Traditional Lecture Versus Procedural Video Randomized Trial: Comparative Analysis of Instructional Methods for Teaching Baclofen Pump Management.

OBJECTIVE: This study compared the effectiveness of traditional lectures and microvideos in teaching baclofen pump programming and refilling to physicians who have completed less than 10 refills for the previous 2 yrs. DESIGN: A mixed-method approach was used with 60 participating physicians specializing in physical medicine and rehabilitation or pain management. Preintervention and postintervention assessments were conducted using a rubric, and the participants' perceptions and preferences were gathered through focus group sessions. RESULTS: Two thirds of the participants specialized in physical medicine and rehabilitation. No significant differences in the preintervention, postintervention, or knowledge retention scores were found between the traditional lecture and microvideo groups. Both methods demonstrated comparable effectiveness in improving the baclofen pump refilling and programming skills. Qualitatively, participants perceived both approaches as equally helpful, but those in the microvideo group raised concerns because of instructors' unavailability and online platform navigation. Nevertheless, they preferred the convenience, accessibility, and time efficiency of the microvideos. CONCLUSIONS: The study concluded that microvideos are an effective alternative to traditional lectures for acquiring knowledge on baclofen pump programming and refilling. Further research should consider learners' characteristics and investigate the benefits of blended learning in medical education.

The Large-Scale Implementation of a Health Information System in Brazilian University Hospitals: Process and Outcomes.

Governments around the globe are paving the way for healthcare services that can have a profound impact on the overall well-being and development of their nations. However, government programs to implement health information technologies on a large-scale are challenging, especially in developing countries. In this article, the process and outcomes of the large-scale implementation of a hospital information system for the management of Brazilian university hospitals are analyzed. Based on a qualitative approach, this research involved 21 hospitals and comprised a documentary search, interviews with 24 hospital managers and two system user focus groups, and a questionnaire of 736 respondents. Generally, we observed that aspects relating to the wider context of system implementation (macro level), the managerial structure, cultural nuances, and political dynamics within each hospital (meso level), as well as the technology, work activities, and individuals themselves (micro level) acted as facilitators and/or obstacles to the implementation process. The dynamics and complex interactions established between these aspects had repercussions on the process, including the extended time necessary to implement the national program and the somewhat mixed outcomes obtained by hospitals in the national network. Mostly positive, these outcomes were linked to the eight emerging dimensions of practices and work processes; planning, control, and decision making; transparency and accountability; optimization in the use of resources; productivity of professionals; patient information security; safety and quality of care; and improvement in teaching and research. We argued here that to maximize the potential of information technology in healthcare on a large-scale, an integrative and cooperative vision is required, along with a high capacity for change management, considering the different regional, local, and institutional contexts.

Pain Medicine Milestones 2.0: a step into the future.

OBJECTIVE: To describe the process of revising the Pain Medicine Milestones 1.0 and implementing changes into the Pain Medicine Milestones 2.0 along with implications for pain medicine trainees. BACKGROUND: Competency-based medical education has been implemented in graduate medical education, including pain medicine. Milestones 1.0, introduced by the Accreditation Council for Graduate Medical Education (ACGME), has been used to assess learners in six competencies and respective sub-competencies. Recognizing areas for improvement in Milestones 1.0, the ACGME initiated the process of Milestones 2.0 and a working group was created to execute this task for pain medicine. The working group discussed revisions; consensus was sought when changes were introduced. Final milestones were agreed upon and made available for public comment prior to publication. RESULTS: Redundant sub-competencies were either merged or eliminated, reducing the number of sub-competencies. A maximum of three rows representing skill, knowledge, behavior and attitude were included for each sub-competency. Harmonized Milestones, aligning with other specialties in a predetermined ACGME framework, were adopted and modified to meet the needs of pain medicine. A supplemental guide was developed to assist educators in implementation of Milestones 2.0 and assessment of trainees. CONCLUSIONS: The intent of the Milestones 2.0 was to create an improved tool that is comprehensive, easier to utilize, and of increased value for pain medicine training programs. It is expected that implementation of Milestones 2.0 will streamline pain medicine trainee assessments by educators and prepare trainees for the future practice of pain medicine while serving to be the foundation of an iterative process to match the evolution of the specialty.

