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The alternate strategy of open-lake discharge may alleviate the need for unusually stringent treatment needed to meet water quality goals of the Hamilton Harbour Remedial Action Plan (RAP). The latest update of the RAP recommended a study of the possibility of offshore discharges. A study conducted for the City of Burlington has proposed a location for outfall in Lake Ontario. This paper utilizes a combination of physical limnological data and mathematical models to predict the waste plume characteristics for the proposed outfall in the lake. Near-field dilutions obtained from a mixing zone model show that, for treated effluents with a discharge condition of 2 m³/s at the proposed outfall site at Burlington, the dilution ratios are in the range of 13:1 to 28:1 for weak to moderate currents during summer stratification. Winter dilution ratios increased to 21:1 to 96:1 for moderate currents. The recommended site for openlake outfall provides acceptable near-field dilutions for treated effluents under typical lake currents and density structure. The extension of outfall to a location farther offshore is only marginally beneficial. With the proposed Burlington outfall location and discharge conditions, no far-field contamination is observed near the beaches or nearby water intakes for typical summer and winter conditions. Thus, this study indicates that by discharging the treated sewage from an outfall in Lake Ontario it is possible to achieve the Hamilton Harbour RAP goals. [ABSTRACT FROM AUTHOR]

Objectives: To update mortality for 34 560 employees from diverse operating segments of a Canadian petroleum company; and to investigate potential relations with occupational factors.Methods: Employees from 1964-83 were linked to the Canadian mortality data base to provide 11 years additional follow up. There were 6760 deaths and 750 683 person-years of follow up compared with 3909 and 428 190, respectively, in the earlier study. Analyses used standardised mortality ratios (SMRs) to compare worker cause specific mortality with the Canadian general population. Duration of employment and latency analyses were performed for causes previously found to be increased in this and other petroleum cohorts, as well as any findings of interest.Results: For the period 1964-94, employees experienced significantly low overall mortality (SMR=0.86 men, SMR=0.80 women). Kidney cancer, which has been increased in some studies of petroleum workers, was not increased. Acute non-lymphocytic leukaemia in exposed operating segments was consistent with the expected or only slightly, non-significantly increased. The most notable finding was increased deaths from mesothelioma among refinery and petrochemical workers (SMR 8.68; 95% confidence interval (95% CI) 5.51 to 13.03), most of whom were long term employees in jobs with presumed exposure to asbestos (mechanical and pipefitters). Deaths from multiple myeloma among marketing and distribution workers, which were previously increased, remained increased (SMR 2.08; 95% CI 0.95 to 3.95) in the update period 1984-94; however, there was no clear pattern by duration of employment or latency. Aortic aneurysms, which also were previously significantly increased among marketing and distribution workers approached the expected in the update period (SMR 1.18; 95% CI 0. 65-1.98). Analyses by duration of employment showed suggestive trends for aortic aneurysms, but earlier studies of this cohort have not found a relation between aortic aneurysms and exposure to hydrocarbons.Conclusion: The additional 2851 deaths and 322 493 person-years of follow up strengthened the assessment of mortality patterns relative to occupational factors. With the exception of mesothelioma, no clear work related increases in disease were identified. [ABSTRACT FROM AUTHOR]

