher risk of harm than other medications and errors in the administration of HAM can have catastrophic clinical outcomes. The purpose of this project is to ensure safe medication practices and to eliminate medication errors that cause harm to our patients.
The Program: KPNC leadership, physicians, nurses, pharmacists, quality leaders, and labor unions worked with regional and local medication safety committees to: 1) standardize high-alert medication-handling practices; 2) enhance education programs related to medication practices, embedding these into annual core competencies of all staff who handle high-alert medications; 3) develop monitoring functions at both the regional and local levels to ensure sustainability and ongoing systems improvements. Begun in December 2005, this program covers the delivery of high-alert medications across the continuum of care and affects all patients receiving HAM.
Measures: The initial phase of the monitoring process was put in place to measure compliance with implementation. Over the first few months of the program the 90% minimal threshold was surpassed with regional overall compliance of 95%. Following this initial process, the Regional Medication Safety Committee developed monitoring tools. Department managers carry out these concurrent observational audits at the medical centers with oversight by the Assistant Administrators for Quality and Service. These audits are designed to measure whether or not all medications on the HAM list are handled specifically to policy requirements, eg, independent double-checks, HAM stickers, etc. Audit specifications are provided for each audit tool. Medical Center audit results from the third quarter of 2006 through the third quarter of 2007 have shown a regional aggregate of 97.7% compliance. As the high percentages of compliance have held constant over time, more actionable metrics are being put in place for 2008.
To determine whether or not the program is reducing HAM errors, data from the regional Quality and Risk database (MIDAS) related to all high-alert medication errors was reviewed. Two interventions were of note: in July of 2005, there was a renewed effort to educate leaders, managers, physicians, and staff on responsible reporting in a “just culture” and the introduction of the new Responsible Reporting Form. An increase in reporting was noted at this time. In December 2005, the HAM program was introduced. There is a statistically significant drop in errors reported for 23 consecutive months following this program. These findings were similar for all phases of the delivery process. A powerful indicator of improvement is the average days between major injury and death. As of November 30, 2007, it has been 232 days since the last significant negative event was reported due to a HAM.
Conclusion: This program has been implemented in all of the KPNC Medical Centers and is in the process of being implemented in all KP regions. This spread has been endorsed by the Medical Directors Quality Committee and by the KP Boards of Directors. The Interregional Medication Safety Committee is overseeing the spread process. A toolkit containing all of the required tools plus additional materials and information has been developed and made available throughout KP. The program is the recipient of the 2007 Lawrence Patient Safety Award.
PMCID: PMC3042285  PMID: 21364807
15.  Monitoring quality in Israeli primary care: The primary care physicians' perspective 
Background
Since 2000, Israel has had a national program for ongoing monitoring of the quality of the primary care services provided by the country's four competing non-profit health plans. Previous research has demonstrated that quality of care has improved substantially since the program's inception and that the program enjoys wide support among health plan managers. However, prior to this study there were anecdotal and journalistic reports of opposition to the program among primary care physicians engaged in direct service delivery; these raised serious questions about the extent of support among physicians nationally.
Goals
To assess how Israeli primary care physicians experience and rate health plan efforts to track and improve the quality of care.
Method
The study population consisted of primary care physicians employed by the health plans who have responsibility for the quality of care of a panel of adult patients. The study team randomly sampled 250 primary-care physicians from each of the four health plans. Of the 1,000 physicians sampled, 884 met the study criteria. Every physician could choose whether to participate in the survey by mail, e-mail, or telephone. The anonymous questionnaire was completed by 605 physicians – 69% of those eligible. The data were weighted to reflect differences in sampling and response rates across health plans.
Main findings
The vast majority of respondents (87%) felt that the monitoring of quality was important and two-thirds (66%) felt that the feedback and subsequent remedial interventions improved medical care to a great extent. Almost three-quarters (71%) supported continuation of the program in an unqualified manner. The physicians with the most positive attitudes to the program were over age 44, independent contract physicians, and either board-certified in internal medicine or without any board-certification (i.e., residents or general practitioners). At the same time, support for the program was widespread even among physicians who are young, board-certified in family medicine, and salaried.