Reduced Antibody Acquisition with Increasing Age following Vaccination with BNT162b2: Results from Two Longitudinal Cohort Studies in The Netherlands.

Vaccine-induced protection against severe COVID-19, hospitalization, and death is of the utmost importance, especially in the elderly. However, limited data are available on humoral immune responses following COVID-19 vaccination in the general population across a broad age range. We performed an integrated analysis of the effect of age, sex, and prior SARS-CoV-2 infection on Spike S1-specific (S1) IgG concentrations up to three months post-BNT162b2 (Pfizer/BioNTech; Comirnaty) vaccination. In total, 1735 persons, eligible for COVID-19 vaccination through the national program, were recruited from the general population (12 to 92 years old). Sixty percent were female, and the median vaccination interval was 35 days (interquartile range, IQR: 35−35). All participants had seroconverted to S1 one month after two vaccine doses. S1 IgG was higher in participants with a history of SARS-CoV-2 infection (median: 4535 BAU/mL, IQR: 2341−7205) compared to infection-naive persons (1842 BAU/mL, 1019−3116), p < 0.001. In infection-naive persons, linear mixed effects regression showed a strong negative association between age and S1 IgG (p < 0.001) across the entire age range. Females had higher S1 IgG than males (p < 0.001). In persons with an infection history, age nor sex was associated with S1 IgG concentrations. The lower magnitude of S1 antibodies in older persons following COVID-19 vaccination will affect long-term protection.

Rehabilitation of Individuals With Cancer.

The survival rate of cancer is increasing as treatment improves. As patients with cancer now live longer, impairments may arise that impact quality of life (QOL) and function. Therefore, a focus on QOL is often as important as survival. An interdisciplinary team can achieve goal-oriented and patient-centered rehabilitation, which can optimize function and QOL, and minimize impairments, restrictions, and activity limitations. In most cases, cancer patients must be active participants in therapy and exhibit carryover. Patients with cancer often have impairments that include fatigue, pain, brain fog, impaired cognition, paresis, mood disorders, difficulty with activities of daily living (ADL), bowel/bladder/sexual dysfunction, and bone and soft tissue involvement. Adaptive equipment, exercise, and ADL training can mitigate restrictions on activity. The trajectory and phase of the disease along the continuum of cancer care may influence the goals of rehabilitation in that time window. QOL is often influenced by participation in vocational, recreational, and home-based activities. A holistic perspective should include an analysis of distress, socioeconomic barriers, and transportation limitations when addressing issues.

Influence of personality and emotional competences on academic performance: direct and indirect pathways mediated by perceived stress.

BACKGROUND: Among the factors influencing academic performance (AP), individual differences at the trait level such as personality and emotional competences (EC) have been found to play a critical role, similarly to state variables such as perceived stress (PS). Participants And Procedure: The aim of this study was to clarify whether the influence of personality (Big Five) and EC on AP (general point average) is direct and/or mediated via PS. 537 undergraduate students from a French university (112 male and 425 female, Mage = 19.84 years, SDage = 1.74 years, range = 18-30 years; first year: n = 293, 55%; second year: n = 162, 30%, third year: n = 82, 15%) filled out the test battery around three weeks before the final examination. RESULTS: Path analysis showed that AP was directly predicted by conscientiousness (+), neuroticism (+), extraversion (-) and perceived stress (-), while perceived stress was predicted by neuroticism (+) and by intrapersonal EC (-). CONCLUSIONS: The results illustrate the robust influence of conscientiousness on AP, while EC was not found to influence AP directly, but indirectly via its effect on PS.