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Despite an increasing number of women pursuing careers in science, engineering, and medicine, gender disparities in patents persist. This study sought to analyze trends in inventor's gender for surgical device patents filed and granted in Canada and the United States from 2015 to 2019., Methods: This study analyzed patents filed and granted by the Canadian Intellectual Property Office (CIPO) in the category of "Diagnosis; Surgery; Identification" and the United States Patent and Trademark Office (USPTO) in the category of "Surgery" from 2015 to 2019. The gender of the patent applicants was determined using a gender algorithm that predicts gender based on first names. Gender matches with names having a probability of less than 95% were excluded., Results: We identified 14,312 inventors on patents filed and 12,737 inventors on patents granted by the CIPO for "Diagnosis; Surgery; Identification". In the USPTO category of "Surgery," we identified 75,890 inventors on patents filed and 44,842 inventors on patents granted. Female inventors accounted for 7%-10% of inventors from 2015 to 2019 for both patents filed and granted. The proportion of female inventors on patents granted was significantly lower than for patents filed for four of the 5 y analyzed for both the USPTO and CIPO., Conclusions: Female representation in surgical device patenting has stagnated, between 7 and 10%, from 2015 to 2019 in Canada and the United States. This underrepresentation of female inventors in surgical device patenting represents sizable gender disparity., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The internet is commonly employed by Radiology trainees to investigate and learn about potential fellowship programs. As a new and emerging subspecialty, Emergency Radiology requires strong internet presence and training program website content. This is vital to ensure good exposure of the fellowship programs to inform medical students, radiology trainees, and program directors, highlight unique aspects of a fellowship and raise awareness of the discipline at large., Methods: To assess the standard and depth of information available online, Canadian and American Radiology fellowship websites were evaluated for content. Thirty-six criteria related to application process and recruitment, departmental structure, incentives, education, and research and clinical training were evaluated for presence or absence., Results: Sixteen Emergency Radiology fellowship program websites were assessed from the United States and Canada for 36 criteria across 5 individual areas; application process and recruitment, departmental structure, incentives, education and research, and clinical training. Overall there was an absence of information found across all 5 areas. In particular areas for improvement were identified in education and research, and incentives both with median values of 12.5% of criteria present., Conclusion: Most Emergency Radiology fellowship program websites demonstrate several information deficiencies. This relative lack of comprehensive information represents an actionable opportunity for individual programs and the field to better educate trainees, program directors and the public about the unique training of Emergency Radiologists., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Radiology trainees frequently use the Internet to research potential fellowship programs across all subspecialties. For a field like nuclear medicine, which has multiple training pathways, program websites can be an essential resource for potential applicants. This study aimed to analyze the online content of Canadian and American Nuclear Medicine fellowship websites., Materials and Methods: The content of all active Canadian and American Nuclear Medicine fellowship websites was evaluated using 26 criteria in the following subdivisions: application, recruitment, education, research, clinical work, and incentives. Fellowships without websites were excluded from the study. Scores were summed per program and compared by geographic region and ranking., Results: A total of 42 active Canadian and American Nuclear Medicine fellowship programs were identified, of which 39 fellowships had dedicated fellowship websites available for the analysis. On average, fellowship websites contained 34.4% (9 ± 3.3) of the 26 criteria. Programs did not score differently on the criteria by geographical distribution ( P = .08) nor by ranking ( P = .18)., Conclusion: Most Canadian and American Nuclear Medicine fellowship websites are lacking content relevant to prospective fellows. Addressing inadequacies in online content may support programs to inform and recruit residents into fellowship programs.

Purpose: Fellowship is an important part of postgraduate medical training as it facilitates advanced training in a subspecialty of interest. Internet is the most readily available and frequently used tool for acquiring information about the fellowship programs by residents worldwide. The aim of this study was to analyze the content of the websites of American and Canadian breast/women's imaging fellowship programs., Methods: The content of active Canadian and American breast/women's imaging fellowship websites was collected and analyzed in August 2019 using 27 different criteria in the categories of application process, recruitment, education, research, clinical work, and incentives. The fellowship program without a webpage were excluded from the study., Results: Out of 76 active breast/women's imaging Radiology fellowship programs in the US and Canada, 75 had dedicated fellowship websites available for analysis. One program was excluded due to lack of a dedicated website. On average, websites showcased 11 of the 27 criteria (40.0%). The category with the least prevalent information was incentives especially career placement after completion of the fellowship (1/75, 1.3%). Majority of the programs around 80.0% (60/75) had adequate information about the application process and requirements. The mean number of schools satisfying the different groups of criteria differed (P< 0.01); more schools satisfied the application criteria (60.5/75; 79.6% ± 20.3%) than the incentives (12.8/75; 16.8% ± 8.2%) and recruitment (24.5/75; 32.2% ± 29.7%) criteria., Conclusion: Majority of the breast and women's imaging fellowship websites lack important information. Providing comprehensive online information about the program and application process may help the applicants to choose the best suited program for their academic needs and career progression., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Prospective radiology fellows often rely on the internet to obtain valuable information regarding the application process as well as the unique qualities and aspects of different fellowship programs. The aim of this study was to analyze the content of Accreditation Council for Graduate Medical Education (ACGME) Pediatric Radiology Fellowship websites within the USA and Canadian Accredited Pediatric Radiology Fellowship program websites., Methods: All active ACGME Pediatric Radiology fellowship websites as of October 2018 were evaluated using 26 criteria in the following domains: application process, recruitment, program structure, education, research, clinical care, and incentives. Fellowships without websites were excluded from the study. Canadian programs were compiled from a list obtained as of October 2018 from the Canadian Association of Radiologists fellowship directory. Each fellowship program was evaluated using the same 26 criteria as the US programs., Results: 45 active ACGME Pediatric Radiology fellowship programs and 9 Canadian programs were identified. 43 of the US fellowships (96%), and 8 of the Canadian fellowships (89%) had dedicated fellowship websites available for analysis. For US data, websites on average contained 8 out of the 26 data points (31%). Whereas, in Canada, websites on average contained 11 out of the 26 data points (41%)., Conclusion: Most fellowship websites demonstrate several information deficiencies. This presents an actionable opportunity for individual programs to better inform trainees, promote Pediatric Radiology, and attract the highest quality applicants., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Many global environmental agendas, including halting biodiversity loss, reversing land degradation, and limiting climate change, depend upon retaining forests with high ecological integrity, yet the scale and degree of forest modification remain poorly quantified and mapped. By integrating data on observed and inferred human pressures and an index of lost connectivity, we generate a globally consistent, continuous index of forest condition as determined by the degree of anthropogenic modification. Globally, only 17.4 million km 2 of forest (40.5%) has high landscape-level integrity (mostly found in Canada, Russia, the Amazon, Central Africa, and New Guinea) and only 27% of this area is found in nationally designated protected areas. Of the forest inside protected areas, only 56% has high landscape-level integrity. Ambitious policies that prioritize the retention of forest integrity, especially in the most intact areas, are now urgently needed alongside current efforts aimed at halting deforestation and restoring the integrity of forests globally.

