Historical ecology with real numbers: past and present extent and biomass of an imperilled estuarine habitat.

Historic baselines are important in developing our understanding of ecosystems in the face of rapid global change. While a number of studies have sought to determine changes in extent of exploited habitats over historic timescales, few have quantified such changes prior to late twentieth century baselines. Here, we present, to our knowledge, the first ever large-scale quantitative assessment of the extent and biomass of marine habitat-forming species over a 100-year time frame. We examined records of wild native oyster abundance in the United States from a historic, yet already exploited, baseline between 1878 and 1935 (predominantly 1885-1915), and a current baseline between 1968 and 2010 (predominantly 2000-2010). We quantified the extent of oyster grounds in 39 estuaries historically and 51 estuaries from recent times. Data from 24 estuaries allowed comparison of historic to present extent and biomass. We found evidence for a 64 per cent decline in the spatial extent of oyster habitat and an 88 per cent decline in oyster biomass over time. The difference between these two numbers illustrates that current areal extent measures may be masking significant loss of habitat through degradation.

Tiered maternity care training in family medicine.

BACKGROUND AND OBJECTIVES: Maternity care training in family medicine is a major component of our specialty. The Association of Family Medicine Residency Directors (AFMRD) issued a position paper calling for a two-tiered system of training for family physicians based on concern that some residency programs are unable to meet the current Residency Committee-Family Medicine (RC-FM) requirements for maternity care training. This two-tiered system was also endorsed by other family medicine organizations, including the AAFP, ADFM, NAPCRG, and STFM. Despite this support of the new system, there remains concern among some family medicine educators about this two-tiered approach. The Society of Teachers of Family Medicine Group on Hospital Medicine and Procedural Training met in 2009 and 2010 to develop an alternative tiered system for the training of family medicine residents in maternity care. METHODS: Working from previous requirements for maternity care training and the AFMRD document, the group used a multi-voting process to identify the tiers and their elements. RESULTS: The group generated a three-tier system for maternity care training in family medicine residencies. These included curriculum, patient volume, faculty expectations, and institutional requirements. CONCLUSIONS: The three tiers we propose address the importance of maternity care, the limitations that some residencies face in providing adequate patient volumes, and the need to teach more advanced skills to those family medicine residents who will work in rural and underserved areas upon graduation. We urge family medicine governing bodies to adopt this system and believe that it will help preserve the essential role that family physicians serve in the care of pregnant women starting with basic maternity care and extending to advanced roles including care of complicated pregnancies and cesarean delivery.

Quantifying the aesthetic outcomes of breast cancer treatment: assessment of surgical scars from clinical photographs.

RATIONALE: Accurate assessment of the degree of scaring that results from surgical intervention for breast cancer would enable more effective pre-operative counselling. The resultant scar that accompanies an open surgical intervention may be characterized by variance in thickness, colour and contour. These factors significantly impact the overall appearance of the breast. A number of studies have addressed the mechanical and pathologic aspects of scarring. The majority of these investigations have focused on the physiologic process of scar formation and means to improve the qualities of a scar. Few studies have focused on quantifying the visual impact of scars. METHODS: This manuscript critically reviews current methods used to assess scars in terms of overall satisfaction after surgery. We introduce objective, quantitative measures for assessing linear breast surgical scars using digital photography. These new measurements of breast surgical scars are based on calculations of contrast and area. RESULTS AND CONCLUSIONS: We demonstrate, using the intra-class correlation coefficient, that the new measures are robust to observer variability in annotating the scar region on clinical photographs. As an example of the utility of the new measures, we use them to quantify the aesthetic differences of reconstruction following skin-sparing mastectomy vs. conventional mastectomy.

Cercopithecine herpesvirus 1 risk in a child bitten by a Bonnet Macaque monkey.

BACKGROUND: Exotic animal importation and trade has the potential to expose the public to a variety of injuries and diseases not endemic to the United States. Bonnet Macaque monkeys are a fairly common primate illegally held in captivity. These monkeys become aggressive as they age past 2 years and are known to carry asymptomatic Cercopithecine herpesvirus 1 infection. OBJECTIVE: This case is presented to illustrate the point that simple wound management alone may not only be insufficient but could be fatal in certain exotic animal bites and that the emergency physician should consult with authorities familiar with exotic animals when treating a patient with an exotic animal bite. CASE REPORT: We present the case of a 2-year-old child that was bitten by his neighbor's pet Bonnet Macaque monkey. This species of Old World monkey carries the Cercopithecine herpesvirus 1 (simian B virus) 73-100% of the time. This infection in humans can lead to an encephalitis that has a 70% mortality rate. Consultation with animal authorities led to the proper treatment, which included routine wound care, rabies prophylaxis, irrigation with sodium hypochlorite solution, and treatment with antiviral medication. CONCLUSION: Simple wound management alone may not be enough in patients bitten by exotic animals. Consultation with local zoo officials, veterinary medical schools, or the Centers for Disease Control and Prevention is recommended in these cases.