Rehabilitation of Individuals With Cancer

The survival rate of cancer is increasing as treatment improves. As patients with cancer now live longer, impairments may arise that impact quality of life (QOL) and function. Therefore, a focus on QOL is often as important as survival. An interdisciplinary team can achieve goal-oriented and patient-centered rehabilitation, which can optimize function and QOL, and minimize impairments, restrictions, and activity limitations. In most cases, cancer patients must be active participants in therapy and exhibit carryover. Patients with cancer often have impairments that include fatigue, pain, brain fog, impaired cognition, paresis, mood disorders, difficulty with activities of daily living (ADL), bowel/bladder/sexual dysfunction, and bone and soft tissue involvement. Adaptive equipment, exercise, and ADL training can mitigate restrictions on activity. The trajectory and phase of the disease along the continuum of cancer care may influence the goals of rehabilitation in that time window. QOL is often influenced by participation in vocational, recreational, and home-based activities. A holistic perspective should include an analysis of distress, socioeconomic barriers, and transportation limitations when addressing issues.

Monitoring Urban Beach Quality on a Summer Day: Determination of the Origin of Fecal Indicator Bacteria and Antimicrobial Resistance at Prophète Beach, Marseille (France).

A highly frequented beach in Marseille, France, was monitored on an hourly basis during a summer day in July 2018, to determine possible water and sand fecal pollution, in parallel with influx of beach users from 8 a.m. to 8 p.m. Fecal indicator bacteria were enumerated, together with four host-associated fecal molecular markers selected to discriminate human, dog, horse, or gull/seagull origins of the contamination. The antimicrobial resistance of bacteria in water and sand was evaluated by quantifying (i) the class 1, 2, and 3 integron integrase genes intI, and (ii) bla TEM, bla CTX-M, and bla SHV genes encoding endemic beta-lactamase enzymes. The number of beach users entering and leaving per hour during the observation period was manually counted. Photographs of the beach and the bathing area were taken every hour and used to count the number of persons in the water and on the sand, using a photo-interpretation method. The number of beach users increased from early morning to a peak by mid-afternoon, totaling more than 1,800, a very large number of users for such a small beach (less than 1 ha). An increase in fecal contamination in the water corresponded to the increase in beach attendance and number of bathers, with maximum numbers observed in the mid-afternoon. The human-specific fecal molecular marker HF183 indicated the contamination was of human origin. In the water, the load of Intl2 and 3 genes was lower than Intl1 but these genes were detected only during peak attendance and highest fecal contamination. The dynamics of the genes encoding B-lactamases involved in B-lactams resistance notably was linked to beach attendance and human fecal contamination. Fecal indicator bacteria, integron integrase genes intI, and genes encoding B-lactamases were detected in the sand. This study shows that bathers and beach users can be significant contributors to contamination of seawater and beach sand with bacteria of fecal origin and with bacteria carrying integron-integrase genes and beta lactamase encoding genes. High influx of users to beaches is a significant factor to be considered in order to reduce contamination and manage public health risk.

Airborne mycotoxins in waste recycling and recovery facilities: Occupational exposure and health risk assessment.

Mycotoxins are metabolites secreted by certain types of moulds, and some of them can be harmful to health. The objective of this study was to estimate the level of exposure to airborne aflatoxin B1, ochratoxin A, gliotoxin and sterigmatocystin in waste recycling and recovery facilities. An additional goal was to assess the related health risks for workers. Targeted mycotoxins were analysed quantitatively in 94 air samples collected in five sites using ultra-performance liquid chromatography coupled with high resolution mass spectrometry. The level of exposure to mycotoxin during working day scenarios was compared to benchmark values, either health-based guidelines when available or the concentration of no toxicological concern (CoNTC) when not. Eleven per cent of samples showed quantifiable measurement results. Aflatoxin B1 and sterigmatocystin were quantified at the mechanical separation area in mechanical-biological treatment (MBT) facilities and in the materials recovery facility (MRF), but not in composting plants and composting units in MBT facilities. The levels of exposure were all below 1 ng m-3. This is the first time exposure to sterigmatocystin in waste management facilities is reported and quantified. Ochratoxin A and gliotoxin were not quantified in any of the air samples. Health risk assessment approaches did not suggest a significant threat to workers' health. These data do not suggest the need for specific prevention measures in addition to those against other airborne biological agents.

