Search

Following basic guidelines and using ergonomic controls can help prevent injuries. [ABSTRACT FROM AUTHOR]

Alternatives to latex gloves. [ABSTRACT FROM AUTHOR]

Precautions depend on the radioactive source, dosage and method of administration. [ABSTRACT FROM AUTHOR]

Protecting the provider as well as the patient. [ABSTRACT FROM AUTHOR]

Deals with a survey among nurses in the U.S. regarding the 1985 Proposal and the plea for unity of the American Nurses Association. Rate of nurses who opposed the 1985 Proposal; Reasons for the support to continued professional licensing for nurses; Implications of the proposal for the nursing profession.

Herein, we have developed a drug-loaded matrix metalloproteinase (MMP)-responsive micellar nanoparticle (NP) intended for minimally invasive intravenous injection during the acute phase of myocardial infarction (MI) and prolonged retention in the heart for small-molecule drug delivery. Peptide-polymer amphiphiles (PPAs) bearing a small-molecule MMP inhibitor (MMPi), PD166793, were synthesized via ring-opening metathesis polymerization (ROMP) and formulated into spherical micelles by transitioning to aqueous solution. The resulting micellar NPs underwent MMP-induced aggregation, demonstrating enzyme responsiveness. Using a rat MI model, we observed that these NPs were capable of successfully extravasating into the infarcted region of the heart where they were retained due to the active, enzyme-mediated targeting, remaining detectable after 1 week post administration without increasing macrophage recruitment. Furthermore, in vitro studies show that these NPs demonstrated successful drug release following MMP treatment and maintained drug bioactivity as evidenced by comparable MMP inhibition to free MMPi. This work establishes a targeted NP platform for delivering small-molecule therapeutics to the heart after MI, opening possibilities for myocardial infarction treatment.

Nanoparticles that undergo a localized morphology change to target areas of inflammation have been previously developed but are limited by their lack of biodegradability. In this paper, we describe a low-ring-strain cyclic olefin monomer, 1,3-dimethyl-2-phenoxy-1,3,4,7-tetrahydro-1,3,2-diazaphosphepine 2-oxide (MePTDO), that rapidly polymerizes via ring-opening metathesis polymerization at room temperature to generate well-defined degradable polyphosphoramidates with high monomer conversion (>84%). Efficient MePTDO copolymerizations with norbornene-based monomers are demonstrated, including a norbornenyl monomer functionalized with a peptide substrate for inflammation-associated matrix metalloproteinases (MMPs). The resulting amphiphilic peptide brush copolymers self-assembled in aqueous solution to generate micellar nanoparticles (30 nm in diameter) which exhibit excellent cyto- and hemocompatibility and undergo MMP-induced assembly into micron-scale aggregates. As MMPs are upregulated in the heart postmyocardial infarction (MI), the MMP-responsive micelles were applied to target and accumulate in the infarcted heart following intravenous administration in a rat model of MI. These particles displayed a distinct biodistribution and clearance pattern in comparison to nondegradable analogues. Specifically, accumulation at the site of MI competed with elimination predominantly through the kidney rather than the liver. Together, these results suggest this as a promising new biodegradable platform for inflammation targeted delivery.