Background: Health systems in Canada and elsewhere are at a crossroads of reform in response to rising economic and societal pressures. The Quadruple Aim advocates for: improving patient experience, reducing cost, advancing population health and improving the provider experience. It is at the forefront of Canadian reform debates aimed to improve a complex and often-fragmented health care system. Concurrently, collaboration between primary care and public health has been the focus of current research, looking for integrated community-based primary health care models that best suit the health needs of communities and address health equity. This study aimed to explore the nature of Canadian primary care - public health collaborations, their aims, motivations, activities, collaboration barriers and enablers, and perceived outcomes., Methods: Ten case studies were conducted in three provinces (Nova Scotia, Ontario, and British Columbia) to elucidate experiences of primary care and public health collaboration in different settings, contexts, populations and forms. Data sources included a survey using the Partnership Self-Assessment Tool, focus groups, and document analysis. This provided an opportunity to explore how primary care and public health collaboration could serve in transforming community-based primary health care with the potential to address the Quadruple Aims., Results: Aims of collaborations included: provider capacity building, regional vaccine/immunization management, community-based health promotion programming, and, outreach to increase access to care. Common precipitators were having a shared vision and/or community concern. Barriers and enablers differed among cases. Perceived barriers included ineffective communication processes, inadequate time for collaboration, geographic challenges, lack of resources, and varying organizational goals and mandates. Enablers included clear goals, trusting and inclusive relationships, role clarity, strong leadership, strong coordination and communication, and optimal use of resources. Cases achieved outcomes addressing the Q-Aims such as improving access to services, addressing population health through outreach to at-risk populations, reducing costs through efficiencies, and improving provider experience through capacity building., Conclusions: Primary care and public health collaborations can strengthen community-based primary health care while addressing the Quadruple Aims with an emphasis on reducing health inequities but requires attention to collaboration barriers and enablers.