Estimating 42 pesticide sampling rates by POCIS and POCIS-MIP samplers for groundwater monitoring: a pilot-scale calibration.

Pesticides occur in groundwater as a result of agricultural activity. Their monitoring under the Water Framework Directive is based on only a few spot-sampling measurements per year despite their temporal variability. Passive sampling, which was successfully tested in surface water to provide a more representative assessment of contamination, could be applied to groundwater for a better definition of its contamination. However, few reliable calibration data under low water flow are available. The objective of our study thus consisted in determining sampling rates by two types of passive samplers, a POCIS (polar organic chemical integrative sampler) for polar pesticides, and a POCIS-MIP sampler based on a receiving phase of molecular imprinted polymers, specific for AMPA and glyphosate under low flow conditions as exist in groundwater. To our knowledge, this is the first time that sampling rates (sampling rate represents the volume of water from which the analyte is quantitatively extracted by the sampler per unit time) are estimated for groundwater applications. Our calibrations took place in an experimental pilot filled with groundwater and with low water flow (a few metres per day). Pesticide uptake in POCIS showed good linearity, with up to 28 days before reaching equilibrium. Two types of accumulation in POCIS were noted (a linear pattern up to 28 days, and after a time lag of 7 to 14 days). Sampling rates for 38 compounds were calculated and compared with those available in the literature or obtained previously under laboratory conditions. The values obtained were lower by a factor 1 to 14 than those estimated under stirring conditions in the literature, whereas water flow velocity (m s-1) differed by a factor of 2000 to 10,000.

Determination of Postacute Hospitalization Level of Care.

In the United States, we are blessed with many options for postacute care: inpatient rehabilitation facilities, long-term acute care hospitals, skilled nursing facilities, home health agencies, and outpatient rehabilitation. However, choosing the appropriate level of care can be a daunting task. It requires interdisciplinary input and involvement of all stakeholders. The decision should be informed by outcomes data specific to the patient's diagnosis, impairments, and psychosocial supports.

Assessing UV filter inputs into beach waters during recreational activity: A field study of three French Mediterranean beaches from consumer survey to water analysis.

In order to assess the release of UV filters from the sunscreen used by beachgoers into seawater within the bathing zone, a field campaign was carried out during the summer of 2017 at three beaches in Marseille, along the French Mediterranean coast. A social survey analyzed beachgoer attendance, the quantities and types of suncare products used and the bathing frequencies, while the bathing water was analyzed spatially and temporally so as to quantify both mineral and organic UV filters directly released and recovered. During the peak recreational time at the three beaches, both mineral and organic UV filters were detected in higher concentrations in the bathing area than offshore. In general, higher concentrations were recovered in the water top surface layer than in the water column, giving respectively 100-900 and 20-50 µg/L for TiO2, 10-15 and 1-3 µg/L for ZnO, 40-420 and 30-150 ng/L for octocrylene, and 10-15 and 10-350 ng/L for avobenzone. More than 75% of the 471 interviewees reported bathing every time they go to the beach, with 68% using a suncare product 2.6 times on average. From these data we estimated that an average mass of 52 kg/day or 1.4 t/month of suncare products are possibly released into bathing water for a beach attended by 3000 people daily. The mass ratio of UV filters in such products typically ranges from 0.03 to 0.1, allowing us to propose theoretical maximum concentrations in the beach water. Our recovery of measured UV filter concentrations in seawater compared to the theoretical concentrations revealed two distinct scenarios for the mineral and organic filters. While up to 49% of the mineral filters used by beachgoers may be released into the seawater, the organic filters were minimally recovered in the environment, most likely due to internalization through the skin barrier or partial photodegradation.

Initial skin cancer screening for solid organ transplant recipients in the United States: Delphi method development of expert consensus guidelines.