Each year in Hawai'i, an estimated 500 - 650 children (about half of confirmed cases of child abuse or neglect) are at high risk of entering foster care because of their parent's substance use disorder (SUD). Children in foster care because of parental SUD are less likely to be reunified with their parents. Experiences in foster care may cause long-term negative health consequences for the children. Early identification and engagement of parents in SUD treatment can improve outcomes for parents and children. The child welfare and SUD treatment systems in Hawai'i are not set up to work together to maximize the likelihood that parents will complete treatment and families will stay together. This article recommends evidence-based interventions including recovery coaches, peer partners, and Family Drug Courts (FDCs). Recovery coaches and peer partners support parents in early engagement and completion of SUD treatment. FDCs provide an interdisciplinary approach that successfully serves parents involved with Child Welfare Services (CWS) who have complex needs. Effectively implementing these interventions in Hawai'i requires an improved infrastructure to collect and analyze data about parents with SUD and their children, parents' SUD needs and status in treatment, and families' level of CWS involvement. Data about the availability and delivery of services for CWS-involved parents with SUD are also needed to understand service efficiency and effectiveness. These suggested interventions would help more parents in Hawai'i complete treatment and keep their children safely with them, thereby protecting children's current and long-term health., (©Copyright 2022 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Chlamydia trachomatis , the most common bacterial sexually transmitted infection worldwide, is responsible for considerable health burden due to its significant sequelae. There are growing concerns about chlamydial treatment and management due to widely documented increasing burden of repeat infections. In the current study, a cohort study design of 305 women with urogenital chlamydial infections demonstrated that 11.8% of women experienced repeat infections after treatment with azithromycin. The chlamydial DNA load measured by quantitative PCR was higher in women who experienced a repeat infection ( p = 0.0097) and repeat infection was associated with sexual contact. There was no genomic or phenotypic evidence of azithromycin resistance within the chlamydial isolates. During repeat infection, or repeat positive tests during follow up, vaginal chlamydial gene expression ( ompA, euo, omcB, htrA, trpAB ) was markedly higher compared to baseline, and two of the selected immune genes analyzed had significantly lower expression at the time of repeat infection. Overall, there are two implications of these results. The results could be generalized to all recent infections, or repeat positive events, and indicate that chlamydial infections are have higher transcriptional activity of select genes early in the infection in women. Alternatively, after azithromycin treatment, repeat infections of Chlamydia may be more transcriptionally active at certain genes, and there may be post-treatment immunological alterations that interplay into repeat exposures establishing an active infection. The potential that recent infections may involve a higher level of activity from the organism may have implications for management by more regular testing of the most at risk women to reduce the risk of sequelae., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Huston, Lawrence, Wee, Thomas, Timms, Vodstrcil, McNulty, McIvor, Worthington, Donovan, Phillips, Chen, Fairley and Hocking.)

Background: The English schools-based human papillomavirus (HPV) vaccination programme is routinely offered to all young people aged 12-13 years, to prevent cancers affecting the cervix, vulva, vagina, penis, anus and mouth. Lower uptake among some population groups has been identified, in part, because of unmet information needs among young people. To address these unmet needs we report intervention planning and development processes to co-produce an educational package about the HPV vaccine., Methods: We used co-production research methodologies and the 'person-based approach' involving the following iterative stages: (i) collating and analysing primary and secondary evidence, including HPV vaccine communication materials, interviews and workshops; (ii) developing guiding principles; (iii) undertaking a behavioural analysis informed by the Behaviour Change Wheel and the Behaviour Change Technique taxonomy; (iv) development of a preliminary logic model; (v) co-production of resources, and; (vi) refinement of resources informed by feedback from young people and key informants., Results: We co-produced EDUCATE, a theory-based educational package, that is designed to be delivered to young people prior to being offered the HPV vaccine to support uptake. Young people and key informants identified the following key issues to include as content: (i) HPV-related information; (ii) how vaccines work; (iii) safety and side-effects of the HPV vaccine; (iii) eligibility for the HPV vaccination programme, and; (iv) preparation of young people to receive the HPV vaccine. A manual for professionals (e.g. immunisation nurses, school staff) delivering the intervention and a PowerPoint presentation, interspersed with five short films, were co-produced with young people and key informants. Following feedback, the content of the EDUCATE package was refined to increase acceptability, engagement, and persuasiveness to the target users., Conclusion: Engagement with young people and key informants was integral to the development of our rigorously developed, theory-based intervention to address young people's information needs about the HPV vaccination programme. The acceptability and persuasiveness of the package has been maximised by working closely with young people and key informants to develop the content. An implementation study to examine how the EDUCATE package is implemented in practice and the impact on uptake of the HPV vaccination programme is underway., (© 2022. The Author(s).)