Introduction: Activation of the RAS/RAF/MEK/ERK pathway may confer resistance to chemotherapy in non-small cell lung cancer (NSCLC). Selumetinib (AZD6244, ARRY142886), a MEK1/2 inhibitor combined with chemotherapy in patients with NSCLC was evaluated in two schedules to evaluate efficacy and toxicity., Methods: IND.219 was a three-arm study of first line pemetrexed/platinum chemotherapy with two schedules of selumetinib (Arm A: intermittent given on days 2-19; Arm B: continuous given on days 1-21) versus chemotherapy alone (Arm C). The primary endpoint was objective response rate (ORR); secondary objectives were tolerability, progression-free survival (PFS), overall survival (OS). The trial was stopped at the planned interim analysis., Results: Arms A/B/C enrolled 20/21/21 patients, ORR was 35% (95% CI 15-59% median duration 3.8 months), 62% (95% CI 38-82%; median duration 6.3 months), 24% (95% CI 8-47%; median duration 11.6 months) respectively. The PFS (months Arm A, B, C) was 7.5, 6.7, 4.0 respectively (hazard ratio (HR) PFS Arm A over Arm C: 0.76 [95% CI, 0.38-1.51, 2-sided p = 0.42]; Arm B over Arm C 0.75 [95% CI 0.37-1.54, p = 0.43]. Skin and gastrointestinal adverse events were more common with the addition of selumetinib. A high incidence of venous thromboembolism was seen in all arms., Conclusions: Selumetinib combined with chemotherapy was associated with a higher response rate. Continuous selumetinib appeared to be superior to an intermittent schedule. PFS was prolonged with the addition of selumetinib, however this was not statistically significant., (Copyright © 2019 Elsevier B.V. All rights reserved.)

AimThe aim of this paper is to examine Canadian key informants' perceptions of intrapersonal (within an individual) and interpersonal (among individuals) factors that influence successful primary care and public health collaboration., Background: Primary health care systems can be strengthened by building stronger collaborations between primary care and public health. Although there is literature that explores interpersonal factors that can influence successful inter-organizational collaborations, a few of them have specifically explored primary care and public health collaboration. Furthermore, no papers were found that considered factors at the intrapersonal level. This paper aims to explore these gaps in a Canadian context., Methods: This interpretative descriptive study involved key informants (service providers, managers, directors, and policy makers) who participated in one h telephone interviews to explore their perceptions of influences on successful primary care and public health collaboration. Transcripts were analyzed using NVivo 9.FindingsA total of 74 participants [from the provinces of British Columbia (n=20); Ontario (n=19); Nova Scotia (n=21), and representatives from other provinces or national organizations (n=14)] participated. Five interpersonal factors were found that influenced public health and primary care collaborations including: (1) trusting and inclusive relationships; (2) shared values, beliefs and attitudes; (3) role clarity; (4) effective communication; and (5) decision processes. There were two influencing factors found at the intrapersonal level: (1) personal qualities, skills and knowledge; and (2) personal values, beliefs, and attitudes. A few differences were found across the three core provinces involved. There were several complex interactions identified among all inter and intra personal influencing factors: One key factor - effective communication - interacted with all of them. Results support and extend our understanding of what influences successful primary care and public health collaboration at these levels and are important considerations in building and sustaining primary care and public health collaborations.

Background: Although abiraterone acetate (abiraterone) has proven efficacy in two randomised phase 3 trials in metastatic castration-resistant prostate cancer (mCRPC), patients who had an Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥2 were either excluded or under-represented in these trials., Objective: To compare outcomes in ECOG PS 0-1 and ≥2 in mCRPC patients treated with abiraterone., Design, Setting, and Participants: Cancer registries from three Canadian centres were used to retrospectively identify mCRPC patients (postdocetaxel and docetaxel-naïve) treated with abiraterone. ECOG PS, clinicopathologic characteristics, prostate-specific antigen (PSA) response, and survival data were collected., Outcome Measurements and Statistical Analysis: Survival outcomes were estimated using the Kaplan-Meier method and compared using the log-rank test. Cox proportional hazards modelling was used to examine the effect of clinicopathologic characteristics on overall survival (OS) and time to PSA progression., Results and Limitations: A total of 519 patients were identified; 61% (n=318) and 39% (n=201) were ECOG PS 0-1 and ≥2, respectively. ECOG PS 0-1 patients were significantly more likely than PS ≥2 patients to achieve a PSA decline ≥50% from baseline (45% vs 32%; p=0.003, Fisher exact test) and had significantly longer median time to PSA progression (5.2 mo vs 4.1 mo; p=0.023), median treatment duration (7.4 mo vs 4.5 mo; p<0.001), and median OS (20.0 mo vs 9.1 mo; p<0.001). On multivariate analysis, ECOG PS was a significant factor for OS (p<0.001), time to PSA progression (p=0.043), and PSA decline (p=0.002). Potential limitations include the retrospective study design and subjective nature of ECOG PS classification., Conclusions: ECOG PS ≥2 mCRPC patients treated with abiraterone have inferior outcomes compared with ECOG 0-1 patients, especially in regard to OS. These data indicate that early initiation of abiraterone prior to a decline in PS may be warranted., Patient Summary: We found that advanced prostate cancer patients who have worse performance status (PS) derive less benefit from abiraterone, indicating that earlier treatment before PS declines could improve outcomes., (Crown Copyright © 2014. Published by Elsevier B.V. All rights reserved.)

