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The nearshore areas of the Laurentian Great Lakes provide valuable ecosystem services including habitat for a variety of species and water for surrounding communities. Recent declines in nearshore water quality have increased the need for understanding the connectivity between nearshore and offshore areas; however observing water quality variability across the dynamic nearshore to offshore transition zone poses logistical challenges for traditional observing systems. Here we evaluate cross-shore and along-shore water quality gradients using observations from two three-week deployments of a Slocum autonomous glider in southern Lake Ontario. The glider was deployed between the Niagara River mouth and Rochester, NY during early and late summer 2018, and each deployment resulted in over 3000 vertical profiles of the water column and several transects between 2 km and 20 km from shore. In early summer, the cross-shore chlorophyll gradient was characterized by highest values just below the surface, at the frontal zone between weakly stratified conditions closer to shore and unstratified conditions offshore. In late summer, stratified conditions extended across the entire survey area. The depth of the thermocline was deeper and chlorophyll values were lower within 10 km of shore than offshore, where the highest chlorophyll values were observed in a distinct layer below the thermocline. In both early and late summer, the frontal boundary indicated by the cross-shore chlorophyll gradient was located below the surface and well offshore of what is typically considered the nearshore zone but was within the width of the coastal boundary layer. The high-resolution glider observations provide a detailed view of patterns of variability across a dynamic coastal zone and pinpoint the cross-shore frontal boundary that may be important for biologists to differentiate biological communities.

Supplemental Digital Content is available in the text, Objective: To estimate the association between weather and COVID-19 fatality rates during US stay-at-home orders. Methods: With a county-level longitudinal design, this study analyzed COVID-19 deaths from public health departments’ daily reports and considered exposure as the 18 to 22 day-period before death. Models included state-level social distancing measures, Census Bureau demographics, daily weather information, and daily air pollution. The primary measures included minimum and maximum daily temperature, precipitation, ozone concentration, PM2.5 concentrations, and U.V. light index. Results: A 1 °F increase in the minimum temperature was associated with 1.9% (95% CI, 0.2% to 3.6%) increase in deaths 20 days later. An ozone concentration increase of 1 ppb (part per billion) decreased daily deaths by 2.0% (95% CI, 0.1% to 3.6%); ozone levels below 38 ppb negatively correlated with deaths. Conclusions: Increased mobility may drive the observed association of minimum daily temperature on COVID-19 deaths.

Background The US COVID-19 epidemic impacted counties differently across space and time, though large-scale transmission dynamics are unclear. The study's objective was to group counties with similar trajectories of COVID-19 cases and deaths and identify county-level correlates of the distinct trajectory groups. Methods Daily COVID-19 cases and deaths were obtained from 3141 US counties from January through June 2020. Clusters of epidemic curve trajectories of COVID-19 cases and deaths per 100,000 people were identified with Proc Traj. We utilized polytomous logistic regression to estimate Odds Ratios for trajectory group membership in relation to county-level demographics, socioeconomic factors, school enrollment, employment and lifestyle data. Results Six COVID-19 case trajectory groups and five death trajectory groups were identified. Younger counties, counties with a greater proportion of females, Black and Hispanic populations, and greater employment in private sectors had higher odds of being in worse case and death trajectories. Percentage of counties enrolled in grades 1–8 was associated with earlier-start case trajectories. Counties with more educated adult populations had lower odds of being in worse case trajectories but were generally not associated with worse death trajectories. Counties with higher poverty rates, higher uninsured, and more living in non-family households had lower odds of being in worse case and death trajectories. Counties with higher smoking rates had higher odds of being in worse death trajectory counties. Discussion In the absence of clear guidelines and personal protection, smoking, racial and ethnic groups, younger populations, social, and economic factors were correlated with worse COVID-19 epidemics that may reflect population transmission dynamics during January–June 2020. After vaccination of high-risk individuals, communities with higher proportions of youth, communities of color, smokers, and workers in healthcare, service and goods industries can reduce viral spread by targeting vaccination programs to these populations and increasing access and education on non-pharmaceutical interventions., Graphical abstract Unlabelled Image