Many physicians also reported that various problems had emerged to a great or very great extent: a heavier workload (65%), over-competitiveness (60%), excessive managerial pressure (48%), and distraction from other clinical issues (35%). In addition, there was some criticism of the quality of the measures themselves. Respondents also identified approaches to addressing these problems.
Conclusions
The findings provide perspective on the anecdotal reports of physician opposition to the monitoring program; they may well accurately reflect the views of the small number of physicians directly involved, but they do not reflect the views of primary care physicians as a whole, who are generally quite supportive of the program. At the same time, the study confirms the existence of several perceived problems. Some of these problems, such as excess managerial pressure, can probably best be addressed by the health plans themselves; while others, such as the need to refine the quality indicators, are probably best addressed at the national level. Cooperation between primary care physicians and health plan managers, which has been an essential component of the program's success thus far, can also play an important role in addressing the problems identified.
doi:10.1186/2045-4015-1-26
PMCID: PMC3472172  PMID: 22913311
16.  The Hospital for Special Surgery 1972–1989; Philip D. Wilson, Jr., Eighth Surgeon-in-Chief 
HSS Journal  2010;6(2):119-133.
After nearly a decade as the seventh Surgeon-in-Chief (1963–1972) of The Hospital for Special Surgery (HSS), Robert Lee Patterson, Jr., MD (1907–1994) retired, having repaired adverse relations between HSS and the New York Hospital-Cornell Medical Center. Patterson, who had first joined the staff of The Hospital for the Ruptured and Crippled in 1936 as a Visiting Surgeon, was able to accomplish this very challenging task mainly through his close relationship with Preston Wade, MD (1901–1982), a general surgeon who had served with Patterson as Co-Chief of the combined New York Hospital-HSS Fracture service. The Board of Trustees of the New York Society for the Relief of the Ruptured and Crippled appointed Philip D. Wilson, Jr. MD, as the eighth Surgeon-in-Chief of The Hospital for Special Surgery. He assumed that office on July 1, 1972. Wilson, who had joined the staff as an Orthopaedic Surgeon to the Out-Patient Department in 1951, had trained as an orthopaedic resident at HSS from 1948 to 1950 and in 1951, finished his residency at the University of California Hospital Medical Center, San Francisco. During his 17 years as Surgeon-in-Chief, he led the hospital into the advanced field of implant research and development and building a world-class center for patient care. Additionally, many other orthopaedic services such as Sports Medicine, Scoliosis and Metabolic Bone Diseases became the leaders in their fields. Supporting Departments of Rheumatology, Anesthesia and others were likewise recognized foremost in the country.
doi:10.1007/s11420-010-9162-3
PMCID: PMC2926356  PMID: 21886524
Robert Lee Patterson, Jr.; Preston Wade; Philip D. Wilson, Jr.; Harlan Amstutz; Philip D. Wilson; John Marshall; Russell F. Warren; David B. Levine; David Clayson; Charles L. Christian; Robert C. Mellors; Chitranjan S. Ranawat; John Insall; Allan E. Inglis; G. Dean Mac Ewen; Joseph M. Lane; Stephen W. Burke; Charles N. Cornell; Thomas P. Sculco; Eduardo Salvati
17.  Health Implications of Increased Coal Use in the Western States 
Western Journal of Medicine  1979;131(1):70-76.
The National Energy Plan proposed by President Carter provides for the rapid development of coal resources in the United States, particularly in the West. The potential consequences for health of this development were considered by the Advisory Committee on Health and Environmental Effects of Increased Coal Utilization, reporting to the Department of Energy. Their report recommended rigid adherence to pertinent existing regulations, improved environmental monitoring, expanded research in selected relevant topics and development of procedures for selecting the sites of new coal-fired power plants. Although the report was a major exercise in technology assessment, it is fundamentally a cautious document that proposes no new solutions or approaches. A review of occupational and community health problems associated with coal mining and coal utilization suggests that lessons from past experiences, especially in Appalachia, cannot be applied to the West uncritically. The two regions are fundamentally different in scale, topography and social development. In the West, future problems related to coal are likely to derive from unknown risks associated with coal processing technologies, land reclamation and water quality at the sites of power generation, and extensive social and demographic changes at centers of industrial activity that may have secondary effects on health. Additional considerations should supplement the recommendations of the Advisory Committee report.