Introduction: Management of Stage III non-small-cell lung cancer (NSCLC) involves surgery, radiotherapy (RT), chemotherapy, and best supportive care. The aims were to describe the patterns of treatment in a population-based cohort of patients, and compare utilization of RT and chemotherapy to model estimates of need., Methods: Patients diagnosed with Stage III NSCLC between January 1, 2000, to December 31, 2007, were identified from the British Columbia Cancer Agency database. Patients who had prior or concomitant malignancy were excluded. Patient demographics, tumor characteristics, and initial treatment were extracted. Survival data were derived from the British Columbia Vital Statistics Death Listings., Results: 2365 patients with Stage III NSCLC were referred, of which 212 patients were excluded, leaving 2153 patients in the study population. Median age was 69 years. Disease stage was IIIA in 49% and IIIB in 51%. Histologies were squamous-cell carcinoma (31%), adenocarcinoma (27%), NSCLC not otherwise specified (31%), and other pathology (11%). Initial treatment included surgery in 12%, RT in 78%, and chemotherapy in 31%. Predicted RT utilization was 77% to 87% and chemotherapy 78%. From 2000 to 2007, curative-intent treatment increased from 21% to 35%, chemoradiotherapy from 8% to 18.6%, and concurrent chemoradiotherapy from 5.1% to 17.6%. Median survival was 30 months for patients who had curative surgery, 21 months for curative RT, 8 months for palliative treatment, and 5 months for best supportive care (p < 0.001)., Conclusion: RT utilization was similar to that predicted by models whereas chemotherapy utilization was less. During the study period, the proportion of patients receiving curative chemoradiotherapy doubled and of those receiving concurrent chemoradiotherapy trebled.

Background: Associations between anemia and outcomes of chemoradiation have been documented in several malignancies, but few data exist for limited small-cell lung cancer (LD-SCLC). This combined analysis of 652 patients in two randomized clinical trials in LD-SCLC carried out by the National Cancer Institute of Canada Clinical Trials Group was undertaken to explore the relationship between anemia at baseline and anemia arising during therapy, and outcomes of chemoradiation in this cancer., Patients and Methods: The relationships between overall survival and local control with hemoglobin levels at baseline and those arising during therapy (nadir hemoglobin (Hb) and maximum percentage drop from baseline values) were explored., Results: No Hb parameter was associated with either outcome. Baseline anemia was found in one-third of patients, was more common in males, in those with a poorer performance status and those with an elevated lactate dehydrogenase; all of these latter factors were associated with shorter survival. A trend towards improved local control in patients with the greatest drop in their Hb did not remain significant in a multivariate analysis., Conclusions: Anemia is common in patients with LD-SCLC. Anemia at diagnosis may have a different prognostic implication than that arising during therapy, and correction of anemia may have no impact on outcomes.

A Lake Erie sediment survey was conducted in 1997 to characterize spatial trends in contamination, and for comparison with a 1971 survey to assess any changes in environmental quality since the advent of measures to reduce contaminant sources. Contaminant data for some contaminant classes in 1971 was based on analysis of frozen archived samples, thereby allowing a direct comparison between surficial sediment contamination in 1971 and 1997 based on modern analytical methods. Lake-wide contaminant concentrations of polychlorinated biphenyls (PCBs) and organochlorine compounds including hexachlorobenzene and the DDT compounds in 1997 were substantially lower, compared to levels in samples collected in 1971. Lake-wide average sediment PCB levels were found to have decreased roughly 70% from 136 ng/g in 1971 to 43 ng/g in 1997. Similarly, reductions in other compound classes ranged from 40% to 80%. In 1997, some individual contaminants classes including PCBs exhibited a spatial trend toward increasing sediment contamination from the eastern basin to the western basin, and from the north-central basin to the south-central basin. Levels of organic contaminants in sediments in some areas of Lake Erie still exceeded the strictest Canadian Federal and Ontario Provincial guidelines. However, exceedances of guidelines describing contaminated environments in 1997 were predominantly restricted to the western basin and near-shore sites in the southern part of the central basin.