Wearing a facial mask can limit COVID-19 transmission. Measurements of communities’ mask use behavior have mostly relied on self-report. This study’s objective was to devise a method to measure the prevalence of improper mask use and no mask use in indoor public areas without relying on self-report. A stratified random sample of retail trade stores (public areas) in Louisville, Kentucky, USA, was selected and targeted for observation by trained surveyors during December 14–20, 2020. The stratification allowed for investigating mask use behavior by city district, retail trade group, and public area size. The total number of visited public areas was 382 where mask use behavior of 2,080 visitors and 1,510 staff were observed. The average prevalence of mask use among observed visitors was 96%, while the average prevalence of proper use was 86%. In 48% of the public areas, at least one improperly masked visitor was observed and in 17% at least one unmasked visitor was observed. The average prevalence of proper mask use among staff was 87%, similar to the average among visitors. However, the percentage of public areas where at least one improperly masked staff was observed was 33. Significant disparities in mask use and its proper use were observed among both visitors and staff by public area size, retail trade type, and geographical area. Observing unmasked and improperly masked visitors was more common in small (less than 1500 square feet) public areas than larger ones, specifically in food and grocery stores as compared to other retail stores. Also, the majority of the observed unmasked persons were male and middle-aged.

This study used statistically robust regression models to control for a large set of confounders (including county-level time-invariant factors and time trends, regional-level daily variation, state-level social distancing measures, ultraviolet light, and levels of ozone and fine particulate matter, PM2.5) to estimate a reliable rather than simple regression for the impact of weather on the most accurately measured outcome of COVID-19, death. When the average minimum temperature within a five-day window increased by one degree Fahrenheit in spring 2020, daily death rates in northern U.S. counties increased by an estimated 5.1%. When ozone concentration over a five-day window rose by one part per billion, daily death rates in southern U.S. counties declined by approximately 2.0%. Maximum temperature, precipitation, PM2.5, and ultraviolet light did not significantly associate with COVID-19 mortality. The mechanism that may drive the observed association of minimum temperature on COVID-19 deaths in spring months may be increased mobility and contacts. The effect of ozone may be related to its disinfectant properties, but this requires further confirmation.

The proliferation of webinars and other similar web-based educational offerings attests to the interest in this instructional modality on the part of educators and learners in the public health workforce. While certain advantages of Internet-based training, including time and costs savings for learners, are evident, it is important to establish the impact of this medium on a variety of health care disciplines. To this end, a search was performed of individual studies and review articles published since 2005 that discuss the use of these methodologies by several disciplines in the domain of public health, with particular attention on randomized controlled trials and meta-analytic studies. Reports over the past decade support the belief that the health care workforce is generally satisfied with Internet-based training and that this type of training yields measurable changes in knowledge and behavior. Overall, the data strongly suggest that these techniques are better than no intervention and essentially equivalent to conventional instructional techniques. However, the specific elements that actually improve the educational value of web-based educational technologies and the evidence base for best practices in the field have yet to be identified.

This chapter outlines the various uses of the interview, and focuses on the interview as an educational tool in teaching adolescence. In psychology, interviews are used in clinical diagnosis, psychotherapy, research, and teaching. A standardized interview is one which is presented to each interviewee in exactly the same fashion. One of the most important goals of interviewing is to ensure that the information received is as honest and accurate as possible. Any small group of interviewees is a highly selected sample, by default. If they are self-selected volunteers, they may be the more enthusiastic, or cooperative, or narcissistic members of their cohort. The interview gives students in the adolescence course the opportunity to talk to and interact with adolescents and to inquire about issues which were raised throughout the course. Watching or participating in an interview with adolescents while taking the adolescence course sometimes allows the students to view their own adolescence in a new perspective.