PMCID: PMC1271647  PMID: 483803
18.  Burnout and Distress Among Internal Medicine Program Directors: Results of A National Survey 
Journal of General Internal Medicine  2013;28(8):1056-1063.
BACKGROUND
Physician burnout and distress has been described in national studies of practicing physicians, internal medicine (IM) residents, IM clerkship directors, and medical school deans. However, no comparable national data exist for IM residency program directors.
OBJECTIVE
To assess burnout and distress among IM residency program directors, and to evaluate relationships of distress with personal and program characteristics and perceptions regarding implementation and consequences of Accreditation Council for Graduate Medical Education (ACGME) regulations.
DESIGN AND PARTICIPANTS
The 2010 Association of Program Directors in Internal Medicine (APDIM) Annual Survey, developed by the APDIM Survey Committee, was sent in August 2010 to the 377 program directors with APDIM membership, representing 99.0 % of the 381 United States categorical IM residency programs.
MAIN MEASURES
The 2010 APDIM Annual Survey included validated items on well-being and distress, including questions addressing quality of life, satisfaction with work-life balance, and burnout. Questions addressing personal and program characteristics and perceptions regarding implementation and consequences of ACGME regulations were also included.
KEY RESULTS
Of 377 eligible program directors, 282 (74.8 %) completed surveys. Among respondents, 12.4 % and 28.8 % rated their quality of life and satisfaction with work-life balance negatively, respectively. Also, 27.0 % reported emotional exhaustion, 10.4 % reported depersonalization, and 28.7 % reported overall burnout. These rates were lower than those reported previously in national studies of medical students, IM residents, practicing physicians, IM clerkship directors, and medical school deans. Aspects of distress were more common among younger program directors, women, and those reporting greater weekly work hours. Work–home conflicts were common and associated with all domains of distress, especially if not resolved in a manner effectively balancing work and home responsibilities. Associations with program characteristics such as program size and American Board of Internal Medicine (ABIM) pass rates were not found apart from higher rates of depersonalization among directors of community-based programs (23.5 % vs. 8.6 %, p = 0.01). We did not observe any consistent associations between distress and perceptions of implementation and consequences of program regulations.
CONCLUSIONS
The well-being of IM program directors across domains, including quality of life, satisfaction with work-life balance, and burnout, appears generally superior to that of medical trainees, practicing physicians, and other medical educators nationally. Additionally, it is reassuring that program directors' perceptions of their ability to respond to current regulatory requirements are not adversely associated with distress. However, the increased distress levels among younger program directors, women, and those at community-based training programs reported in this study are important concerns worthy of further study.
doi:10.1007/s11606-013-2349-9
PMCID: PMC3710382  PMID: 23595924
graduate medical education; residency; burnout; well-being
19.  MORTALITY OF COAL-MINERS FROM CARCINOMA OF THE LUNG 
The results are presented from an investigation into the mortality of miners and ex-miners employed by the National Coal Board, from a comprehensive survey of respiratory disease in a Welsh mining community, and from a study of the comparative mortality from lung cancer in Welsh mining and non-mining towns. These results, together with previously published data which have been reviewed, show that in Great Britain the death rate of coal-miners from cancer of the lung is appreciably lower than the national rate for men of comparable age.
This occupational trend is not explicable by any of the factors which are known to influence the prevalence of the disease in the general population. In particular there is much evidence that the cigarette consumption of miners at least equals that of men in other occupations. The exclusion of this and other recognized aetiological factors suggests that the reduced mortality of miners from this disease is a specific effect of their occupation.
This effect might be a consequence of the inhalation of coal-dust, for there is some evidence that the incidence of death from lung cancer is lowest among miners whose exposure to coal-dust has been greatest.
PMCID: PMC1008218  PMID: 14261709
20.  The Toxicology Investigators Consortium Case Registry—The 2012 Experience 
Journal of Medical Toxicology  2013;9(4):380-404.