Towards quantifying the aesthetic outcomes of breast cancer treatment: comparison of clinical photography and colorimetry.

RATIONALE, AIMS AND OBJECTIVES: Scarring is a significant cause of dissatisfaction for women who undergo breast surgery. Scar tissue may be clinically distinguished from normal skin by aberrant colour, rough surface texture, increased thickness (hypertrophy) and firmness. Colorimeters or spectrophotometers can be used to quantitatively assess scar colour, but they require direct patient interaction and can cost thousands of dollars. By comparison, digital photography is already in widespread use to document clinical outcomes and requires less patient interaction. Thus, assessment of scar coloration by digital photography is an attractive alternative. The goal of this study was to compare colour measurements obtained by digital photography and colorimetry. METHODS: Agreements between photographic and colorimetric measurements of colour were evaluated. Experimental conditions were controlled by performing measurements on artificial scars created by a make-up artist. The colorimetric measurements of the artificial scars were compared with those reported in the literature for real scars in order to confirm the validity of this approach. We assessed the agreement between the colorimetric and photographic measurements of colour using a hypothesis test for equivalence, the intraclass correlation coefficient and the Bland-Altman method. RESULTS: Overall, good agreement was obtained for three parameters (L*a*b*) measured by colorimetry and photography from the results of three statistical analyses. CONCLUSION: Colour measurements obtained by digital photography were equivalent to those obtained using colorimetry. Thus, digital photography is a reliable, cost-effective measurement method of skin colour and should be further investigated for quantitative analysis of surgical outcomes.

Quantifying the aesthetic outcomes of breast cancer treatment: assessment of artificial scars.

All breast cancer treatment involves surgery, which inevitably leaves scars. Some previous studies of scarring in other healthcare settings have employed colorimeters. However, specialized colorimetry equipment is not widely used in plastic surgery; Instead, surgical outcomes are documented using digital photography. In this study, we used controlled experiments with artificial scars to compare measurements obtained by a colorimeter and a digital camera.

Prenatal ultrasound: a tale of two cities.

At the beginning of the 21st century, community-based physicians have a technology which is safe, noninvasive and relatively inexpensive. It allows immediate access to visual data inside the body for the evaluation of health and disease. Prenatal ultrasound is vital for the efficient provision of preventive care even in community health centers, where physicians may not be the delivering physicians. To assess the frequency of this diagnostic technology, a longitudinal study of 36 months tabulated prenatal ultrasound scans performed in two community-based offices providing generalist healthcare from 2001 through 2003. Between the two offices, 68,938 patients were seen, 679 deliveries were attended and 1,286 medically indicated prenatal ultrasound examinations were performed. Prenatal ultrasound scans--compared to other common office procedures, such as electrocardiograms, chest radiographs, circumcisions, blood sugar checks, Papanicolaous and colposcopies--emerged as one of the most frequently preformed diagnostic tests in the office. Based on these results, medical educators preparing generalist physicians for community medicine may want to consider some training in prenatal ultrasound. Future research can confirm the generalizability of the findings of this pilot study in two urban health centers.

Towards quantifying the aesthetic outcomes of breast cancer treatment: assessment of surgical scars.

Our long-term goal is to develop decision aids that will improve breast cancer treatment by explicitly taking aesthetics in the consideration. Essentially all breast cancer treatment involves surgery, which inevitably leaves scars. However, the extent and type of scarring is not the same for different surgeries (e.g., different forms of reconstruction.) We present our preliminary experiences in using image processing techniques to quantify scar characteristics in clinical photographs.

Teaching prenatal ultrasound to family medicine residents.

Prenatal ultrasound is a powerful diagnostic tool, but there has been little research on how to teach ultrasound to family physicians. The available evidence supports teaching through didactics followed by supervised scanning. Didactic topics include physics and machine usage, indications, fetal biometry, anatomic survey, practice management, ethical issues, and resources. Supervised scanning reinforces the didactic components of training. A "hand-on-hand" supervised scanning technique is recommended for the transmission of psychomotor skills in these sessions. Curricula for teaching ultrasound should include information on which residents will be taught prenatal ultrasound, who will teach them, how to create time for learning ultrasound skills, and how to test for competency. The literature suggests that competency can be achieved within 25-50 supervised scans. Measures of competency include examination and qualitative analysis of scanning. Competency-based testing needs further development because no uniform standards have been established.