Wind-driven turbidity plumes frequently occur in the western arm of Lake Superior and may represent a significant cross shelf transport mechanism for sediment, nutrient and biota. Here we characterize a plume that formed in late April 2016 using observations from in situ sensors and remote sensing imagery, and estimate the volume of cross shelf transport using both the observations and an idealized analytical model of plume formation. The steady-state, barotropic model is used to determine a relationship between the intensity and duration of a wind event and the volume of water transported from nearshore to offshore during the event. The model transport is the result of nearshore flow in the direction of the wind and a pressure-gradient-driven counter flow in the deeper offshore waters, consistent with observations. The volume of offshore transport associated with the 2016 plume is estimated by both methods to have been on the order of 10(10) m(3). Analysis of similar events from 2008–2016 shows a strong relationship between specific wind impulse and plume volume. Differences in the intensity and duration of individual events as well as ice cover, which prevents plume formation, lead to interannual variability of offshore transport ranging over an order of magnitude and illustrates how wind-driven processes may contribute to interannual variability of ecosystem functioning.

In an Internet-based study with 2,201 participants, the new Epstein Love Competencies Inventory (ELCI) was shown to have high internal-consistency reliability and to be a good predictor of various self-reported measures of success in romantic relationships; scores on the ELCI predicted satisfaction in current relationships especially well. A blind review of test content by licensed therapists also suggested that the test has strong content validity. The new test measured seven relationship competencies that various research suggests are important in the maintenance of long-term romantic relationships: (a) communication, (b) conflict resolution, (c) knowledge of partner, (d) life skills, (e) self management, (f) sex and romance, and (g) stress management. ELCI scores were found to improve with both age and the number of hours spent in relationship skills training. After communication, knowledge of partner and life skills were the competencies that best predicted self-reported positive outcomes in relations...

Making use of the fine resolution of satellite SAR imagery, we observe small eddies during the spring and summer months in several locations in Lake Superior. During these months there is a thermal gradient between warmer nearshore waters and colder offshore waters which enhances cyclonic coastal currents. Using spaceborne SAR imagery from the European Space Agency's ERS-1 and ERS-2 missions from 1992 to 1998, we observe small eddies, identifying and mapping basic eddy characteristics including diameter, location, and rotational sense. In total, 45 eddies were located, of which 41 were cyclonic and 4 anticyclonic. Average diameter was 9.8 km and average distance to shore was 8.1 km. Based on sea surface temperature data from AVHRR, the eddies are located within the region of sharp thermal gradients of order 3–5 °C per 3 km. Spatial and temporal coverage was uneven, however, more eddies were seen in SAR images taken in late summer along the southern and eastern shores as well as areas where the boundary current interacts with topographic features including islands and promontories.

Background: In 1995, a yearly drive-thru immunization program was initiated in Louisville, KY. Since then, more than 50,000 doses of influenza vaccine have been administered, with no reports of syncopal episodes or vehicular accidents. This report aimed to identify reported adverse events from other areas that could threaten drive-thru mass immunization approaches.Methods: To identify reported adverse events in any drive-thru mass immunization event, the authors queried the following sources: 1) the vaccine adverse event reporting system, 2) court cases, 3) healthcare risk management databases, 4) MEDLINE, and 5) communication with vaccine experts. The authors also calculated the probability of syncopal episodes using data from our past immunization experiences to further elucidate the possibility of these events occurring.Results: No adverse events due to a drive-thru mass immunization event were identified in any of the sources queried. In our data, the forecasted probability of one adverse event was 0.8 percent for a 2-day event (20,000 immunizations).Conclusions: Although syncope may occur following immunization, it is a risk that can be managed, and due to the rarity of these events, should not be used as a reason to avoid drive-thru administration of influenza vaccine.

This study is an exploration of the "sense of community" in a college classroom. The construct was successfully developed by incorporating six variables borrowed from neighborhood community research. Sense of community scores significantly predicted students' classroom attitudes, perception of learning, and actual performance on course exams.

In September 2003, a consortium of bioterrorism and health education experts from the University of Louisville, the University of Kentucky, the Kentucky Department for Public Health, and the Louisville Metro Health Department received funding from the Health Resources and Services Administration (HRSA) to develop a broadly based bioterrorism education program for health professionals in the Commonwealth of Kentucky and the surrounding region. This grant will fund a series of presentations tailored to the needs of professionals in medicine, dentistry, public health, nursing, behavioral medicine, allied health, pharmacy, veterinary medicine, and agriculture, providing coordinated training both on site and through distance learning technology. This article outlines the major grant-funded activities envisioned for the grant years 2003 through 2005, focusing on the use of standardized patients and computerized biosimulators, the transdisciplinary partnerships of the universities involved, and the essential collaboration provided by the state and local health departments.