In 2010, the American College of Medical Toxicology (ACMT) established its Case Registry, the Toxicology Investigators Consortium (ToxIC). All cases are entered prospectively and include only suspected and confirmed toxic exposures cared for at the bedside by board-certified or board-eligible medical toxicologists at its participating sites. The primary aims of establishing this Registry include the development of a realtime toxico-surveillance system in order to identify and describe current or evolving trends in poisoning and to develop a research tool in toxicology. ToxIC allows for extraction of data from medical records from multiple sites across a national and international network. All cases seen by medical toxicologists at participating institutions were entered into the database. Information characterizing patients entered in 2012 was tabulated and data from the previous years including 2010 and 2011 were included so that cumulative numbers and trends could be described as well. The current report includes data through December 31st, 2012. During 2012, 38 sites with 68 specific institutions contributed a total of 7,269 cases to the Registry. The total number of cases entered into the Registry at the end of 2012 was 17,681. Emergency departments remained the most common source of consultation in 2012, accounting for 61 % of cases. The most common reason for consultation was for pharmaceutical overdose, which occurred in 52 % of patients including intentional (41 %) and unintentional (11 %) exposures. The most common classes of agents were sedative-hypnotics (1,422 entries in 13 % of cases) non-opioid analgesics (1,295 entries in 12 % of cases), opioids (1,086 entries in 10 % of cases) and antidepressants (1,039 entries in 10 % of cases). N-acetylcysteine (NAC) was the most common antidote administered in 2012, as it was in previous years, followed by the opioid antagonist naloxone, sodium bicarbonate, physostigmine and flumazenil. Anti-crotalid Fab fragments were administered in 109 cases or 82 % of cases in which a snake envenomation occurred. There were 57 deaths reported in the Registry in 2012. The most common associated agent alone or in combination was the non-opioid analgesic acetaminophen, being reported in 10 different cases. Other common agents and agent classes involved in death cases included ethanol, opioids, the anti-diabetic agent metformin, sedatives-hypnotics and cardiovascular agents, in particular amlodipine. There were significant trends identified during 2012. Abuse of over-the-counter medications such as dextromethorphan remains prevalent. Cases involving dextromethorphan continued to be reported at frequencies higher than other commonly abused drugs including many stimulants, phencyclidine, synthetic cannabinoids and designer amphetamines such as bath salts. And, while cases involving synthetic cannabinoids and psychoactive bath salts remained relatively constant from 2011 to 2012 several designer amphetamines and novel psychoactive substances were first reported in the Registry in 2012 including the NBOME compounds or “N-bomb” agents. LSD cases also spiked dramatically in 2012 with an 18-fold increase from 2011 although many of these cases are thought to be ultra-potent designer amphetamines misrepresented as “synthetic” LSD. The 2012 Registry included over 400 Adverse Drug Reactions (ADRs) involving 4 % of all Registry cases with 106 agents causing at least 2 ADRs. Additional data including supportive cares, decontamination, and chelating agent use are also included in the 2012 annual report. The Registry remains a valuable toxico-surveillance and research tool. The ToxIC Registry is a unique tool for identifying and characterizing confirmed cases of significant or potential toxicity or complexity to require bedside care by a medical toxicologist.
doi:10.1007/s13181-013-0352-5
PMCID: PMC3846972  PMID: 24178902
Poisonings; Registry; Overdose; Toxicology; Medical toxicology
21.  Outcomes of Medical Emergencies on Commercial Airline Flights 
The New England journal of medicine  2013;368(22):2075-2083.
Background
Worldwide, 2.75 billion passengers fly on commercial airlines annually. When inflight medical emergencies occur, access to care is limited. We describe in-flight medical emergencies and the outcomes of these events.
Methods
We reviewed records of in-flight medical emergency calls from five domestic and international airlines to a physician-directed medical communications center from January 1, 2008, through October 31, 2010. We characterized the most common medical problems and the type of on-board assistance rendered. We determined the incidence of and factors associated with unscheduled aircraft diversion, transport to a hospital, and hospital admission, and we determined the incidence of death.