Skin cancer is the most common malignancy affecting solid organ transplant recipients (SOTR), and SOTR experience increased skin cancer-associated morbidity and mortality. There are no formal multidisciplinary guidelines for skin cancer screening after transplant, and current practices are widely variable. We conducted three rounds of Delphi method surveys with a panel of 84 U.S. dermatologists and transplant physicians to establish skin cancer screening recommendations for SOTR. The transplant team should risk stratify SOTR for screening, and dermatologists should perform skin cancer screening by full-body skin examination. SOTR with a history of skin cancer should continue regular follow-up with dermatology for skin cancer surveillance. High-risk transplant patients include thoracic organ recipients, SOTR age 50 and above, and male SOTR. High-risk Caucasian patients should be screened within 2 years after transplant, all Caucasian, Asian, Hispanic, and high-risk African American patients should be screened within 5 years after transplant. No consensus was reached regarding screening for low-risk African American SOTR. We propose a standardized approach to skin cancer screening in SOTR based on multidisciplinary expert consensus. These guidelines prioritize and emphasize the need for screening for SOTR at greatest risk for skin cancer.

Inhalable dust as a marker of exposure to airborne biological agents in composting facilities.

OBJECTIVES: Industrial composting is associated with high levels of worker exposure to bioaerosols. Measurement of airborne microorganisms and endotoxin is complex and the related cost is high. The objective was therefore to examine whether dust measurement could be used as a marker of exposure to bioaerosols in composting facilities. METHODS: A dataset of 110 measurements carried out in eight sludge composting plants was explored. Mixed-effects models were constructed to explain between-site and within-site variability in concentration of endotoxin and culturable mesophilic bacteria, mesophilic moulds and thermophilic actinomycetes in air. Fixed-effects variables were inhalable dust concentration, the season, the outdoor/indoor location of sampling and the process area. RESULTS: The level of dust was a highly significant determinant of concentration for all biological agents. Within-site variability was always larger than between-site variability. The proportion of within-site variability explained by determinants was 68%, 65%, 56% and 60% for endotoxin, bacteria, moulds and actinomycetes, respectively. Inclusion of dust in the final model resulted in an increase of 24, 20, 12 and 17 points of percentage within-site variability, respectively. Inclusion of season resulted in an increase of 9, 12, 12 and 15 points, respectively. Within-site variability was less influenced by outdoor/indoor location and process area, except for moulds. CONCLUSION: Dust was the factor that most influenced within-site variability in endotoxin and culturable bacteria concentration. Measurement of dust can efficiently assist decision making for prevention measures against endotoxin and bacteria in sludge composting plants. Our results are not as conclusive for actinomycetes and especially for moulds.

Reduced Chlorine in Drinking Water Distribution Systems Impacts Bacterial Biodiversity in Biofilms.

In drinking water distribution systems (DWDS), a disinfectant residual is usually applied to limit bacterial regrowth. However, delivering water with no or reduced chlorine residual could potentially decrease the selection for antimicrobial resistant microorganisms, favor bacterial regrowth and result in changes in bacterial populations. To evaluate the feasibility of water reduction in local DWDS while ensuring water safety, water quality was measured over 2 months in two different networks, each of them harboring sub-areas with normal and reduced chlorine. Water quality remained good in chlorine reduced samples, with limited development of total flora and absence of coliforms. Furthermore, 16S rRNA amplicon-based metagenomics was used to investigate the diversity and the composition of microbial communities in the sub-networks. Taxonomic classification of sequence reads showed a reduced bacterial diversity in sampling points with higher chlorine residuals. Chlorine disinfection created more homogeneous bacterial population, dominated by Pseudomonas, a genus that contains some major opportunistic pathogens such as P. aeruginosa. In the absence of chlorine, a larger and unknown biodiversity was unveiled, also highlighted by a decreased rate of taxonomic classification to the genus and species level. Overall, this experiment in a functional DWDS will facilitate the move toward potable water delivery systems without residual disinfectants and will improve water taste for consumers.

TOPBP1Dpb11 plays a conserved role in homologous recombination DNA repair through the coordinated recruitment of 53BP1Rad9.

