The treatment of alcohol-impaired drivers injured in a motor vehicle collision (MVC) is a complex public health issue. We conducted a systematic review to describe the legal consequences for alcohol-impaired drivers injured in a MVC and taken to a hospital or trauma center. Methods We searched MEDLINE, Embase, and CINAHL databases from inception until August 2014. We included studies that reported legal consequences including charges or convictions of injured drivers taken to a hospital or trauma center after a MVC with a blood alcohol concentration (BAC) exceeding the legal limit.Results Twenty-six studies met inclusion criteria; twenty studies were conducted in the USA, five in Canada, and one in Sweden. All were cohort studies (23 retrospective, 3 prospective) and included 11,409 patients overall. A total of 5,127 drivers had a BAC exceeding the legal limit, with legal consequences reported in 4937 cases. The median overall DUI/DWI conviction rate was 13% (range 0-85%). The median percentage of drivers with a previous conviction on their record for driving under the influence (DUI) or driving while intoxicated (DWI) was 15.5% (range 6-40%). The median percentage of drivers convicted again for DUI/DWI during the study period was 3.5% (range 2-10%). Heterogeneity between study designs, legal jurisdictions, institutional procedures and policies for obtaining a legally admissible BAC measurement precluded a meta-analysis. Conclusions The majority of intoxicated drivers injured in MVCs and seen in the emergency department are never charged or convicted. A substantial proportion of injured intoxicated drivers had more than one conviction for DUI/DWI on their police record.
The visions of more integrated care have created new roles and accountabilities for organizations and professionals. Thus, professionals are increasingly expected to engage in boundary spanning activities in order to facilitate inter-organizational and inter-sectoral collaboration. However, this task can be difficult for individual actors and it is important to investigate the work and challenges of boundary spanners in various settings. This study explores the challenges related to a new boundary spanning role for general practitioners employed to facilitate collaboration between the municipalities and general practice.
The study is based on semi-structured interviews with ten general practitioners acting as municipal practice consultants in the Capital Region of Denmark. The transcribed interviews were analyzed in several steps organizing the material into a set of coherent and distinct categories covering the different types of challenges experienced by the informants.
The main challenges of the general practitioners acting as boundary spanners were: 1) defining and negotiating the role in terms of tasks and competencies; 2) representing and mobilizing colleagues in general practice; 3) navigating in an unfamiliar organizational context.
The results support previous studies in emphasizing the difficult and multifaceted character of the boundary spanning role. While some of these challenges are not easily dealt with due to their structural causes, organizations employing boundary spanners should take note of these challenges and support their boundary spanners with matching resources and competencies.
Cites: Fam Pract. 1996 Dec;13(6):522-59023528
Cites: J Adv Nurs. 2006 Oct;56(2):144-5617018063
Cites: Ugeskr Laeger. 2010 Mar 8;172(10):775-720211081
Cites: BMC Health Serv Res. 2010;10:33021134295
Cites: J Am Board Fam Med. 2012 Mar;25 Suppl 1:S34-822403249
Cites: BMC Fam Pract. 2014;15:16425284048
Cites: BMC Health Serv Res. 2013;13:15823631517
Cites: Scand J Public Health. 2013 Aug;41(6):616-2223604037
At small spatial and temporal scales, genetic differentiation is largely controlled by constraints on gene flow, while genetic diversity across a species' distribution is shaped on longer temporal and spatial scales. We assess the hypothesis that oceanographic transport and other seascape features explain different scales of genetic structure of giant kelp, Macrocystis pyrifera. We followed a hierarchical approach to perform a microsatellite-based analysis of genetic differentiation in Macrocystis across its distribution in the northeast Pacific. We used seascape genetic approaches to identify large-scale biogeographic population clusters and investigate whether they could be explained by oceanographic transport and other environmental drivers. We then modelled population genetic differentiation within clusters as a function of oceanographic transport and other environmental factors. Five geographic clusters were identified: Alaska/Canada, central California, continental Santa Barbara, California Channel Islands and mainland southern California/Baja California peninsula. The strongest break occurred between central and southern California, with mainland Santa Barbara sites forming a transition zone between the two. Breaks between clusters corresponded approximately to previously identified biogeographic breaks, but were not solely explained by oceanographic transport. An isolation-by-environment (IBE) pattern was observed where the northern and southern Channel Islands clustered together, but not with closer mainland sites, despite the greater distance between them. The strongest environmental association with this IBE pattern was observed with light extinction coefficient, which extends suitable habitat to deeper areas. Within clusters, we found support for previous results showing that oceanographic connectivity plays an important role in the population genetic structure of Macrocystis in the Northern hemisphere.