American travelers increasingly are selecting exotic destinations in the developing world. This poses a challenge to primary care clinicians who wish to provide recommendations to their patients regarding optimal protection from infectious disease risks. Recommendations should be individualized for each traveler and journey, accounting for personal health, health risks of specific destinations, style of travel, and activities anticipated. This article updates practitioners on the essentials of immunization before international travel.

The purpose of this study was to examine the goodness of ”t of autonomy timetable expectations between Asian-American late adolescents and their parents. The “goodness of ”t” model (Lerner & Lerner, 1983; Thomas & Chess, 1977) was used as a framework to guide this study. All 99 Asian-American late adolescents completed self-report questionnaires. Results indicate that, overall, late adolescents would have liked to experience an earlier timetable of autonomy than their parents had allowed. However, there was variation in the sample, that is, there were some adolescents who did not want a different timetable than they were allowed. Also, it was found that the goodness of ”t between the autonomy timetable that adolescents would have liked and what their parents had allowed was a better predictor of adolescent adjustment than simply knowing the timetable of autonomy that adolescents had actually experienced. Late adolescents who experienced a good ”t with perceived parental expectations of autonomy reported higher levels of self-esteem and emotional closeness to their parents, and lower levels of depression, behaviour misconduct, and insecurity with parents, compared to their poor ”tting counterparts. It is proposed that the concept of “goodness of ”t” is a useful framework for the investigation of autonomy development, and subsequent adjustment in Asian-American late adolescents.

ContextInfluenza vaccination lowers, but does not eliminate, the risk of influenza. Making a reliable, rapid clinical diagnosis is essential to appropriate patient management that may be especially important during shortages of antiviral agents caused by high demand.ObjectivesTo systematically review the precision and accuracy of symptoms and signs of influenza. A secondary objective was to review the operating characteristics of rapid diagnostic tests for influenza (results available in

J/P Associates is a consulting firm which implements school-wide, whole-system programs of Direct Instruction. Administrators as well as teachers and ancillary personnel received pre-service and in-service training including in-classroom coaching to conduct high quality Direct Instruction lessons. The critical indicator of teacher performance is student learning, which is evaluated using both program-based criterion-referenced, as well as norm-referenced (standardized achievement), tests. Teaching is adjusted as needed based on student performance. In an evaluation, when a school implemented this on its own, significant achievement gains were noted. When then again implemented with appropriate support and training, scores increased even more. Some classes of mostly minority students obtained top scores in the state.

Appendicitis is a common cause of abdominal pain for which prompt diagnosis is rewarded by a marked decrease in morbidity and mortality. The history and physical examination are at least as accurate as any laboratory modality in diagnosing or excluding appendicitis. Those signs and symptoms most helpful in diagnosing or excluding appendicitis are reviewed. The presence of a positive psoas sign, fever, or migratory pain to the right lower quadrant suggests an increased likelihood of appendicitis. Conversely, the presence of vomiting before pain makes appendicitis unlikely. The lack of the classic migration of pain, right lower quadrant pain, guarding, or fever makes appendicitis less likely. This article reviews the literature evaluating the operating characteristics of the most useful elements of the history and physical examination for the diagnosis of appendicitis.

In a study with 17,785 subjects obtained over the Internet from the United States and 47 other countries, Kinsey's hypothesis that sexual orientation lies on a continuum was supported. Self-identifications of subjects as gay, straight, bisexual, and other corresponded to broad, skewed distributions, suggesting that such terms are misleading for many people. Sexual orientation range—roughly, how much flexibility someone has in expressing sexual orientation—was also measured. The results support a fluid-continuum model of sexual orientation, according to which genetic and environmental factors determine both the size of the sexual orientation range and the point at which an individual's sexual orientation is centered on the continuum.