Genome maintenance and cancer suppression require homologous recombination (HR) DNA repair. In yeast and mammals, the scaffold protein TOPBP1Dpb11 has been implicated in HR, although its precise function and mechanism of action remain elusive. In this study, we show that yeast Dpb11 plays an antagonistic role in recombination control through regulated protein interactions. Dpb11 mediates opposing roles in DNA end resection by coordinating both the stabilization and exclusion of Rad9 from DNA lesions. The Mec1 kinase promotes the pro-resection function of Dpb11 by mediating its interaction with the Slx4 scaffold. Human TOPBP1Dpb11 engages in interactions with the anti-resection factor 53BP1 and the pro-resection factor BRCA1, suggesting that TOPBP1 also mediates opposing functions in HR control. Hyperstabilization of the 53BP1-TOPBP1 interaction enhances the recruitment of 53BP1 to nuclear foci in the S phase, resulting in impaired HR and the accumulation of chromosomal aberrations. Our results support a model in which TOPBP1Dpb11 plays a conserved role in mediating a phosphoregulated circuitry for the control of recombinational DNA repair.

Aspergillus fumigatus and mesophilic moulds in air in the surrounding environment downwind of non-hazardous waste landfill sites.

Non-hazardous waste landfilling has the potential to release biological agents into the air, notably mould spores. Some species, such as Aspergillus fumigatus, may be a cause of concern for at-risk nearby residents. However, air concentration in the surrounding environment of non-hazardous waste landfill sites is poorly documented. An extensive sampling programme was designed to investigate the relationship between culturable mesophilic moulds and A. fumigatus concentrations in air and distance downwind of non-hazardous waste landfill sites. On-site and off-site repeated measurements were performed at four landfill sites during cold and warm seasons. A high-flow air-sampler device was selected so as to allow peak concentration measurement. Linear mixed-effects models were used to explain variability in the concentrations in air over time and across sites, seasons, instantaneous meteorological conditions and discharged waste tonnage. Concentrations of mesophilic moulds and A. fumigatus at off-site upwind sampling locations were compared with concentrations at each of the downwind sampling locations. At the tipping face location, peak concentration reached 480,000CFUm(-3) for mesophilic moulds and 9300CFUm(-3) for A. fumigatus. Compared with upwind background levels, these concentrations were, on average, approximately 20 and 40 times higher respectively. A steep decline in the concentration of both mesophilic moulds and A. fumigatus was observed between the tipping face location and the downwind property boundary (reduction by 77% and 84% respectively), followed by a low decline leading to a 90% and 94% reduction in concentration at 200m from the property boundary and beyond. With the 200m and 500m downwind sampling point values added together, the 97.5th percentile of concentration was 6013CFUm(-3) and 87CFUm(-3) for mesophilic moulds and A. fumigatus, respectively. Other determining factors were the discharged waste tonnage, the season, instantaneous temperature and wind velocity for mesophilic mould, and instantaneous temperature for A. fumigatus. At 200m and 500 downwind from the property boundary, mesophilic moulds and A. fumigatus concentrations were still higher than the local background level. However, whilst statistically significant, this increase does not suggest an excess risk to nearby residents' health when compared with the wide range of outdoor background levels reported in literature. These findings suggest that moulds and A. fumigatus may be transported beyond 200m from the property boundary in concentrations above those found locally upwind of the landfill site. Nevertheless, for exposure assessment purposes, comparison should also be made with background levels in wider areas which are either residential or through which people travel to work for example.

Minding the Gaps in Cancer Pain Management Education: A Multicenter Study of Clinical Residents and Fellows in a Low- Versus High-Resource Setting.

