Understanding the impact of COVID-19 on antibiotic use in Canadian primary care: a matched-cohort study using EMR data.

BACKGROUND: Inappropriate or overuse of antibiotic prescribing in primary care highlights an opportunity for antimicrobial stewardship (AMS) programs aimed at reducing unnecessary use of antimicrobials through education, policies and practice audits that optimize antibiotic prescribing. Evidence from the early part of the pandemic indicates a high rate of prescribing of antibiotics for patients with COVID-19. It is crucial to surveil antibiotic prescribing by primary care providers from the start of the pandemic and into its endemic stage to understand the effects of the pandemic and better target effective AMS programs. METHODS: This was a matched pair population-based cohort study that used electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Participants included all patients that visited their primary care provider and met the inclusion criteria for COVID-19, respiratory tract infection (RTI), or non-respiratory or influenza-like-illness (negative). Four outcomes were evaluated (a) receipt of an antibiotic prescription; (b) receipt of a non-antibiotic prescription; (c) a subsequent primary care visit (for any reason); and (d) a subsequent primary care visit with a bacterial infection diagnosis. Conditional logistic regression was used to evaluate the association between COVID-19 and each of the four outcomes. Each model was adjusted for location (rural or urban), material and social deprivation, smoking status, alcohol use, obesity, pregnancy, HIV, cancer and number of chronic conditions. RESULTS: The odds of a COVID-19 patient receiving an antibiotic within 30 days of their visit is much lower than for patients visiting for RTI or for a non-respiratory or influenza-like-illnesses (AOR = 0.08, 95% CI[0.07, 0.09] compared to RTI, and AOR = 0.43, 95% CI[0.38, 0.48] compared to negatives). It was found that a patient visit for COVID-19 was much less likely to have a subsequent visit for a bacterial infection at all time points. CONCLUSIONS: Encouragingly, COVID-19 patients were much less likely to receive an antibiotic prescription than patients with an RTI. However, this highlights an opportunity to leverage the education and attitude change brought about by the public health messaging during the COVID-19 pandemic (that antibiotics cannot treat a viral infection), to reduce the prescribing of antibiotics for other viral RTIs and improve antibiotic stewardship.

Mortality surrogates in combined pulmonary fibrosis and emphysema.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) with coexistent emphysema, termed combined pulmonary fibrosis and emphysema (CPFE) may associate with reduced forced vital capacity (FVC) declines compared to non-CPFE IPF patients. We examined associations between mortality and functional measures of disease progression in two IPF cohorts. METHODS: Visual emphysema presence (>0% emphysema) scored on computed tomography identified CPFE patients (CPFE/non-CPFE: derivation cohort n=317/n=183, replication cohort n=358/n=152), who were subgrouped using 10% or 15% visual emphysema thresholds, and an unsupervised machine-learning model considering emphysema and interstitial lung disease extents. Baseline characteristics, 1-year relative FVC and diffusing capacity of the lung for carbon monoxide (D LCO) decline (linear mixed-effects models), and their associations with mortality (multivariable Cox regression models) were compared across non-CPFE and CPFE subgroups. RESULTS: In both IPF cohorts, CPFE patients with ≥10% emphysema had a greater smoking history and lower baseline D LCO compared to CPFE patients with <10% emphysema. Using multivariable Cox regression analyses in patients with ≥10% emphysema, 1-year D LCO decline showed stronger mortality associations than 1-year FVC decline. Results were maintained in patients suitable for therapeutic IPF trials and in subjects subgrouped by ≥15% emphysema and using unsupervised machine learning. Importantly, the unsupervised machine-learning approach identified CPFE patients in whom FVC decline did not associate strongly with mortality. In non-CPFE IPF patients, 1-year FVC declines ≥5% and ≥10% showed strong mortality associations. CONCLUSION: When assessing disease progression in IPF, D LCO decline should be considered in patients with ≥10% emphysema and a ≥5% 1-year relative FVC decline threshold considered in non-CPFE IPF patients.