Background Healthcare-associated infections are a major source of morbidity and mortality in the United States. Infection Preventionists (IPs) are healthcare workers tasked at overseeing the prevention and control of these infections, but they may have difficulties obtaining up-to-date information, primarily in rural states. The objective of this study was to evaluate the importance of public health involvement on the knowledge-sharing network of IPs in a rural state. Findings A total of 95 attendees completed our survey. The addition of public health professionals increased the density of the network, reduced the number of separate components of the network, and reduced the number of key players needed to contact nearly all of the other network members. All network metrics were higher for public health professionals than for IPs without public health involvement. Conclusions The addition of public health professionals involved in healthcare infection prevention activities augmented the knowledge sharing potential of the IPs in Iowa. Rural states without public health involvement in healthcare-associated infection (HAI) prevention efforts should consider the potential benefits of adding these personnel to the public health workforce to help facilitate communication of HAI-related information.

Background Guidelines exist that recommend specific vaccines for health care personnel and supporting documents provide guidance for program development and implementation, but the extent to which those guidelines have been implemented in health care personnel immunization programs has not been fully explored. This project aimed to evaluate current practices in US health care facilities concerning health care personnel immunization programs. Methods A Web-based survey was deployed to 13,670 infection preventionists to assess 5 major program areas: (1) immunization program management; (2) vaccines provided to health care personnel; (3) vaccine handling practices; (4) training provided for the individual(s) responsible for the program; and (5) quality indicators for the program. A scoring scale was developed that demonstrated an overall measure of program performance. Results The Web-based survey resulted in 1,006 completed responses. When assessing overall program performance, the median vaccine program score was 47.6%. Respondents certified in infection prevention (CIC) scored significantly higher in overall program performance than respondents not certified (54% vs, 43%, respectively, P = .003). Conclusion Results of the survey have identified a number of education and training opportunities that can be addressed by professional associations using available evidence-based and proven implementation materials as resource documents.

The relationship between self-esteem and the practice of going steady among high school students was investigated. Information was gathered about both current and past dating practices of 121 sophomores and the respondents' self-esteem was assessed with the Rosenberg scale. Results indicated that going steady among high school sophomores was associated with lower self-esteem. For girls, the difference in self-esteem between those who were going steady and those who were not was greatest among those who had gone steady in the past. Girls with the highest self-esteem were those who had gone steady in the past and were no longer doing so, while the lowest self-esteem scores were held by girls who had gone steady in the past and were still going steady. For boys, however, the difference in self-esteem between those who were going steady and those who were not was unrelated to their past dating practices. Possible interpretations of this unexpected, but highly significant, interaction were suggested.

To attempt to validate a previously reported clinical prediction rule derived to assist in distinguishing between acute bacterial meningitis and acute viral meningitis.Retrospective chart review of patients treated at five hospitals between 1981 and 1990. The criterion standard for bacterial meningitis was a positive cerebrospinal fluid (CSF) or blood culture or a positive test for bacterial antigen in the CSF. For viral meningitis, the criterion standard was a positive viral culture from CSF, stool, or blood or a discharge diagnosis of viral meningitis with no other etiology evident.Two Department of Veterans Affairs (VA) hospitals, two county hospitals, and one private hospital, each affiliated with one of two medical schools.All persons aged more than 17 years who were hospitalized over a ten-year period at one of five academically affiliated hospitals for the management of acute meningitis.Sixty-two cases of bacterial meningitis and 98 cases of viral meningitis were confirmed. With all patients included, the discriminatory power of the model as measured by the area under the receiver operating characteristic curve (AUC) was 0.977 (95% CI, 0.957-0.997), compared with the AUC of 0.97 in the derivation set of the original publication. The AUCs (95% CIs) for data subsets were: Dallas cases 0.994 (0.986-1.0). Milwaukee cases 0.912 (0.834-0.990); ages 18-39 years 0.952 (0.892-1.0), ages 40-59 years 0.99 (0.951-1.0), and ageor = 60 years 0.955 (0.898-1.0).The authors conclude that the clinical prediction rule proved robust when applied to a geographically distinct population comprised exclusively of adults. There was sustained performance of the model when applied to cases from each city and from three age strata. Prospective validation of this prediction rule will be necessary to confirm its utility in clinical practice.