Background: A survey was developed to characterize disease incidence, common pathology lesions, environmental characteristics, and nutrition programs within captive research marmoset colonies., Methods: Seventeen research facilities completed the electronic survey., Results: Nutritional management programs varied amongst research institutions housing marmosets; eight primary base diets were reported. The most common clinical syndromes reported were gastrointestinal disease (i.e. inflammatory bowel disease like disease, chronic lymphocytic enteritis, chronic malabsorption, chronic diarrhea), metabolic bone disease or fracture, infectious diarrhea, and oral disease (tooth root abscesses, gingivitis, tooth root resorption). The five most common pathology morphologic diagnoses were colitis, nephropathy/nephritis, enteritis, chronic lymphoplasmacytic enteritis, and cholecystitis. Obesity was more common (average 20% of a reporting institution's population) than thin body condition (average 5%)., Conclusions: Through review of current practices, we aim to inspire development of evidence-based practices to standardize husbandry and nutrition practices for marmoset research colonies., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Confusion around health insurance reforms persist. The purpose of this study was to assess demographic differences in Affordable Care Act (ACA) and health insurance knowledge in a multi-ethnic urban sample. Data came from 243 adults from racial/ethnic communities. Participants were asked about elements of health insurance and the ACA. Generalized linear and logistic regression models were used to examine relationships between demographic predictors and knowledge domains. Female gender (p < 0.05) and Latino/Hispanic race/ethnicity (p < 0.001) were most predictive of lower eligibility knowledge, while non-citizen with residency status (p < 0.001) and other/not declared residency status (p < 0.001) were most predictive of lower insurance coverage knowledge. No demographic factors predicted enrollment knowledge. Latino/Hispanic race/ethnicity (p < 0.01) was most predictive of not knowing that more people can get insurance because of the ACA. In conclusion, there is variation in health insurance and ACA-related knowledge in multi-ethnic populations. More compatible health communication interventions are needed to support outreach to key demographic groups.

During 2016-2017, we tested asymptomatic men who have sex with men (MSM) in Melbourne, Australia, for Mycoplasma genitalium and macrolide resistance mutations in urine and anorectal swab specimens by using PCR. We compared M. genitalium detection rates for those asymptomatic men to those for MSM with proctitis and nongonococcal urethritis (NGU) over the same period. Of 1,001 asymptomatic MSM, 95 had M. genitalium; 84.2% were macrolide resistant, and 17% were co-infected with Neisseria gonorrhoeae or Chlamydia trachomatis. Rectal positivity for M. genitalium was 7.0% and urine positivity was 2.7%. M. genitalium was not more commonly detected in the rectums of MSM (n = 355, 5.6%) with symptoms of proctitis over the same period but was more commonly detected in MSM (n = 1,019, 8.1%) with NGU. M. genitalium is common and predominantly macrolide-resistant in asymptomatic MSM. M. genitalium is not associated with proctitis in this population.

Background: Rising macrolide and quinolone resistance in Mycoplasma genitalium necessitate new treatment approaches. We evaluated outcomes of sequential antimicrobial therapy for M. genitalium guided by a macrolide-resistance assay., Methods: In mid-2016, Melbourne Sexual Health Centre switched from azithromycin to doxycycline (100 mg twice daily for 7 days) for nongonococcal urethritis, cervicitis, and proctitis. Cases were tested for M. genitalium and macrolide-resistance mutations (MRMs) by polymerase chain reaction. Directly after doxycycline, MRM-negative infections received 2.5 g azithromycin (1 g, then 500 mg daily for 3 days), and MRM-positive infections received sitafloxacin (100 mg twice daily for 7 days). Assessment of test of cure and reinfection risk occurred 14-90 days after the second antibiotic., Results: Of 244 evaluable M. genitalium infections (52 women, 68 heterosexual men, 124 men who have sex with men) diagnosed from 20 June 2016 to 15 May 2017, MRMs were detected in 167 (68.4% [95% confidence interval {CI}, 62.2%-74.2%]). Treatment with doxycycline decreased bacterial load by a mean 2.60 log10 (n = 56; P < .0001). Microbiologic cure occurred in 73 of 77 MRM-negative infections (94.8% [95% CI, 87.2%-98.6%]) and in 154 of 167 MRM-positive infections (92.2% [95% CI, 87.1%-95.8%]). Selection of macrolide resistance occurred in only 2 of 76 (2.6% [95% CI, .3%-9.2%]) macrolide-susceptible infections., Conclusions: In the context of high levels of antimicrobial resistance, switching from azithromycin to doxycycline for presumptive treatment of M. genitalium, followed by resistance-guided therapy, cured ≥92% of infections, with infrequent selection of macrolide resistance.