CenTime: Event-conditional modelling of censoring in survival analysis.

Survival analysis is a valuable tool for estimating the time until specific events, such as death or cancer recurrence, based on baseline observations. This is particularly useful in healthcare to prognostically predict clinically important events based on patient data. However, existing approaches often have limitations; some focus only on ranking patients by survivability, neglecting to estimate the actual event time, while others treat the problem as a classification task, ignoring the inherent time-ordered structure of the events. Additionally, the effective utilisation of censored samples-data points where the event time is unknown- is essential for enhancing the model's predictive accuracy. In this paper, we introduce CenTime, a novel approach to survival analysis that directly estimates the time to event. Our method features an innovative event-conditional censoring mechanism that performs robustly even when uncensored data is scarce. We demonstrate that our approach forms a consistent estimator for the event model parameters, even in the absence of uncensored data. Furthermore, CenTime is easily integrated with deep learning models with no restrictions on batch size or the number of uncensored samples. We compare our approach to standard survival analysis methods, including the Cox proportional-hazard model and DeepHit. Our results indicate that CenTime offers state-of-the-art performance in predicting time-to-death while maintaining comparable ranking performance. Our implementation is publicly available at https://github.com/ahmedhshahin/CenTime.

A hybrid CNN-RNN approach for survival analysis in a Lung Cancer Screening study.

In this study, we present a hybrid CNN-RNN approach to investigate long-term survival of subjects in a lung cancer screening study. Subjects who died of cardiovascular and respiratory causes were identified whereby the CNN model was used to capture imaging features in the CT scans and the RNN model was used to investigate time series and thus global information. To account for heterogeneity in patients' follow-up times, two different variants of LSTM models were evaluated, each incorporating different strategies to address irregularities in follow-up time. The models were trained on subjects who underwent cardiovascular and respiratory deaths and a control cohort matched to participant age, gender, and smoking history. The combined model can achieve an AUC of 0.76 which outperforms humans at cardiovascular mortality prediction. The corresponding F1 and Matthews Correlation Coefficient are 0.63 and 0.42 respectively. The generalisability of the model is further validated on an 'external' cohort. The same models were applied to survival analysis with the Cox Proportional Hazard model. It was demonstrated that incorporating the follow-up history can lead to improvement in survival prediction. The Cox neural network can achieve an IPCW C-index of 0.75 on the internal dataset and 0.69 on an external dataset. Delineating subjects at increased risk of cardiorespiratory mortality can alert clinicians to request further more detailed functional or imaging studies to improve the assessment of cardiorespiratory disease burden. Such strategies may uncover unsuspected and under-recognised pathologies thereby potentially reducing patient morbidity.

Integrating User Preferences for Asthma Tools and Clinical Guidelines Into Primary Care Electronic Medical Records: Mixed Methods Study.

BACKGROUND: Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices. OBJECTIVE: The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance. METHODS: In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis. RESULTS: Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care. CONCLUSIONS: Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

Comprehensiveness of care for women with depression: Association between primary care use and cervical cancer screening.

OBJECTIVE: To explore comprehensiveness of care in patients with depression by examining associations between a diagnosis of depression, frequency of primary care visits, and Papanicolaou test completion. DESIGN: Cross-sectional retrospective survey using electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network. SETTING: Primary care practices in Ontario. PARTICIPANTS: Women aged 21 to 69 eligible to receive Pap tests in 2015. MAIN OUTCOME MEASURES: Associations between 2 predictors (depression and number of primary care visits in 2015) and Pap test completion were measured. RESULTS: Overall, 125,258 women were included: 20.5% completed a Pap test and 16.4% had a diagnosis of depression. Having a diagnosis of depression was associated with lower likelihood of Pap test completion (adjusted odds ratio [AOR]=0.92, 95% CI 0.88 to 0.95). A greater number of primary care visits was associated with a higher likelihood of Pap test completion; this association was stronger in women with a diagnosis of depression (AOR=4.9, 95% CI 4.16 to 5.69) than in those without (AOR=3.4, 95% CI 3.25 to 3.60). CONCLUSION: While depression was associated with fewer completed Pap tests, women with depression who saw their family doctors more often were more likely to be screened for cervical cancer. More primary care visits for depression treatment may be associated with an improved likelihood of screening for cervical cancer.