Results
There were 11,920 in-flight medical emergencies resulting in calls to the center (1 medical emergency per 604 flights). The most common problems were syncope or presyncope (37.4% of cases), respiratory symptoms (12.1%), and nausea or vomiting (9.5%). Physician passengers provided medical assistance in 48.1% of in-flight medical emergencies, and aircraft diversion occurred in 7.3%. Of 10,914 patients for whom postflight follow-up data were available, 25.8% were transported to a hospital by emergency-medical-service personnel, 8.6% were admitted, and 0.3% died. The most common triggers for admission were possible stroke (odds ratio, 3.36; 95% confidence interval [CI], 1.88 to 6.03), respiratory symptoms (odds ratio, 2.13; 95% CI, 1.48 to 3.06), and cardiac symptoms (odds ratio, 1.95; 95% CI, 1.37 to 2.77).
Conclusions
Most in-flight medical emergencies were related to syncope, respiratory symptoms, or gastrointestinal symptoms, and a physician was frequently the responding medical volunteer. Few in-flight medical emergencies resulted in diversion of aircraft or death; one fourth of passengers who had an in-flight medical emergency underwent additional evaluation in a hospital. (Funded by the National Institutes of Health.)
doi:10.1056/NEJMoa1212052
PMCID: PMC3740959  PMID: 23718164
22.  Longitudinal and cross sectional analyses of exposure to coal mine dust and pulmonary function in new miners. 
The association between exposure to dust and pulmonary function was studied by longitudinal and cross sectional analyses in a group of United States underground coal miners beginning work in or after 1970. Quantitative estimates of exposure to respirable coal mine dust were derived from air samples taken periodically over the entire study period. The cohort included 977 miners examined both in round 2 (R2) (1972-5) and round 4 (R4) (1985-8) of the National Study of Coal Workers' Pneumoconiosis. Multiple linear regression models were developed for both cross sectional (pulmonary function at R2 and R4) and longitudinal (change in pulmonary function between R2 and R4) analyses with exposure partitioned into pre-R2 and post-R2 periods and controlled for covariates including smoking history. The results indicate a rapid initial (at R2) loss of FVC and FEV1 in association with cumulative exposure of the order of 30 ml per mg/m3-years. Between R2 and R4 (about 13 years) no additional loss of function related to dust exposure was detected although the percentage of predicted FVC and FEV1 did decline over the period. After some 15 years since first exposure (at R4), a statistically significant association of cumulative exposure with FEV1 of about -5.9 ml per mg/m3-years was found. These results indicate a significant non-linear effect of exposure to dust on pulmonary function at dust concentrations present after regulations took effect. The initial responses in both the FVC and FEV1 are consistent with inflammation of the small airways in response to exposure to dust.
PMCID: PMC1035523  PMID: 8217853
23.  Effects of gradual exposure to carbon dioxide gas on the blood pressure status of workers in coal mines of Kerman province, Iran 
ARYA Atherosclerosis  2012;8(3):149-152.
BACKGROUND
The present study was conducted to investigate the probable changes in blood pressure of workers in coal mines.
METHODS
In this study 91 workers, who worked in forwarding, preparation and exploitation units of coal mines and were in direct contact with carbon dioxide gas (from fireworks), have been selected as the case group, and 70 workers, who did not have direct contact with this gas, from other units were selected as the control group by simple random sampling method. The inclusion criteria were over 10 years of work experience and the age range of 30 to 45 years. The blood pressure values and their classification were determined based on the Seventh Report of the Joint National Committee on Prevention of Hypertension. Statistical analysis was performed using t-test.
RESULTS
The results of this study showed that mean systolic and diastolic blood pressures in the case group were significantly lower than the control group (P < 0.001).
CONCLUSION
The mean diastolic blood pressure of workers in coal mines is less than other people due to the CO2 gas. A greater control of the existing gas in mines by relevant factors is required. Necessary medical care and support measures should also be considered.
PMCID: PMC3557009  PMID: 23359216
Blood Pressure Changes; Workers; Coal Mine
24.  Projecting prevalence by stage of care for prostate cancer and estimating future health service needs: protocol for a modelling study 
BMJ Open  2011;1(1):e000104.