Spontaneous resolution of urogenital Chlamydia trachomatis (CT) without treatment has previously been described, but a limitation of these reports is that DNA or RNA-based amplification tests used do not differentiate between viable infection and non-viable DNA. We modified a previously published CT mRNA detection (omp2) method to differentiate between viable infection and non-viable DNA in a sample of CT DNA PCR positive women. We modified a CT mRNA detection (omp2) method from reverse transcriptase qPCR (RTqPCR) to digital PCR (dPCR) and evaluated it in samples from CT DNA positive women. Firstly, CT infected McCoy B cells treated with azithromycin in vitro identified detectable mRNA levels disappeared <2 days, while DNA persisted up to 6 days. We used 55 self-collected vaginal swabs from a cohort of women diagnosed as DNA positive for chlamydia obtained pre- and 7 days of post-azithromycin treatment. Concordance with DNA results was higher for dPCR than RTqPCR (74.5% versus 65.5%). At visit 1, there was a strong linear relationship between DNA and mRNA (r = 0.9, p < 0.000); 24 samples had both mRNA and DNA detected (82.8%) and 5 had only DNA detected with a potential false positive proportion of 17.2% (95%CI: 5.8, 35.8). At visit 2, there was poor correlation between DNA and mRNA (r = 0.14, p = 0.55); eight specimens had only DNA detected (42.1%; 95%CI: 20.25, 66.50) and one had mRNA detected. DNA detection methods alone may detect non-viable DNA. Consideration should be given to further develop mRNA assays as ancillary tests to improve detection of viable chlamydia.

High levels of macrolide resistance and increasing fluoroquinolone resistance are found in Mycoplasma genitalium in many countries. We evaluated pristinamycin for macrolide-resistant M. genitalium in a sexual health center in Australia. Microbiologic cure was determined by M. genitalium-specific 16S PCR 14-90 days after treatment began. Of 114 persons treated with pristinamycin, infection was cured in 85 (75%). This percentage did not change when pristinamycin was given at daily doses of 2 g or 4 g or at 3 g combined with 200 mg doxycycline. In infections with higher pretreatment bacterial load, treatment was twice as likely to fail for each 1 log 10 increase in bacterial load. Gastrointestinal side effects occurred in 7% of patients. Pristinamycin at maximum oral dose, or combined with doxycycline, cured 75% of macrolide-resistant M. genitalium infections. Pristinamycin is well-tolerated and remains an option where fluoroquinolones have failed or cannot be used.

Background: Improving health insurance coverage and retention in communities of color is a national priority and new approaches are needed., Objectives: To describe 1) the formation of Insure Detroit, a community-based participatory research (CBPR) partnership aimed at addressing health insurance and Affordable Care Act (ACA) literacy challenges in economically disadvantaged areas, 2) the development of Insuring Good Health, a novel, multimedia, health information technology-focused intervention to address the health aims of the partnership, and 3) the evaluation plan for the intervention., Methods: Insure Detroit, a partnership between researchers and community-based organizations, was established. Principles of CBPR were followed closely in the conduct of this project. The Insure Detroit partnership developed the intervention and evaluation plan through an iterative process. The Insuring Good Health intervention is multilingual and composed of a responsive website. It includes nine short, animated videos informed by storytelling techniques that communicate key learning points pertaining to health insurance navigation and use., Lessons Learned: Lessons learned included narrowing learning points for the intervention, balancing the volume of work to comply with the study timeline, and balancing the political climate with the development of the intervention., Conclusions: The Insure Detroit partnership demonstrates that a CBPR approach can develop media-based health communications to address health insurance literacy. Our experiences highlight that CBPR principles that encourage shared decision making and co-learning can result in high-quality, innovative interventions that have the potential to resonate well with communities of color.