Does availability of point of care C-reactive protein measurement affect provision of antibiotics in a community respiratory service?

Antibiotic resistance presents a growing threat to health systems and patients at a global scale. Point of care (POC) C-reactive protein (CRP) measurement, as an adjunct to exacerbation assessment, has been studied in primary and secondary care and may represent a useful tool for community teams. A retrospective service review was conducted to determine the effect of CRP measurement on antibiotic provision in a community respiratory setting, with chronic obstructive pulmonary disease (COPD) and bronchiectasis exacerbations. This review compared antibiotic provision for COPD and bronchiectasis patients for those where CRP was measured versus those where it was not. It was found that antibiotic provision dropped by almost 25% points for COPD exacerbations, and almost 59% in bronchiectasis, when a CRP measurement was taken as a component of a respiratory assessment. Antibiotics were also provided at a greater amount based on symptom presentation. Therefore, it is concluded that CRP measurement correlates with a reduction in antibiotic provision, highlighting its use alongside symptom assessment in future work.

Factors influencing primary care provider referral for bariatric surgery: Systematic review.

OBJECTIVE: To identify barriers to and facilitators of primary care provider (PCP) referral for bariatric surgery in patients with obesity. DATA SOURCES: MEDLINE, EMBASE, and PsycINFO databases were searched and reference lists of included articles were screened to identify additional relevant articles. Two reviewers independently reviewed citations and full-text articles, and appraised the quality of the included articles using the Critical Appraisal Skills Programme Tool Qualitative Checklist and the Appraisal Tool for Cross-Sectional Studies. They extracted data on the study characteristics and the barriers to and facilitators of PCP referral for bariatric surgery. Appraisal discrepancies were resolved through consensus among authors. STUDY SELECTION: Overall, 882 citations were identified and 18 articles were then selected for this review. SYNTHESIS: Barriers included fear of surgery complications and side effects, cost, lack of availability, perception that surgery is a quick fix or a last resort, and prior negative experiences. Facilitators included direct requests from patients, patient motivation, previously failed weight-loss interventions, and obesity-related comorbidities. Those PCPs who were knowledgeable about the risks and benefits of bariatric surgery were more likely to refer their patients. CONCLUSION: Education and continuing professional development programs regarding bariatric surgery are needed to improve PCP knowledge and capacity to manage patients with obesity. Also, educating the general public on obesity, weight management, and available treatment options can empower patients and families to manage their weight and pursue evidence-informed treatments.

Investigation into the geometry and distribution of oil inclusions in sea ice using non-destructive X-ray microtomography and its implications for remote sensing and mitigation potential.

As climate change brings reduced sea ice cover and longer ice-free summers to the Arctic, northern Canada is experiencing an increase in shipping and industrial activity in this sensitive region. Disappearing sea ice, therefore, makes the Arctic region susceptible to accidental releases of different types of oil and fuel pollution resulting in a pressing need for the development of appropriate scientific knowledge necessary to inform regulatory policy formulation. In this study, we examine the microstructure of the surficial layers of sea ice exposed to oil using X-ray microtomography. Through analysis, 3D imaging of the spatial distribution of the ice's components (brine, air, and oil) were made. Additional quantitative information regarding the size, proximity, orientation, and geometry of oil inclusions were computed to ascertain discernable relationships between oil and the other components of the ice. Our results indicate implications for airborne remote sensing and bioremediation of the upper sea ice layers.

Photooxidation and biodegradation potential of a light crude oil in first-year sea ice.