PURPOSE: Inadequate pain management training has been reported as a major cause of undertreatment of cancer pain. Yet, past research has not comprehensively compared the quality of cancer pain management education among physicians in training in high-resource countries (HRCs) with those in low-resource countries (LRCs). The purpose of this study was to examine and compare gaps in cancer pain management education among physician trainees in an HRC (United States) versus an LRC (Ghana). METHODS: A cross section of physicians at four major academic medical centers completed surveys about the adequacy of cancer pain training. Participation in the study was completely voluntary, and paper or online surveys were completed anonymously. RESULTS: The response rate was 60% (N = 120). Major gaps were identified in cancer pain management education across the spectrum of medical school training. Training was rated as inadequate (by approximately 80% of trainees), although approximately 10% more trainees in HRCs versus LRCs felt this way; 35% said residency training was inadequate in both settings; and 50% in LRCs versus 44% in HRCs said fellowship training was less than good. On the basis of the lowest group means, the three key areas of perceived deficits included interventional pain procedures (2.34 ± 1.12), palliative care interventions (2.39 ± 1.12), and managing procedural and postoperative pain (2.94 ± 0.97), with significant differences in the distribution of deficits in 15 cancer-pain competencies between LRCs and HRCs (P < .05). CONCLUSION: This study identifies priority areas that could be targeted synergistically by LRCs and HRCs to advance cancer care globally. The findings underscore differential opportunities to broaden and improve competencies in cancer pain management via exchange training, in which physicians from HRCs spend time in LRCs and vice versa.

Drinking water, diet, indoor air: Comparison of the contribution to environmental micropollutants exposure.

This study collated 254,441 analytical results from drinking water quality monitoring in order to compare levels of exposure of the French adult population from drinking water with that from total diet for 37 pesticides, 11 mineral elements, 11 polycyclic aromatic hydrocarbons (PAH), 6 non dioxin-like polychlorobiphenyls (NDL PCB), 5 ether polybromodiphenyl ethers (BDE), 2 perfluorinated compounds. It also compares levels of exposure from drinking water with that from inhalation of indoor air for 9 volatile organic compounds (VOC) and 3 phthalates. The vast majority of the water analysis results showed values below the limits of quantification and this comparison was primarily made on the basis of a highly pessimistic scenario consisting in considering the data below the limits of quantification as being equal to the limits of quantification. With this conservative scenario, it can be seen that tap water makes a minor but potentially non-negligible contribution for a few micropollutants, by comparison with diet and air. It also shows that exposure through drinking water remains below the toxicity reference values for these substances. Apart from a few extreme values reflecting exceptional local situations, the concentrations measured for the minority of positive samples (below the 95th percentile value) suggest a very low risk for human health. Lower limits of quantification would however be of use in better estimating the safety margin with regard to the toxicity reference values, in particular for BDE, PAH and NDL PCB.

A pediatric residency experience with surgical co-management.

BACKGROUND AND OBJECTIVE: Acquisition of knowledge and skills in the care of surgical patients is defined as an essential element of training by the Pediatric Residency Review Committee. The pediatric-surgical comanagement model of care is increasingly utilized, yet its impact on residency training has not been described. The goal of this study was to describe a 5-year experience with a co-management model in a pediatric residency program. METHODS: We describe the planning and implementation of a surgical co-management model in a pediatric residency program and report on case volume and diversity from 2005 to 2010. We assessed the experience of pediatric residents and faculty through rotation evaluations, program leadership meetings, and an anonymous online survey. In the survey, residents rated the value of their exposure on knowledge and skills in selected perioperative domains and their experience with interprofessional teamwork. RESULTS: The volume of co-managed patients increased threefold from 2005 to 2010; most (79%) had concurrent medical conditions, and one-third (36%) were children with special health care needs (CYSHCN). Residents reported that co-management helped them gain knowledge and skills in pain management, fluid and electrolytes, respiratory, and nutritional support, as well as in interprofessional teamwork. Other strengths included greater exposure to CYSHCN and subspecialty faculty, and preparedness for critical care rotations. Challenges included clarity of roles and responsibilities between pediatric and surgery residents and interservice communication. CONCLUSIONS: A surgical co-management model in pediatric residency training presented important opportunities for development of residents' knowledge and skills in perioperative care and interprofessional teamwork.