Background: Azithromycin is recommended for the treatment of uncomplicated urogenital chlamydia infection although the standard 1gram dose sometimes fails to eradicate the infection (treatment failure). One hypothesis proposed for treatment failure has been insufficient levels of the antibiotic at the site of infection. We developed an assay using liquid chromatography and tandem mass spectrometry (LC-MS/MS) to measure azithromycin concentration in high-vaginal swabs and monitor how concentration changes over time following routine azithromycin treatment., Methods: Azithromycin concentrations were measured in two groups of women either within the first 24h of taking a 1g dose (N = 11) or over 9 days (N = 10). Azithromycin concentrations were normalised to an internal standard (leucine enkephalin), and the bulk lipid species phosphatidylcholine [PC(34:1)], using an Agilent 6490 triple quadrupole instrument in positive ionisation mode. The abundances of azithromycin, PC(34:1), and leu-enkephalin were determined by multiple reaction monitoring and absolute levels of azithromycin estimated using standard curves prepared on vaginal specimens., Results: Vaginal azithromycin concentrations of women were rapidly obtained after 5h post-treatment (mean concentration = 1031mcg/mg of lipid, range = 173-2693mcg/mg). In women followed for 9 days, peak concentrations were highest after day 2 (mean concentration = 2206mcg/mg, range = 721-5791mcg/mg), and remained high for at least 9 days with a mean concentration of 384mcg/mg (range = 139-1024mcg/mg) on day 9., Conclusion: Our study confirmed that a single 1g dose of azithromycin is rapidly absorbed and remains in the vagina at relatively high levels for at least a week, suggesting that poor antibiotic absorption is unlikely to be an explanation for treatment failure.

CDC's National Institute for Occupational Safety and Health (NIOSH), state health departments, and other state entities maintain a state-based surveillance program of confirmed silicosis cases. Data on confirmed cases are collected and compiled by state entities and submitted to CDC. This report summarizes information for cases of silicosis that were reported to CDC for 2003-2011 by Michigan and New Jersey, the only states that continue to provide data voluntarily to NIOSH. The data for this report were final as of January 8, 2015. Data are presented in tabular form on the number and distribution of cases of silicosis by year (Table 1), duration of employment in occupations with potential exposure to dust containing respirable crystalline silica (Table 2), industry (Table 3), and occupation (Table 4). The number of cases by year is presented graphically (Figure). This report is a part of the Summary of Notifiable Noninfectious Conditions and Disease Outbreaks - United States, which encompasses various surveillance years but is being published in 2016 (1). The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases (2).

Fertility in mammals requires appropriate communication within the hypothalamic-pituitary-gonadal axis and the GnRH receptor (GnRHR) is a central conduit for this communication. The GnRHR resides in discrete membrane rafts and raft occupancy is required for signaling by GnRH. The present studies use immunoprecipitation and mass spectrometry to define peptides present within the raft associated with the GnRHR and flotillin-1, a key raft marker. These studies revealed peptides from the F0F1 ATP synthase complex. The catalytic subunits of the F1 domain were validated by immunoprecipitation, flow cytometry, and cell surface biotinylation studies demonstrating that this complex was present at the plasma membrane associated with the GnRHR. The F1 catalytic domain faces the extracellular space and catalyzes ATP synthesis when presented with ADP in normal mouse pituitary explants and a gonadotrope cell line. Steady-state extracellular ATP accumulation was blunted by coadministration of inhibitory factor 1, limiting inorganic phosphate in the media, and by chronic stimulation of the GnRHR. Steady-state extracellular ATP accumulation was enhanced by pharmacological inhibition of ecto-nucleoside triphosphate diphosphohydrolases. Kisspeptin administration induced coincident GnRH and ATP release from the median eminence into the hypophyseal-portal vasculature in ovariectomized sheep. Elevated levels of extracellular ATP augmented GnRH-induced secretion of LH from pituitary cells in primary culture, which was blocked in media containing low inorganic phosphate supporting the importance of extracellular ATP levels to gonadotrope cell function. These studies indicate that gonadotropes have intrinsic ability to metabolize ATP in the extracellular space and extracellular ATP may serve as a modulator of GnRH-induced LH secretion.