Disappearing sea ice in the Arctic region results in a pressing need to develop oil spill mitigation techniques suitable for ice-covered waters. The uncertainty around the nature of an oil spill in the Arctic arises from the ice-covered waters and sub-zero temperatures, and how they may influence natural attenuation efficiency. The Sea-ice Environmental Research Facility was used to create a simulated Arctic marine setting. This paper focuses on the potential for biodegradation of the bulk crude oil content (encapsulated in the upper regions of the ice), to provide insight regarding the possible fate of crude oil in an Arctic marine setting. Cheaper and faster methods of chemical composition analysis were applied to the samples to assess for weathering and transformation effects. Results suggest that brine volume in ice may not be sufficient at low temperatures to encompass biodegradation and that seawater is more suitable for biodegradation.

Patients eligible and referred for bariatric surgery in southeastern Ontario: Retrospective cohort study.

OBJECTIVE: To evaluate the proportion of eligible individuals, within one health region in Ontario, who were referred for publicly funded medical and surgical weight-loss interventions (MSWLI). DESIGN: A retrospective cohort study that used primary care data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and referral data from the Ontario Bariatric Network (OBN). SETTING: Primary care practices within southeastern Ontario that contribute data to CPCSSN. PARTICIPANTS: Patients with class II (body mass index [BMI] 35.0 to 39.9 kg/m2) or III (BMI ≥ 40 kg/m2) obesity who were eligible for referral to the OBN for MSWLI. MAIN OUTCOME MEASURES: Primary care data about patients within the CPCSSN database were linked to referral records within the OBN database using 3 indirect identifiers to determine the proportion of patients with class II and III obesity who were referred to the OBN for MSWLI. An adjusted multivariate logistic regression model was used to determine the most significant predictors of referral. RESULTS: Of the 87 276 patients within one health region in Ontario, 15 526 (17.8%) patients had class II or III obesity and were eligible for referral for MSWLI. Only 966 out of those 15 526 (6.2%) patients were actually referred for MSWLI. In the multivariate regression analysis, BMI had the strongest association with referral in terms of adjusted odds ratio (AOR), varying from 2.50 (95% CI 2.04 to 3.06) for a BMI of 40.0 to 44.9 kg/m2, to 5.15 (95% CI 4.21 to 6.30) for a BMI of 50.0 kg/m2 or greater. Referral was more likely for female than male patients (AOR = 2.18; 95% CI 1.86 to 2.57), those living rurally than for urban dwellers (AOR = 1.39; 95% CI 1.20 to 1.60), and those aged 30 to 39 (AOR = 1.61; 95% CI 1.24 to 2.09) and 40 to 49 (AOR = 1.53; 95% CI 1.18 to 1.98) compared with other age groups. CONCLUSION: Within one health region in Ontario, the referral rate of patients with class II and III obesity for MSWLI was low. Our findings highlight the need for further research to understand and address the barriers to referral of patients with class II and III obesity for MSWLI.

Survey of perceptions and educational needs of primary care providers regarding management of patients with class II and III obesity in Ontario, Canada.

BACKGROUND: Primary care providers (PCPs) are typically the primary contact for patients with obesity seeking medical and surgical weight loss interventions; however, previous studies suggest that fewer than 7% of eligible adult patients are referred to publically funded medical and surgical weight loss interventions (MSWLI). METHODS: We performed an anonymous survey study between October 2017 and June 2018 to explore the knowledge, experiences, perceptions, and educational needs of PCPs in Southeastern Ontario in managing patients with class II and III obesity. RESULTS: Surveys were distributed to 591 PCPs (n = 538 family physicians; n = 53 nurse practitioners) identified as practicing in the Southeastern Ontario and 92 (15.6%) participated. PCPs serving a rural population estimated that 14.2 ± 10.9% of patients would qualify for MSWLI compared to 9.9 ± 8.5% of patients of PCPs serving an urban population (p = .049). Overall, 57.5% of respondents did not feel competent prescribing MSWLI to patients with class II/III obesity, while 69.8% stated they had 'good' knowledge of the referral criteria for MSWLI. 22.2% of respondents were hesitant to refer patients for bariatric surgery (BS) due to concerns about postoperative surgical complications and risks associated with surgery. Only 25% of respondents were comfortable providing long-term follow up after BS, and only 39.1% had participated in continuing education on management of patients with class II/III obesity in the past 5 years. CONCLUSION: The majority of PCPs believe there is a need for additional education about MSWLI for patients with class II/III obesity. Future studies are needed to develop and compare the effectiveness of additional education and professional development around risks of contemporary BS, indications to consider referral for MSWLI, management and long-term follow-up of patients after BS.