The Paducah Gaseous Diffusion Plant (PGDP) became operational in 1952; it is located in the western part of Kentucky. We conducted a mortality study for adverse health effects that workers may have suffered while working at the plant, including exposures to chemicals.We studied a cohort of 6820 workers at the PGDP for the period 1953 to 2003; there were a total of 1672 deaths to cohort members. Trichloroethylene (TCE) is a specific concern for this workforce; exposure to TCE occurred primarily in departments that clean the process equipment. The Life Table Analysis System (LTAS) program developed by NIOSH was used to calculate the standardized mortality ratios for the worker cohort and standardized rate ratio relative to exposure to TCE (the U.S. population is the referent for ageadjustment). LTAS calculated a significantly low overall SMR for these workers of 0.76 (95% CI: 0.72-0.79). A further review of three major cancers of interest to Kentucky produced significantly low SMR for trachea, bronchus, lung cancer (0.75, 95% CI: 0.72-0.79) and high SMR for Non-Hodgkin's lymphoma (NHL) (1.49, 95% CI: 1.02-2.10).No significant SMR was observed for leukemia and no significant SRRs were observed for any disease. Both the leukemia and lung cancer results were examined and determined to reflect regional mortality patterns. However, the Non-Hodgkin's Lymphoma finding suggests a curious amplification when living cases are included with the mortality experience.Further examination is recommended of this recurrent finding from all three U.S. Gaseous Diffusion plants.

Hurricane Katrina of August 2005 forced more than one million people to evacuate the Gulf Coast of the United States. This study examines the psychological health and well-being of a subset of evacuees to determine the prevalence of ongoing mental health problems. Interviews were conducted with 101 adults who evacuated to Louisville, Kentucky, and were living in the state at the one-year anniversary of the event or had recently returned to the Gulf Coast. The psychological health and well-being of respondents was evaluated using several well-validated measures. More than one-half met the criteria for post-traumatic stress disorder and a majority were suffering from depression and anxiety. The mean quality of life score was 0.6 on a scale from 0-1, suggesting that adaptation and return to pre-hurricane well-being had not occurred 12 months after the storm. The potential for long-term psychological damage exists in this sample of Hurricane Katrina evacuees. Results suggest other evacuees may also be at heightened risk.

To determine the frequency of ACE inhibitor cough in an outpatient medical clinic population, a cross-sectional epidemiologic survey using mailed questionnaires was done. Patients were randomly selected from a computerized hospital pharmacy data base. The overall prevalence of cough was 19 percent in the ACE inhibitor groups compared with 9 percent in the hydrochlorothiazide-treated group. The observed odds ratio for cough among ACE inhibitor users was 2.3 (95 percent CI, 1.02 to 5.00). This study is the first systematic investigation of frequency and characteristics of ACE inhibitor cough that includes a control group. Our results suggest that cough may more frequently accompany treatment with ACE inhibitors than has been previously reported. We recommend that physicians specifically inquire about cough in patients taking an ACE inhibitor. Recognition of this side effect may prevent unnecessary testing and treatment of patients receiving ACE inhibitors. (Chest 1991; 99:36–39)

To determine the current level of use, characteristics, and perceived value of the clinicopathologic conference (CPC), we sent a 22-item survey questionnaire to the program directors of internal medicine residency training programs. Of the 278 residency training programs that returned questionnaires, 221 (80%) indicated that they held CPCs regularly. The conference received a mean rating (Likert scale 1 = best to 5 = worst) of 2.2 (95% confidence interval 2.2, 2. 3) for both its perceived educational value and its popularity. The CPC remains widely used in internal medicine training programs. Although relatively few programs have rigorous guidelines for preparation and evaluation of their presentations, the CPC is generally viewed as being popular and having sound educational value.