Introduction
Current strategies for the management of prostate cancer are inadequate in Australia. We will, in this study, estimate current service needs and project the future needs for prostate cancer patients in Australia.
Methods and analysis
First, we will project the future prevalence of prostate cancer for 2010–2018 using data for 1972–2008 from the New South Wales (NSW) Central Cancer Registry. These projections, based on modelled incidence and survival estimates, will be estimated using PIAMOD (Prevalence, Incidence, Analysis MODel) software. Then the total prevalence will be decomposed into five stages of care: initial care, continued monitoring, recurrence, last year of life and long-term survivor. Finally, data from the NSW Prostate Cancer Care and Outcomes Study, including data on patterns of treatment and associated quality of life, will be used to estimate the type and amount of services that will be needed by prostate cancer patients in each stage of care. In addition, Central Cancer Registry episode data will be used to estimate transition rates from localised or locally advanced prostate cancer to metastatic disease. Medicare and Pharmaceutical Benefits data, linked with Prostate Cancer Care and Outcomes Study data, will be used to complement the Cancer Registry episode data. The methods developed will be applied Australia-wide to obtain national estimates of the future prevalence of prostate cancer for different stages of clinical care.
Ethics and dissemination
This study was approved by the NSW Population and Health Services Research Ethics Committee. Results of the study will be disseminated widely to different interest groups and organisations through a report, conference presentations and peer-reviewed articles.
Article summary
Article focus
To describe the statistical models we will develop to obtain estimates of the future prevalence of prostate cancer in Australia for each stage of clinical care.
To describe how the methods developed will be used to determine:
i. How many prostate cancer patients will need medical attention in the near future, and
ii. What types of services they will need.
Key messages
This study will provide the first Australian estimates of current health service needs and projections of future needs for prostate cancer patients.
This information will be essential for ensuring that men with prostate cancer have adequate access to the different types of care they will require as they move through the disease trajectory.
Strengths and limitations of this study
Strengths
Breakdown of prevalence according to health service needs by patient subgroup
Development and testing of validated statistical methods for use in other settings
Multiple population-based data sources: cancer registry, a patterns of care study and Medicare and Pharmaceutical Benefits data.
Limitations
PIAMOD software has substantial data demands (requiring detailed specially-formatted input data including externally modelled survival estimates)
Numerous decisions are required regarding the best statistical models for incidence and survival
Several assumptions are needed regarding the future trends in incidence and survival.
doi:10.1136/bmjopen-2011-000104
PMCID: PMC3191396  PMID: 22021763
Organisation of health services; epidemiology; public health; statistics & research methods; urological tumours; health service research
25.  Accreditation council for graduate medical education (ACGME) annual anesthesiology residency and fellowship program review: a "report card" model for continuous improvement 
BMC Medical Education  2010;10:13.
Background
The Accreditation Council for Graduate Medical Education (ACGME) requires an annual evaluation of all ACGME-accredited residency and fellowship programs to assess program quality. The results of this evaluation must be used to improve the program. This manuscript describes a metric to be used in conducting ACGME-mandated annual program review of ACGME-accredited anesthesiology residencies and fellowships.
Methods
A variety of metrics to assess anesthesiology residency and fellowship programs are identified by the authors through literature review and considered for use in constructing a program "report card."
Results
Metrics used to assess program quality include success in achieving American Board of Anesthesiology (ABA) certification, performance on the annual ABA/American Society of Anesthesiology In-Training Examination, performance on mock oral ABA certification examinations, trainee scholarly activities (publications and presentations), accreditation site visit and internal review results, ACGME and alumni survey results, National Resident Matching Program (NRMP) results, exit interview feedback, diversity data and extensive program/rotation/faculty/curriculum evaluations by trainees and faculty. The results are used to construct a "report card" that provides a high-level review of program performance and can be used in a continuous quality improvement process.
Conclusions
An annual program review is required to assess all ACGME-accredited residency and fellowship programs to monitor and improve program quality. We describe an annual review process based on metrics that can be used to focus attention on areas for improvement and track program performance year-to-year. A "report card" format is described as a high-level tool to track educational outcomes.
doi:10.1186/1472-6920-10-13
PMCID: PMC2830223  PMID: 20141641

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