Cruise shipping supply chains and the impacts of disruptions: The case of the Caribbean.

Cruise shipping supply chains have unique characteristics where product and service providers accommodate stringent requirements related to the nature of the cruise product. Since cruise ships are floating resorts that must be resupplied during their short port rotations, they require customized procurement practices. The sustainability of such practices is investigated through the lenses of contract dynamics among actors, including sourcing patterns, consumption patterns, pricing, and delivery patterns. The disruptions caused by hurricanes in the Caribbean underline the challenge the industry is facing at reconciling the risks of climate change with sustainable cruise supply chains.

The distribution network of Amazon and the footprint of freight digitalization.

The emergence of e-commerce as a dominant retail paradigm is associated with a rapid shift in the commercial footprint towards distributional-based consumption. Through the analysis of the geographical expansion, market coverage, and functional specialization of Amazon's distribution network, the research underlines that digitalization has a pronounced physicality. E-commerce is favoring a transition from the conventional retail freight landscape towards a new physicality of freight distributions involving purpose-designed facilities, modes, and channels. The case of Amazon underlines a consistent locational behavior to achieve a distributional hierarchy of facilities granting logistical access to consumer markets. The distributional hierarchy is organized in three stages, which are procurement and fulfillment, distribution, and last-mile.

Percutaneous Thrombectomy with the JETi8 Peripheral Thrombectomy System for the Treatment of Deep Vein Thrombosis.

PURPOSE: This study evaluated the safety and efficacy of the JETi8 peripheral thrombectomy system in treating acute deep vein thrombosis (DVT). MATERIALS AND METHODS: A retrospective study was conducted in 18 consecutive patients (mean age, 41 years old [range, 15-74 years old]; 5 men and 13 women). There were 21 instances of DVTs (9 iliofemoral, 10 axillosubclavian, and 2 portal), which were treated using the JETi8 thrombectomy device between November 2016 and July 2018. Thrombus was laced with recombinant tissue plasminogen activator (r-TPA) (9.3 mg, on average; range, 2-12 mg) in 17 procedures (81%) prior to thrombectomy. Technical success was defined as restoration of antegrade flow using the JETi8 with or without additional treatment of an underlying obstructive lesion. Procedural success was defined as technical success with or without the addition of overnight catheter-directed thrombolysis (CDT) RESULTS: Mean procedure time was 83 minutes (range, 30-160 minutes), and mean thrombus reduction with the JETi8 alone was 92% (range, 60%-100%). Stent placement was required in 6 procedures (29%). Technical success using the JETi8 system alone was 76% (16 of 21 procedures), whereas 5 procedures (24%) required subsequent overnight CDT in the intensive care unit. Procedural success rate was 100% (20 of 20 procedures). Mean aspirated volume was 531 mL (range, 250-1,230 mL). The only adverse event was a subsegmental pulmonary embolism. Seven patients (33%) were discharged the same day. Recurrent thrombosis was observed in 5 patients (24%), of whom 3 were successfully treated with the JETi8 system. CONCLUSIONS: The JETi8 system may be a safe and effective option for thrombectomy of acute DVT.

Optimizing clinical and organizational practice in cancer survivor transitions between specialized oncology and primary care teams: a realist evaluation of multiple case studies.