Objective: Tobacco use is high among US extraction and construction workers, who can also incur occupational dust exposure. Information on different types of tobacco use among quarry/mine workers is sparse., Methods: During mandated training sessions, New Jersey quarry workers were surveyed about their tobacco use. Prevalence was calculated for single and multiple tobacco use by demographic and workplace characteristics; logistic regression was used to assess associations with smoking., Results: Two hundred forty (97.1%) workers completed surveys. Among respondents, 41.7% [95% confidence interval (95% CI) 35.4 to 48.3] currently used any tobacco product of whom 28.1% smoked cigarettes. In multivariate analysis, positive associations with smoking included working as a contractor versus mine employee (odds ratio 2.32, 95% CI 1.01 to 5.36) and a usual job title of maintenance (odds ratio 2.02, 95% CI 0.87 to 4.94)., Conclusion: Industry-specific information may be helpful in developing targeted tobacco-cessation programs., Competing Interests: The authors declare no conflicts of interest

In May 2014, the Texas Department of State Health Services was notified of a case of silicosis with progressive massive fibrosis in a Hispanic male aged 37 years who worked for an engineered stone countertop company as a polisher, laminator, and fabricator. He was exposed to dust for 10 years from working with conglomerate or quartz surfacing materials containing 70%-90% crystalline silica. This is the first reported case of silicosis associated with exposure to quartz surfacing materials in North America.

Background: Chlamydia trachomatis is the most commonly diagnosed bacterial sexually transmitted infection in the developed world and diagnosis rates have increased dramatically over the last decade. Repeat infections of chlamydia are very common and may represent re-infection from an untreated partner or treatment failure. The aim of this cohort study is to estimate the proportion of women infected with chlamydia who experience treatment failure after treatment with 1 gram azithromycin., Methods/design: This cohort study will follow women diagnosed with chlamydia for up to 56 days post treatment. Women will provide weekly genital specimens for further assay. The primary outcome is the proportion of women who are classified as having treatment failure 28, 42 or 56 days after recruitment. Comprehensive sexual behavior data collection and the detection of Y chromosome DNA and high discriminatory chlamydial genotyping will be used to differentiate between chlamydia re-infection and treatment failure. Azithromycin levels in high-vaginal specimens will be measured using a validated liquid chromatography-tandem mass spectrometry method to assess whether poor azithromycin absorption could be a cause of treatment failure. Chlamydia culture and minimal inhibitory concentrations will be performed to further characterize the chlamydia infections., Discussion: Distinguishing between treatment failure and re-infection is important in order to refine treatment recommendations and focus infection control mechanisms. If a large proportion of repeat chlamydia infections are due to antibiotic treatment failure, then international recommendations on chlamydia treatment may need to be re-evaluated. If most are re-infections, then strategies to expedite partner treatment are necessary.

Background: Violence against health care workers is a serious occupational health hazard, especially for emergency department (ED) employees. A significant degree of variability in security programs among hospital EDs is present in part due to the absence of federal legislation requiring baseline security features. Nationally, only voluntary guidelines from the Occupational Safety and Health Administration (OSHA) for the protection of health care workers exist., Objectives: The purpose of this study was to examine ED security programs and employee assault rates among EDs with different financial resources, size, and background community crime rates., Methods: This cross-sectional survey was conducted among large and small hospitals located in communities with low or high rates of community crime. Hospital financial data were collected through the state health department, and employee assault data were abstracted from hospital OSHA logs. Comparisons were made using a chi-squared or Wilcoxon test., Results: Small hospitals located in towns with low community crime rates implemented the fewest security program features despite having the second highest rate of assault-related OSHA-recordable injuries among ED employees (0.66 per 100,000 staff hours)., Conclusion: Due to the highly stressful workplace characteristics of EDs, the risk of employee assault is universal among all hospital sizes in all types of communities., (Copyright © 2012 Elsevier Inc. All rights reserved.)