This is a report of brain cancer survival patterns in certain Area Development Districts (ADDs) in Kentucky, the state, and the nation. Brain cancer is of national and regional concern as it is a disease of high case fatality rates and relatively short survival. Comparisons for survival were made between the U.S.A. and the state. Kentucky has higher brain cancer mortality rates than the U.S.A., but significantly better cause-specific survival (p0.05). In order to examine within state variations for brain cancer survival, data organized for the fifteen ADDs from the state's central cancer registry were used. The analytic focus of this analysis were three regions expressly: the Purchase ADD (location of the Paducah Gaseous Diffusion Plant), the Green River ADD (the location of elevated brain cancer mortality rates), and the Kentucky River ADD (comprising counties that each have significantly more than the state average of persons living below the national poverty level). We found no evidence of lower survival for brain cancer among the poorer region of the state. The western districts were found to have lower cause-specific survival than the state (p0.05) and the U.S.A. Such a regional variation alerts population-based researchers to consider varying survival trends within the state's population.

The UofL Center for the Deterrence of Biowarfare and Bioterrorism's (CDBB's) training involving standardized patients, who can make convincingly accurate representations of clinical signs and symptoms, and patient simulators has proven to be an effective means of enhancing bioterrorism preparedness. In addition to providing ready access to formative measures of preparedness, both of these teaching and learning tools also offer the option of summative evaluation of skills and knowledge acquired during training sessions. The use of moulage allows for very realistic representations of cutaneous anthrax and smallpox as well as other conditions such as recluse spider bites and chickenpox with which these biothreat infections can be confused. Exercises and drills expose deficiencies and permit essential reinforcement of skills developed in training. Unannounced exercises are especially useful in assessing public health preparedness.

The objective of this paper was to determine predictors of complementary and alternative medicine (CAM) use among individuals with specific health problems. Data were derived from the 1998 Medical Expenditure Panel Survey (MEPS). After adjustment for potential confounders, individuals with perceived barriers to obatining care were more likely to use any CAM treatment (OR 2.16), herbal therapy (OR 2.70) and spiritual care (OR 3.99) for a specific health problem. Individuals dissatisfied with their family's access to care were more likely to use acupuncture (OR 3.43). Dissatisfaction with quality of care was associated with increased use of spiritual therapy (OR 4.74). Perceptions of inadequate access to health care may contribute to utilization of CAM therapies; such therapies in this instance appear to be used as an alternative to mainstream medicine.

To establish rates of and risk factors for cardiac complications after noncardiac surgery in veterans.Prospective cohort study.A large urban veterans affairs hospital.One thousand patients with known or suspected cardiac problems undergoing 1,121 noncardiac procedures.Patients were assessed preoperatively for important clinical variables. Postoperative evaluation was done by an assessor blinded to preoperative status with a daily physical examination, electrocardiogram, and creatine kinase with MB fraction until postoperative day 6, day of discharge, death, or reoperation (whichever occurred earliest). Serial electrocardiograms, enzymes, and chest radiographs were obtained as indicated. Severe cardiac complications included cardiac death, cardiac arrest, myocardial infarction, ventricular tachycardia, and fibrillation and pulmonary edema. Serious cardiac complications included the above, heart failure, and unstable angina.Severe and serious complications were seen in 24% and 32% of aortic, 8.3% and 10% of carotid, 11.8% and 14.7% of peripheral vascular, 9.0% and 13.1% of intraabdominal/intrathoracic, 2.9% and 3.3% of intermediate-risk (head and neck and major orthopedic procedures), and 0.27% and 1.1% of low-risk procedures respectively. The five associated patient-specific risk factors identified by logistic regression are: myocardial infarction6 months (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.9 to 12.9), emergency surgery (OR, 2.6; 95% CI, 1.2 to 5.6), myocardial infarction6 months (OR, 2.2; 95% CI, 1.4 to 3.5), heart failure ever (OR, 1.9; 95% CI, 1.2 to 3.0), and rhythm other than sinus (OR, 1.7; 95% CI, 0.9 to 3.2). Inclusion of the planned operative procedure significantly improves the predictive ability of our risk model.Five patient-specific risk factors are associated with high risk for cardiac complications in the perioperative period of noncardiac surgery in veterans. Inclusion of the operative procedure significantly improves the predictive ability of the risk model. Overall cardiac complication rates (pretest probabilities) are established for these patients. A simple nomogram is presented for calculation of post-test probabilities by incorporating the operative procedure.