BACKGROUND: Cancer is now viewed as a chronic disease, presenting challenges to follow-up and survivorship care. Models to shift from haphazard, suboptimal and fragmented episodes of care to an integrated cancer care continuum must be developed, tested and implemented. Numerous studies demonstrate improved care when follow-up is assured by both oncology and primary care providers rather than either group alone. However, there is little data on the roles assumed by specialized oncology teams and primary care providers and the extent to which they work together. This study aims to develop, pilot test and measure outcomes of an innovative risk-based coordinated cancer care model for patients transitioning from specialized oncology teams to primary care providers. METHODS/DESIGN: This multiple case study using a sequential mixed-methods design rests on a theory-driven realist evaluation approach to understand how transitions might be improved. The cases are two health regions in Quebec, Canada, defined by their geographic territory. Each case includes a Cancer Centre and three Family Medicine Groups selected based on differences in their determining characteristics. Qualitative data will be collected from document review (scientific journal, grey literature, local documentation), semi-directed interviews with key informants, and observation of care coordination practices. Qualitative data will be supplemented with a survey to measure the outcome of the coordinated model among providers (scope of practice, collaboration, relational coordination, leadership) and patients diagnosed with breast, colorectal or prostate cancer (access to care, patient-centredness, communication, self-care, survivorship profile, quality of life). Results from descriptive and regression analyses will be triangulated with thematic analysis of qualitative data. Qualitative, quantitative, and mixed methods data will be interpreted within and across cases in order to identify context-mechanism associations that explain outcomes. DISCUSSION: The study will provide empirical data on a risk-based coordinated model of cancer care to guide actions at different levels in the health system. This in-depth multiple case study using a realist approach considers both the need for context-specific intervention research and the imperative to address research gaps regarding coordinated models of cancer care.

Early Radiographic and Tomographic Manifestations of Legionnaires' Disease.

PURPOSE: Legionnaires' disease (LD) may occur sporadically or in the course of outbreaks, where the typical radiological manifestations of the disease may better be delineated. We took advantage of a rare community-based epidemic of LD (181 patients) that occurred in 2012 in Quebec City, Canada, to describe the radiographic features of LD and compare the its tomographic presentation with that of community-acquired pneumonia caused by common bacteria other than Legionella pneumophila. METHODS: From the 181 individuals affected in the outbreak, we obtained the chest radiographs of 159 individuals (mean 63 ± 15 years of age) for detailed analysis; 33 patients had a computed tomography (CT) scan performed during the course of their illness. In a case-control study, we compared the CT scans of patients with LD with those of patients who had received a diagnosis of community-acquired pneumonia caused by a pathogen other than Legionella and confirmed by chest CT scan. RESULTS: Overall, LD most often presented as an airspace consolidation involving 1 of the lower lobes. Pleural effusion and mediastinal adenopathies were apparent only in a minority, whereas no pneumothorax or cavitation was noted. We did not find any significant difference in chest CT scan findings in patients with LD vs those with community-acquired pneumonia from other bacterial origin. No radiological finding was clearly associated with an increased risk of intensive care unit admission or mortality. CONCLUSIONS: The early radiographic and tomographic manifestations of LD are nonspecific and similar to those found in community-acquired pneumonia from other bacterial origin.

Combining administrative data feedback, reflection and action planning to engage primary care professionals in quality improvement: qualitative assessment of short term program outcomes.

BACKGROUND: Improving primary care for chronic disease management requires a coherent, integrated approach to quality improvement. Evidence in the continuing professional development (CPD) field suggests the importance of using strategies such as feedback delivery, reflective practice and action planning to facilitate recognition of gaps and service improvement needs. Our study explored the outcomes of a CPD intervention, named the COMPAS Project, which consists of a three-hour workshop composed of three main activities: feedback, critical reflection and action planning. The feedback intervention is delivered face-to-face and presents performance indicators extracted from clinical-administrative databases. This aim of this study was to assess the short term outcomes of this intervention to engage primary care professional in continuous quality improvement (QI). METHODS: In order to develop an understanding of our intervention and of its short term outcomes, a program evaluation approach was used. Ten COMPAS workshops on diabetes management were directly observed and qualitative data was collected to assess the intervention short term outcomes. Data from both sources were combined to describe the characteristics of action plans developed by professionals. Two independent coders analysed the content of these plans to assess if they promoted engagement in QI and interprofessional collaboration. RESULTS: During the ten workshops held, 26 interprofessional work teams were formed. Twenty-two of them developed a QI project they could implement themselves and that targeted aspects of their own practice they perceived in need of change. Most frequently prioritized strategies for change were improvement of systematic clientele follow-up, medication compliance, care pathway and support to improve adoption of healthier life habits. Twenty-one out of 22 action plans were found to target some level of improvement of interprofessional collaboration in primary care. DISCUSSION: Our study results demonstrate that the COMPAS intervention enabled professionals to target priorities for practice improvements and to develop action plans that promote interprofessional collaboration. The COMPAS intervention aims to increase capability for continuous QI, readiness to implement process of care changes and team shared goals but available resources, climate and culture for change and leadership, are also important required conditions to successfully implement these practice changes. CONCLUSION: We think that the proposed approach can be very useful to support and engage primary care professionals in the planning stage of quality improvement projects since it combines key successful ingredients: feedback, reflection and planning of action.