18F-fluorodeoxyglucose PET/CT (PET/CT) is the current state-of-the-art in the staging of diffuse large B-cell lymphoma (DLBCL) and has a high sensitivity for extranodal involvement. Therefore, reassessment of extranodal involvement and the current prognostic indices in the PET/CT era is warranted. We screened patients with newly diagnosed DLBCL seen at the academic centers of Aalborg, Copenhagen, and British Columbia for eligibility. Patients that had been staged with PET/CT and treated with R-CHOP(-like) 1(st) line treatment were retrospectively included. In total 443 patients met the inclusion criteria. With a median follow-up of 2.4 years, the 3-year overall (OS) and progression-free survival (PFS) were 73% and 69%, respectively. The Ann Arbor classification had no prognostic impact in itself with the exception of stage IV disease (HR 2.14 for PFS, P2 extranodal sites, including HR 7.81 (P?3 sites. Bone/bone marrow involvement was the most commonly involved extranodal site identified by PET/CT (29%) and was associated with an inferior PFS and OS. The IPI, R-IPI, and NCCN-IPI were predictive of PFS and OS, and the two latter could identify a very good prognostic subgroup with 3-year PFS and OS of 100%. PET/CT-ascertained extranodal involvement in DLBCL is common and involvement of >2 extranodal sites is associated with a dismal outcome. The IPI, R-IPI, and NCCN-IPI predict outcome with high accuracy.
OBJECTIVES: This article reports recent trends in influenza vaccination rates in Canada, provides data on predictors of vaccination in Canada for 2005, and examines longer-term effects of Ontario's universal influenza immunization program on vaccine uptake. DATA SOURCES: Data are from the 1996/1997 National Population Health Survey (NPHS) and the 2000/2001, 2003, and 2005 Canadian Community Health Survey (CCHS). ANALYTICAL TECHNIQUES: NPHS and CCHS data were used to estimate influenza vaccination rates of the population aged 12 or older. The Z test was used to assess differences between surveys, and the chi-squared test for trend was used to examine trends over time. Logistic regression was used to identify predictors of vaccination and to compare the odds of being vaccinated in Ontario versus other provinces. MAIN RESULTS: Nationally, influenza vaccination rates rose from 15% in 1996/1997 to 27% in 2000/2001, stabilized between 2000/2001 and 2003, and increased further to 34% by 2005. Vaccination rates for most high-risk groups still fall short of national targets. Ontarians continue to be more likely to be vaccinated than are residents of any other province, while residents of two of the territories--Nunavut and the Northwest Territories--are even more likely to be vaccinated than are Ontarians.
Recent research suggests that tumor necrosis factor-alpha (TNF alpha) may play an important role in obesity-associated insulin resistance and diabetes. We studied the relationship between TNF alpha and the anthropometric and physiological variables associated with insulin resistance and diabetes in an isolated Native Canadian population with very high rates of type 2 diabetes mellitus (DM). A stratified random sample (n = 80) of participants was selected from a population-based survey designed to determine the prevalence of type 2 DM and its associated risk factors. Fasting blood samples for glucose, insulin, triglyceride, leptin, and TNF alpha were collected; a 75-g oral glucose tolerance test was administered, and a second blood sample was drawn after 120 min. Insulin resistance was estimated using the homeostasis assessment (HOMA) model. Systolic and diastolic blood pressure (BP), height, weight, and waist and hip circumferences were determined, and percent body fat was estimated using biological impedance analysis. The relationship between circulating concentrations of TNF alpha and the other variables was assessed using Spearman correlation coefficients, analysis of covariance, and multiple linear regression. The mean TNF alpha concentration was 5.6 pg/mL (SD = 2.18) and ranged from 2.0-12.9 pg/mL, with no difference between men and women (P = 0.67). There were moderate, but statistically significant, correlations between TNF alpha and fasting insulin, HOMA insulin resistance (HOMA IR) waist circumference, fasting triglyceride, and systolic BP (r = 0.23-0.34; all P 0.25). Regression analysis indicated that log HOMA IR and log systolic BP were significant independent contributors to variations in log TNF alpha concentration (model r2 = 0.32). We conclude that in this homogeneous Native Canadian population, circulating TNF alpha concentrations are positively correlated with insulin resistance across a spectrum of glucose tolerance. The data suggest a possible role for TNF alpha in the pathophysiology of insulin resistance.