Transcriptome and physiological effects of toxaphene on the liver-gonad reproductive axis in male and female largemouth bass (Micropterus salmoides).

Toxaphene is an organochlorine pesticide and environmental contaminant that is concerning due to its atmospheric transport and persistence in soil. In Florida, toxaphene and other organochlorine pesticides were used heavily in agriculture on the north shore of Lake Apopka and they are still detectable in soil. Wild largemouth bass that inhabit the lake and the marshes along the north shore have been exposed to a variety of organochlorine pesticides including dieldrin, methoxychlor, and p,p'-DDE, among others. While these other organochlorine pesticides have been studied for their endocrine disrupting effects in largemouth bass, there is little information for toxaphene. In this study, male and female largemouth bass were given food containing 50 mg/kg toxaphene for almost 3 months, to achieve tissue levels similar to those found in fish at Lake Apopka. Sex-specific toxicity was then evaluated by measuring various reproductive endpoints and transcriptomic changes. In females, gonadosomatic index showed a trend towards reduction (p = 0.051) and plasma vitellogenin was reduced by ~40% relative to controls. However plasma levels of 17ß-estradiol and testosterone were not perturbed by toxaphene exposure. These data suggest that toxaphene does not act as a weak estrogen as many other organochlorine pesticides do, but rather appears to be acting as an antiestrogen in female fish. There were no obvious changes in the gonadosomatic index and plasma hormones in male bass. However, ex vivo explant experiments revealed that toxaphene prevented human chorionic gonadotropin-stimulated testosterone production in the testis. This suggested that toxaphene had anti-androgenic effects in males. Subsequent transcriptomic analyses of the testis revealed that androgen receptor/beta-2-microglobulin signaling was up-regulated while insulin-related pathways were suppressed with toxaphene, which could be interpreted as a compensatory response to androgen suppression. In the male liver, the transcriptome analysis revealed an overwhelming suppression in immune-related signaling cascades (e.g. lectin-like receptor and ITSM-Containing Receptor signaling, CD16/CD14 Proinflammatory Monocyte Activation, and CD38/CD3-JUN/FOS/NF-kB Signaling in T-cell Proliferation). Overall, this study showed that toxaphene induced sex-specific effects. The transcriptomic and physiological responses observed can contribute to the development of adverse outcome pathways for toxaphene exposure in fish.

Effect of dissolution, evaporation, and photooxidation on crude oil chemical composition, dielectric properties and its radar signature in the Arctic environment.

Accidental release of petroleum in the Arctic is of growing concern owing to increases in ship traffic and possible future oil exploration. A crude oil-in-sea ice mesocosm experiment was conducted to identify oil-partitioning trends in sea ice and determine the effect of weathering on crude oil permittivity. The dissolution of the lighter fractions increased with decreasing bulk oil-concentration because of greater oil-brine interface area. Movement of the oil towards the ice surface predominated over dissolution process when oil concentrations exceeded 1 mg/mL. Evaporation decreased oil permittivity due to losses of low molecular weight alkanes and increased asphaltene-resin interactions. Photooxidation increased the permittivity of the crude oil due to the transformation of branched aromatics to esters and ketones. Overall, the weathering processes influenced crude oil permittivity by up to 15%, which may produce sufficient quantifiable differences in the measured normalized radar cross-section of the ice.

Steroidogenic acute regulatory protein transcription is regulated by estrogen receptor signaling in largemouth bass ovary.