Engaging primary care practitioners in quality improvement: making explicit the program theory of an interprofessional education intervention.

BACKGROUND: The scientific literature continues to advocate interprofessional collaboration (IPC) as a key component of primary care. It is recommended that primary care groups be created and configured to meet the healthcare needs of the patient population, as defined by patient demographics and other data analyses related to the health of the population being served. It is further recommended that the improvement of primary care services be supported by the delivery of feedback and performance measurements. This paper describes the theory underlying an interprofessional educational intervention developed in Quebec's Montérégie region (Canada) for the purpose of improving chronic disease management in primary care. The objectives of this study were to explain explicitly the theory underlying this intervention, to describe its components in detail and to assess the intervention's feasibility and acceptability. METHOD: A program impact theory-driven evaluation approach was used. Multiple sources of information were examined to make explicit the theory underlying the education intervention: 1) a literature review and a review of documents describing the program's development; 2) regular attendance at the project's committee meetings; 3) direct observation of the workshops; 4) interviews of workshop participants; and 5) focus groups with workshop facilitators. Qualitative data collected were analysed using thematic analysis. RESULTS: The theoretical basis of the interprofessional education intervention was found to be work motivation theory and reflective learning. Five themes describing the workshop objectives emerged from the qualitative analysis of the interviews conducted with the workshop participants. These five themes were the importance of: 1) adopting a regional perspective, 2) reflecting, 3) recognizing gaps between practice and guidelines, 4) collaborating, and 5) identifying possible practice improvements. The team experienced few challenges implementing the intervention. However, the workshop's acceptability was found to be very good. CONCLUSION: Our observation of the workshop sessions and the interviews conducted with the participants confirmed that the objectives of the education intervention indeed targeted the improvement of interprofessional collaboration and quality of care. However, it is clear that a three-hour workshop alone cannot lead to major changes in practice. Long-term interventions are needed to support this complex change process.

Detection of low pathogenic avian influenza viruses in wild ducks from Canada: comparison of two sampling methods.

Surveillance for avian influenza viruses in wild birds was initiated in Canada in 2005. In 2006, in order to maximize detection of highly pathogenic avian influenza viruses, the sampling protocol used in Canada's Inter-agency Wild Bird Influenza Survey was changed. Instead of collecting a single cloacal swab, as previously done in 2005, cloacal and oropharyngeal swabs were combined in a single vial at collection. In order to compare the two sampling methods, duplicate samples were collected from 798 wild dabbling ducks (tribe Anatini) in Canada between 24 July and 7 September 2006. Low pathogenic avian influenza viruses were detected significantly more often (P<0.0001) in combined oropharyngeal and cloacal samples (261/798, 33%) than in cloacal swabs alone (205/798, 26%). Compared to traditional single cloacal samples, combined samples improved virus detection at minimal additional cost.

Protecting public health and global freight transportation systems during an influenza pandemic.

The H5N1 influenza threat is resulting in global preparations for the next influenza pandemic. Pandemic influenza planners are prioritizing scarce vaccine, antivirals, and public health support for different segments of society. The freight, bulk goods, and energy transportation network comprise the maritime, rail, air, and trucking industries. It relies on small numbers of specialized workers who cannot be rapidly replaced if lost due to death, illness, or voluntary absenteeism. Because transportation networks link economies, provide critical infrastructures with working material, and supply citizens with necessary commodities, disrupted transportation systems can lead to cascading failures in social and economic systems. However, some pandemic influenza plans have assigned transportation workers a low priority for public health support, vaccine, and antivirals. The science of Transportation Geography demonstrates that transportation networks and workers are concentrated at, or funnel through, a small number of chokepoints and corridors. Chokepoints should be used to rapidly and efficiently vaccinate and prophylax the transportation worker cohort and to implement transmission prevention measures and thereby protect the ability to move goods. Nations, states, the transportation industry and unions, businesses, and other stakeholders must plan, resource, and exercise, and then conduct a transportation health assurance and security campaign for an influenza pandemic.