Allogeneic peripheral blood progenitor cell (PBPC) transplants are an alternative to BMT, although G-CSF mobilization dose, timing of pheresis and risk of GVHD are not well defined. We compared harvest characteristics, donor and recipient outcomes and costs of two PBPC transplant strategies with historical controls who received BMT. Twenty donors mobilized with four daily s.c. G-CSF doses (5 microg/kg/day) (group 1) and 20 mobilized with 10 microg/kg/day G-CSF (group 2) were compared with 20 BM controls (group 3). G-CSF and phereses were well tolerated. Four of 40 PBPC donors required femoral catheter placement. At least 2.5 x 10(6) CD34+/kg recipient weight were collected with two phereses in 19/20 donors (group 1) and 18/20 donors (group 2). Time to neutrophil (18 vs 20 vs 22 days, P = 0.02) and platelet (21 vs 24 vs 27 days, P = 0.005) engraftment was shorter in the PBPC groups (group 2 vs group 1 vs group 3) but secondary engraftment outcomes were not different. The incidence of grade 2-4 aGVHD was higher in the low-dose G-CSF group (group 1) but there was no difference in cGVHD, 100-day or 1-year survival. The mean PBPC transplant cost (group 1) at first hospital discharge was less than BM (group 3) ($34,643 vs $37,354) but the mean overall cost for both groups was similar at 100 days ($46,334 vs $46,083). Allogeneic PBPC transplant with short course, low-dose G-CSF mobilization is safe, feasible and cost equivalent to allogeneic BMT.
The number of elderly Canadians is likely to double in 20 years, spurring a discussion of end-of-life care. We analyze the literature on the costs of this care and compare cost assessments of different models of palliative care. The cost of treatments for which there is little empirical support is factored into our cost-savings analysis and the methodological limits of cost-analysis studies are also discussed. We conclude that (a) depending upon the model of care, costs of end-of-life care are considerable, (b) costs of care become more expensive with distance from the home setting, (c) cost savings reported in palliative care settings may be a function of nearness to death; (d) family expenses on end-of-life care are substantial and are not factored into most cost-analysis studies, (e) a two-tiered system of palliative home care allows families with higher incomes to afford help in supporting home deaths, and (f) some treatments given to dying patients are costly while yielding little benefit.
Changes in the demographics and prescription of peritoneal dialysis (PD) during the past decade are reviewed using data from the United States and Canada. The number of patients in North America undergoing PD has increased markedly over the past decade, but the percentage of total chronic dialysis patients using the modality has remained relatively stable or decreased slightly during recent years. The average age of the patients undergoing PD has increased, and the percentage with diabetes has also increased. Comorbidity has otherwise remained relatively stable and tends to be significantly less than that in patients undergoing chronic hemodialysis (HD). The proportion of PD patients undergoing automated PD (APD) has increased markedly over the past decade and now includes more than one third of the PD patients in North America. The issue of adequacy of clearance achieved on PD has received a lot of attention over the past decade, and this is now being translated into changes in prescription. Patients undergoing continuous ambulatory PD (CAPD) are being prescribed larger dwell volumes, and more than one quarter use 2.5-L dwells or greater. A small number in the United States are being prescribed more than four exchanges a day, but this practice is more common in Canada. With regard to APD, the proportion of patients doing day dwells is now more than two thirds, and the average cycler dwell volumes have also increased. There are no baseline clearance data from a decade ago for comparative purposes, but it appears that clearances have increased in recent years. In general, more than 70% of the patients are achieving recommended clearance targets at the initiation of PD but, among prevalent US patients, the percentage achieving targets is in the range of 40% to 45%, reflecting a loss of residual renal function. In Canada, 60% to 70% of prevalent patients are achieving these targets. PD is a rapidly changing therapy at present. There have been dramatic and impressive improvements in prescription practices, but they need to change further if a higher proportion of patients is to achieve recommended clearance targets.
This paper analyzes the welfare economics of three arrangements for purchasing health insurance: competitive markets in which consumers are free to choose among options with different levels of coverage and prices; systems with compulsory partial pooling which permit private firms to sell supplementary coverage; and government-run pools that purchase comprehensive coverage at a single price for all consumers. Competitive insurance markets are assumed to face the problem of 'adverse selection'. This refers to a situation in which the insurer cannot observe characteristics of individuals that affect the cost of insurance and that are known to the individuals. Competitive markets with adverse selection are not efficient because low risks cannot purchase comprehensive insurance coverage. However, government-run pools with comprehensive coverage are an inefficient solution to the problem of adverse selection. Compulsory partial coverage may represent an attractive alternative to both competitive markets and comprehensive pools. We discover two situations when government intervention of this type will succeed: when there are not many high risks in the population, and when the risk types are similar. We discuss the implications of these results for health insurance programs in several countries. Our results also have implications for the allocation of public funds for disease-prevention projects. A project targeted at high risks will produce external benefits for low risks, even though they are not directly affected by the program. However, a successful project might eliminate the market for private insurance; in this case the government should consider mandating partial insurance coverage.