Estrogenic contaminants in the environment are linked to the occurrence of reproductive abnormalities in many aquatic species, including largemouth bass (Micropterus salmoides; LMB). Previous work has shown that many different types of xenoestrogens regulate expression of the Steroidogenic Acute Regulatory protein (StAR), a cholesterol-transporting protein vital to steroid hormone biosynthesis; however, the regulatory mechanisms of StAR are incompletely characterized in fish. To learn more about endogenous expression patterns of StAR in the ovary, LMB were collected from the St. John's River (Florida, USA) over an entire breeding season to investigate StAR expression. Plasma 17ß-estradiol (E2) and StAR mRNA levels were positively correlated in females, and StAR mRNA levels displayed ~ 100-fold increase between primary oocyte growth stages and final maturation. To further study the regulation of StAR, female LMB in the laboratory were fed at ≃2% of their weight on a diet laden with 17α-ethinylestradiol (EE2, 70 or 200 ng EE2 per gram feed). Diets were designed to achieve a physiologically-relevant exposure to EE2, and StAR expression was assessed in vivo. We observed a dose-dependent suppression of StAR mRNA levels, however both diets led to high, pharmacological levels in the blood and do not represent normal physiological ranges of estrogens. In the 200 ng EE2/gm feed group, ovarian StAR mRNA levels were suppressed to approximately 5% of that of the LMB control group. These investigations suggest that LMB StAR increases in expression during oocyte maturation and that it is suppressed by E2 feedback when estrogen levels are high, through the HPG axis. A 2.9 kb segment of the LMB StAR promoter was examined for putative E2 response elements using in silico software, and a putative estrogen receptor binding element (ERE/-1745) was predicted in the promoter. The functionality of the ERE was examined using MA-10 mouse Leydig cells transfected with the LMB StAR promoter. Estrogen receptor (ER) interaction with ERE/-1745 was evaluated under basal and human chorionic gonadotropin (hCG)-treated conditions in the presence and absence of E2. Chromatin immunoprecipitation (ChIP) experiments revealed that ESR1 binding to the promoter was enriched under basal conditions and E2 exposure elicited an increase in enrichment (4-fold) above that observed under basal conditions. ESR2 was not strongly enriched at the ERE/-1745 site, suggesting that StAR may be preferentially regulated by LMB estrogen receptor 1 (esr1). Taken together, these different experiments provide evidence that LMB StAR is under the control of estrogens and that ESR1 binds directly to the LMB StAR promoter in an E2-responsive manner.

Barriers to accessing weight-loss interventions for patients with class II or III obesity in primary care: a qualitative study.

BACKGROUND: Over 1 million Canadians have class II or III obesity; however, access to weight-loss interventions for these patients remains limited. The purpose of our study was to identify the barriers to accessing medical and surgical weight-loss interventions from the perspectives of 3 groups: family physicians, patients who were referred for weight-loss intervention and patients who were not referred for weight-loss intervention. METHODS: Between November 2017 and May 2018, we conducted a qualitative exploratory research study using focus groups with family physicians and interviews with patients with class II or III obesity from 1 region in southern Ontario. We conducted a thematic analysis to identify emergent themes and used the barriers to change theory to classify the similarities and differences between the perspectives of family physicians, referred patients and nonreferred patients in first- and second-order barriers. RESULTS: Seventeen family physicians participated in 7 focus groups (1-4 participants/group), and we interviewed 8 referred patients and 7 nonreferred patients. We identified lack of resource supports, logistics and lack of knowledge about weight-loss interventions as first-order barriers to change, and lack of knowledge about root causes of obesity, lack of patient readiness for change and family physicians' perceptions about surgical weight loss as second-order barriers to change. Family physicians and patients had similar perceptions regarding lack of resource supports in the community, logistical issues, family physicians' lack of knowledge regarding weight-loss interventions, patients' lack of motivation and family physicians' perceptions of bariatric surgery as being high risk. They differed regarding the root cause of obesity, with family physicians attributing obesity to multiple extrinsic and intrinsic causes, whereas patients believed obesity was largely due to intrinsic causes alone. INTERPRETATION: It is important to address first- and second-order barriers to accessing weight-loss interventions through continuing professional development activities for family physicians to help ensure effective and timely treatment for patients with class II or III obesity and related comorbidities.