Practice features associated with patient-reported accessibility, continuity, and coordination of primary health care.

PURPOSE: On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients. METHODS: Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic. RESULTS: One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office. CONCLUSIONS: The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.

Wild bird influenza survey, Canada, 2005.

Of 4,268 wild ducks sampled in Canada in 2005, real-time reverse transcriptase-PCR detected influenza A matrix protein (M1) gene sequence in 37% and H5 gene sequence in 5%. Mallards accounted for 61% of samples, 73% of M1-positive ducks, and 90% of H5-positive ducks. Ducks hatched in 2005 accounted for 80% of the sample.

Room for improvement: patients' experiences of primary care in Quebec before major reforms.

OBJECTIVE: To investigate variations in accessibility, continuity of care, and coordination of services as experienced by patients in Quebec on the eve of major reforms, and to provide baseline information against which reforms could be measured. DESIGN: Multilevel cross-sectional survey of practice. SETTING: One hundred primary health care settings were randomly selected in urban, suburban, rural, and remote locations in 5 health regions in Quebec. PARTICIPANTS: In each clinic, we chose up to 4 physicians and 20 consecutive patients consulting each physician. MAIN OUTCOME MEASURES: Patients' responses to a self-administered questionnaire, the Primary Care Assessment Tool, that assessed patient-provider affiliation, accessibility, relational continuity, coordination of primary and specialty care, and whether patients received health promotion and preventive services. RESULTS: A total of 3441 patients participated (87% acceptance rate) in 100 clinics (64% response rate). Timely access was difficult; only 10% expressed confidence they could be seen by their regular doctors within a day if they became suddenly ill. Average waiting time for a doctor's appointment was 24 days. Coordination of care with specialists was at minimally acceptable levels. Patients with family physicians recalled them addressing only 56% of the health promotion and preventive issues appropriate for their age and sex, and patients without family physicians recalled physicians addressing substantially fewer (38%). Most patients reported they were highly confident that their physicians knew them well and would manage their care beyond clinical encounters (relational continuity). The exception was the 16% of patients overall who did not have family physicians (34% of patients at walk-in clinics). CONCLUSION: This survey highlights serious problems with accessibility. Improvement is needed urgently to avoid deterioration of patients' confidence in the health system even though patients rate their relationships with their physician highly. Health promotion, preventive services, and coordination with specialists also needed to be improved, and careful thought must be given to the plight of those without family physicians.

Cadmium concentrations in tissues of willow ptarmigan (Lagopus lagopus) and rock ptarmigan (Lagopus muta) in Nunavik, Northern Québec.

Willow and rock ptarmigan were obtained from Northern Québec. Willow ptarmigan were found to have mean cadmium concentrations of 179.7 microg/g (dw) in the kidneys and 25.8 microg/g (dw) in the liver; these levels were three times higher than those found in the rock ptarmigan. The cadmium levels in the ptarmigan were below the threshold above which adverse effects can be observed in birds. The difference between the two ptarmigan species in cadmium content is explained by the diet. A comparison of their diet showed that willow, which stores cadmium, is an important food resource for willow ptarmigan but not for rock ptarmigan. Because there is limited information available on the consumption of ptarmigan kidneys and liver by the Inuit, and the fact that this is a traditional way of life and provides nutritional benefits to the Inuit population, no consumption guidelines are proposed.

Contamination and biomarkers in the great blue heron, an indicator of the state of the st. Lawrence river.