In situ enrichment experiments have shown that the growth of bloom-forming diatoms in the major high-nitrate low-chlorophyll (HNLC) regions of the world's oceans is limited by the availability of iron. Yet even the largest of these manipulative experiments represents only a small fraction of an ocean basin, and the responses observed are strongly influenced by the proliferation of rare species rather than the growth of naturally dominant populations. Here we link unique fluorescence attributes of phytoplankton to specific physiological responses to nutrient stress, and use these relationships to evaluate the factors that constrain phytoplankton growth in the tropical Pacific Ocean on an unprecedented spatial scale. On the basis of fluorescence measurements taken over 12 years, we delineate three major ecophysiological regimes in this region. We find that iron has a key function in regulating phytoplankton growth in both HNLC and oligotrophic waters near the Equator and further south, whereas nitrogen and zooplankton grazing are the primary factors that regulate biomass production in the north. Application of our findings to the interpretation of satellite chlorophyll fields shows that productivity in the tropical Pacific basin may be 1.2-2.5 Pg C yr(-1) lower than previous estimates have suggested, a difference that is comparable to the global change in ocean production that accompanied the largest El Niño to La Niña transition on record.

Patient satisfaction is not merely a "smile and be nice" set of behaviors. It is a philosophy that is founded in the concept that the patient's experience of care is important and ultimately translates into their actual response to care. The improved response to care that patients exhibit makes patient satisfaction important from a clinical vantage point. That point alone is enough to justify implementation of and commitment to a customer satisfaction program. There are, however, other compelling reasons also. Customer satisfaction has profound ramifications for the financial status of the institution and for its professional reputation in the community. The caregivers who participate in a system of good customer satisfaction experience fewer malpractice suits than their counterparts. And they enjoy a work environment that is more stable and pleasant than other institutions. The implementation of a meaningful customer service program is a huge task. It is a fundamental culture change that requires vision, long-term commitment, and constant surveillance. The single most critical factor in the successful implementation of a program that produces all the gains that it promises is leadership. Leadership must set the stage, create the atmosphere,demand that staff meet expectations, reward success, provide an example,and shape the new culture. Without strong, clear leadership, any customer service initiative will be simply a hospital-wide exercise, and those staff members who harbor a cynical viewpoint will be proved right in the end.One major difference between a successful customer service initiative and an unsuccessful one is the level of sincerity the hospital and its staff have about the care they express for their patients. If the whole process is merely an exercise to improve scores, the success will be limited and without deep roots. If the push is to establish an atmosphere of genuine care and interest for patients, however, the results are more meaningful, longer lasting, and more appreciated by patients and staff.

Background: Research efforts and policy initiatives in health care errors and injury to health care workers have attracted increasing attention in recent years. An emerging theme in both these areas is the importance of organizational and other systems factors in the occurrence of medical error and health care worker injury. These commonalities call for the identification of common research efforts and, when appropriate, policy efforts., Moving From Hypothesis to Conclusion: The proposition that health care error and worker injury are linked to the same organizational variables requires further research and deserves the same type of human factors approach that has characterized much of the investigative efforts that have occurred in the patient safety arena during the past decade. Serious problems exist with respect to access to data on staffing levels, skill mix, consecutive work hours, and other information that is crucial to examining the link between practice conditions, health care error, and health care worker injury., Human Factors: One important resource in identifying effective approaches to prevent error and health care worker injury is the field of human factors, the discipline concerned with the design of tools, machines, and systems that takes into account human capabilities, limitations, and characteristics., Conclusion: The potential benefits of linking patient safety and health care worker safety efforts are significant. The research, experience, and successful practices from multiple disciplines must be utilized in identifying areas of common interest and concern in advancing work in both of these important areas.