Prayer is a behavior that is performed by most people at least at some time, and yet social scientists appear to have neglected this topic. College students were interviewed, given the Objective Measure of Ego Identity Status, and asked to keep 7-day diaries about their prayer activities, whether spontaneous or formal. Correlational analyses revealed a relationship between identity status and frequency of praying, as well as between identity status and commitment to religion. A qualitative analysis of the diary data suggested that prayer may be a revealing approach to the psychosocial lives of late adolescents, including their central concerns, temporal orientation, and the social bounds of their definition of self.

Human sexual intercourse, or coitus, is one of the most common sexual outlets among adults. Sexual intercourse generally refers to penile penetration of the vagina, the most common sexual expression between opposite-sexed partners practiced in the United States. In a large national survey study of more than 3,000 participants, Laumann, Gagnon, Michael, and Michaels (1994) found that 95% of men and 97% of women report that they have experienced vaginal intercourse. Other sexual techniques with opposite-sex partners include mutual masturbation, anal intercourse, and oral sex (both cunnilingus, i.e., male mouth on female genitalia, and fellatio, i.e., female mouth on male genitalia). Although less common than vaginal intercourse both in terms of life incidence and most recent experience, these sexual expressions are more openly discussed in the media and more frequently practiced than in the past, especially among adolescents (Weiss & Bullough, 2004). Keywords: coitus; intimacy; sexual standards

The revised international health regulations recognise the importance of shortening the time from a disease outbreak to its detection and notification to the international public health community so that effective responses that enhance global biosecurity can be taken. The new international health regulations aim at requiring countries to issue alerts early enough so that responses can be initiated in a timely manner. But these regulations represent a real challenge for achieving early detection and translating notification into effective public health actions that reduce the risks of mass casualties from emerging infectious diseases and bioterrorism. Coordinated early warning mechanisms to facilitate rapid recognition of a disease outbreak are needed so that an effective response within the medical and public health communities can be initiated. Effective training is essential for early recognition of rare biothreat diseases; such training needs to be realistic to achieve an effective response. Responder and system capabilities should be verified periodically through the use of full-scale exercises or virtual drills. Such training and skills are critical for achieving biosecurity.

The cumulative risk of human immunodeficiency virus (HIV) infection over a healthcare career has rarely been estimated, but is more relevant to the description of an occupational hazard than the risk of seroconversion from a single exposure. We describe a model for assessing the individualized risk for HIV infection after multiple potential exposures over many years for surgeons and other operating room personnel, a high-risk group. For the average surgeon operating over a 30-year career on patients with an HIV seroprevalence of 0.01, the cumulative risk is estimated at 1%. The same surgeon operating on patients with a seroprevalence of 0.10 has an estimated cumulative risk of 10%. These risks may vary dramatically depending on the assumed rate of skin punctures during surgery. Healthcare workers need to be aware of the cumulative risk from multiple exposures to infectious blood and body fluids, to follow proposed suggestions for the reduction of percutaneous blood exposures and to assist in developing new technology to further reduce these risks. Failure to protect these professionals could result in the reduction of services for the approximately 1 to 1.5 million HIV-infected persons in the United States.

It has been shown that potential exposure to patients infected with the human immunodeficiency virus (HIV) should be a concern for emergency services personnel, based on the seroprevalence of HIV among severely injured or critically ill patients.1 Moreover, emergency services personnel have been surveyed about their knowledge and attitudes toward the acquired immunodeficiency syndrome (AIDS) and hepatitis B, revealing substantial fears about contracting AIDS but an underestimate of the occupational risk of hepatitis B virus (HBV) infection.2 However, to this author's knowledge, there are no published accounts of the evacuation of HIV-infected patients during an actual hospital fire and its infection control consequences. This article was written to provide infection control practitioners with information on how to reduce the potential for chaos and unwarranted concern resulting from such an emergency.