In 1996-1997, nine breeding colonies of the great blue heron on the St. Lawrence River and its estuary (Québec, Canada) were investigated in the framework of a biomonitoring program. Fledglings from colonies in freshwater were more contaminated with mercury, PCBs and many organic contaminants than those from estuarine colonies. The level of contamination in the St. Lawrence River is generally below the levels of toxicological effects for the great blue heron. The molar ratio of retinol: retinyl palmitate in heron eggs was correlated with total PCBs (r=0.79) and Mirex (r=0.90). In plasma, all biochemical parameters were significantly different between freshwater and marine colonies. Plasma retinol concentrations at the Dickerson and Hérons colonies were significantly lower compared with those at Grande Ile (p<0.05) and Steamboat (p<0.001). Based on retinoid and beta-carotene concentrations in eggs, low plasma retinol was not associated with possible dietary deficiency. Plasma retinol was negatively correlated with many PCB congeners, total PCBs (r=-0.78), p,p'-DDE, trans-nonachlor and alpha-HCH. Similarly, the hormone T3 was correlated with many PCB congeners, total PCBs (r=-0.69) and the same organochlorine chemicals. Plasma LDH concentrations were different among freshwater colonies, Grande Ile and Hérons colonies having LDH values significantly greater than those of Steamboat (respectively, p<0.05 and p<0.01). Globally, the health status of the St. Lawrence great blue heron population was judged to be acceptable, however, several biomarkers indicated positive responses to contaminants.

Lead and stable lead isotope ratios in soil, earthworms, and bones of American woodcock (Scolopax minor) from eastern Canada.

A study to discriminate among different possible sources of elevated Pb exposure for American woodcock (Scolopax minor) in eastern Canada is described. Undamaged wing bones excised from young-of-the-year woodcock collected from several locations in southern Ontario, southern Quebec, New Brunswick, and Nova Scotia, Canada, along with soil and earthworm (Aporrectodea tuberculata and Lumbricus rubellus) samples from the same sites, were analyzed for total Pb, and stable Pb isotopes. Ignoring six soil samples with high (> 60 microg/g) Pb concentration from the vicinity of Montreal (QC, Canada), the mean soil-Pb concentration for all sites combined was 19 microg/g (dry wt; n = 64), with a mean 206Pb:207Pb ratio of 1.19, values typical for uncontaminated rural soils in eastern North America. In earthworms, Pb concentrations ranged from 2.4 to 865 (microg/g [dry wt], mean = 24 microg/g). Concentrations of Pb in worms and soils were positively correlated (r = 0.71; p < 0.01), and 206Pb:207Pb ratios for worms and soils were also positively correlated (r = 0.54; p < 0.05). However, most young-of-the-year woodcock with high bone-Pb accumulation (> 20 microg/g) had 206Pb:207Pb ratios substantially different from worms and soils sampled from the same areas, even though woodcock feed extensively on soil invertebrates, especially earthworms. The range of 206Pb:207Pb ratios in wing bones of woodcock with elevated Pb exposure was not consistent with exposure to environmental Pb from past gasoline combustion nor Precambrian mining wastes but was consistent with ingestion of spent Pb shotgun pellets.

Assessment of contamination and biomarker responses in two species of herons on the St. Lawrence river.

This study was undertaken to validate potential biomarkers of exposure and effects due to chemical contaminants in breeding colonies of the Great Blue Heron and the Black-crowned Night-Heron on the St. Lawrence River. Eggs and fledglings from both species were collected from many colonies along the River. The fledglings from colonies in freshwater and brackish water were more contaminated by mercury and PCBs than those from estuarine and gulf colonies. With respect to fledglings of the two heron species, some morphometric and blood biochemical measurements, including plasma thyroid hormones and retinol, were significantly different among colonies. Significant differences were also observed in liver retinoids, EROD and porphyrins among colonies. The results of this study suggest that plasma retinoids and thyroid hormones are good biomarkers of exposure and effects, and are sufficiently sensitive to reflect local and regional variations in contamination. Along with the measure of contaminants in egg and plasma, they constitute non-invasive biomarkers which represent an important criteria for long term monitoring of wildlife species. It is concluded that the Great Blue Heron is an appropriate sentinel species in the surveillance network for the St. Lawrence River.