Oil behavior in sea ice: Changes in chemical composition and resultant effect on sea ice dielectrics.

There has been increasing urgency to develop methods for detecting oil in sea ice owing to the effects of climate change in the Arctic. A multidisciplinary study of crude oil behavior in a sea ice environment was conducted at the University of Manitoba during the winter of 2016. In the experiment, medium-light crude oil was injected underneath young sea ice in a mesocosm. The physical and thermodynamic properties of the oil-infiltrated sea ice were monitored over a three-week time span, with concomitant analysis of the oil composition using analytical instrumentation. A resonant perturbation technique was used to measure the oil dielectric properties, and the contaminated sea ice dielectric properties were modeled using a mixture model approach. Results showed that the interactions between the oil and sea ice altered their physical and thermodynamic properties. These changes led to an overall decrease in sea ice dielectrics, potentially detectable by remote sensing systems.

Examining the physical processes of corn oil (medium crude oil surrogate) in sea ice and its resultant effect on complex permittivity and normalized radar cross-section.

Due to the effects of heightened warming in the Arctic, there has been an urgency to develop methods for detecting oil in (or under) sea ice, owing to increasing potential for oil exploration and ship traffic in the more accessible Arctic regions. To test the potential for radar utilizing the normalized radar cross section (NRCS) of the sea ice, an oil-in-ice mesocosm experiment was performed. Throughout the experiment, corn oil was used as a surrogate for medium crude oil, to assess oil movement tendencies in sea ice, and the resultant impact on the complex permittivity through measurement and modelling techniques. We performed a modelling study to establish the effects of corn oil on the NRCS of sea ice. The oil presence in the sea ice increased the temperature and reduced the salinity of the sea ice, thereby lowering its complex permittivity and modeled NRCS when compared to control sea ice.

Determining the impact of a new physiotherapist-led primary care model for back pain: protocol for a pilot cluster randomized controlled trial.

BACKGROUND: Back pain is a leading contributor to disability, healthcare costs, and lost work. Family physicians are the most common first point of contact in the healthcare system for people with back pain, but physiotherapists (PTs) may be able to support the primary care team through evidence-based primary care. A cluster randomized trial is needed to determine the clinical, health system, and societal impact of a primary care model that integrates physiotherapists at the first visit for people with back pain. Prior to conducting a future fully powered cluster randomized trial, we need to demonstrate feasibility of the methods. Therefore, the purpose of this pilot study will be to: 1) Determine feasibility of patient recruitment, assessment procedures, and retention. 2) Determine the feasibility of training and implementation of a new PT-led primary care model for low back pain (LBP) 3) Explore the perspectives of patients and healthcare providers (HCPs) related to their experiences and attitudes towards the new service delivery model, barriers/facilitators to implementation, perceived satisfaction, perceived value, and impact on clinic processes and patient outcomes. METHODS: This pilot cluster randomized controlled trial will enroll four sites and randomize them to implement a new PT-led primary care model for back pain or a usual physician-led primary care model. All adults booking a primary care visit for back pain will be invited to participate. Feasibility outcomes will include: recruitment and retention rates, completeness of assessment data, PT training participation and confidence after training, and PT treatment fidelity. Secondary outcomes will include the clinical, health system, cost, and process outcomes planned for the future fully powered cluster trial. Results will be analyzed and reported descriptively and qualitatively. To explore perspectives of both HCPs and patients, we will conduct semi-structured qualitative interviews with patients and focus groups with HCPs from participants in the PT-led primary care sites. DISCUSSION: If this pilot demonstrates feasibility, a fully powered trial will provide evidence that has the potential to transform primary care for back pain. The full trial will inform future service design, whether these models should be more widely implemented, and training agendas. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03320148 . Submitted for registration on 17 September 2017.