Aims: To assess mortality and cancer morbidity in Canadian petroleum workers and explore exposure-response relations for specific petroleum agents., Methods: A total of 25 292 employees hired between 1964 and 1994 were linked to the Canadian tumour registry and national mortality database. Exposure-response trends were assessed for hydrocarbon solvents/fuels, hydrocarbon lubricants, petroleum coke/spent catalyst, and hydrogen sulphide (H2S)., Results: External comparison analyses (mortality and incidence) showed deficits for all causes and all malignant neoplasms combined and were consistent with expectation for most malignant and non-malignant sites analysed. Gall bladder cancer mortality was increased among males based on four deaths, but cases had no common job assignments and the increase was focused in workers employed <10 years. Mesothelioma incidence was increased. Most exposure-specific analyses were compromised by small numbers. Statistically significant increases were observed for H2S exposure and a subgroup of accidental deaths as well as for petroleum coke/spent catalyst exposure and lung cancer. While both findings have a degree of biologic plausibility, the H2S association, which exhibited a clearer exposure-response pattern, could be subject to unmeasured confounders. Additionally, interpretation was complicated by the high correlation between hydrocarbon and H2S exposures. With regard to lung cancer, the analysis could not adequately control for smoking, was based on small numbers, and exhibited a tenuous exposure-response pattern., Conclusion: The findings for mesothelioma suggest the need for continued attention to asbestos in the petroleum industry. The relation between accidental deaths and H2S exposure deserves closer scrutiny in similarly exposed populations. Further analyses of lung cancer are underway and will be reported separately.

Purpose: Children who have significant hearing loss often experience difficulty in engaging in everyday conversations. They may spend an inordinate amount of time in communication breakdown or in silence. The purpose of the present investigation was to assess the oral conversation fluency of young cochlear implant users using both objective and subjective measuring procedures. Conversational fluency relates to how smoothly a conversation unfolds. The children's performance was compared with that of children who have normal hearing, and related to other measures of communication skill and other child variables., Design: One hundred eighty-one cochlear implant users and 24 children with normal hearing engaged in conversations with a clinician, using an oral mode of communication. Audio-video tapes of the conversations were analyzed to yield the following measures: percent of time the child and clinician spent trying to repair a breakdown in communication, percent of time the two spent sitting in silence, and the ratio between the amount of time the child spoke and the amount of time the clinician spoke. In addition, for the cochlear implant users, 10 judges viewed excerpts of the tapes and gave their impressions and reactions to the children and their conversations, using five-point rating scales. The objective and subjective measures were related to the children's speech intelligibility, mean length utterance, and speech recognition in both an auditory-only and auditory-plus-vision condition., Results: The cochlear implant users spent significantly more time in communication breakdown and in silence than the children with normal hearing, and children who are in an educational placement that emphasizes oral communication spent less time in breakdown than children who are in educational placement that use both speech and sign. Speech intelligibility and receptive language were the best predictors of communication breakdown. Judges perceived children who spent less time in communication breakdown more favorably than children who spent more time, and reacted to them more positively. Finally, there was a high correlation between the subjective measures of the conversation and the objective measures., Conclusions: Educational programs should provide explicit instruction to promote conversational fluency. The results show a need for communication therapy, and suggest that the children will be perceived and reacted to more favorably if they learn how to manage communication difficulties. The results also support the need for extensive speech-language therapy for these children. The objective measures employed in this investigation appear to be a valid and useful means for assessing conversational fluency.

Purpose: To determine whether an intensive weekly chemotherapy regimen plus thoracic irradiation is superior to standard chemotherapy in the treatment of extensive-stage small-cell lung cancer (ESCLC)., Patients and Methods: Patients with ESCLC were considered eligible for the study if they were younger than 68 years, had a performance status of 0 to 2, and were free of brain metastases. Patients were randomized to receive cisplatin, vincristine, doxorubicin, and etoposide (CODE) or alternating cyclophosphamide, doxorubicin, vincristine/etoposide and cisplatin (CAV/EP). Consolidative thoracic irradiation and prophylactic cranial irradiation were given to patients responding to CODE and according to investigator discretion on the CAV/EP arm., Results: The fidelity of drug delivery on both drug regimens was equal, and more than 70% of all patients received the intended protocol chemotherapy. Although rates of neutropenic fever were similar, nine (8.2%) of 110 patients on the CODE arm died during chemotherapy, whereas one (0.9%) of 109 patients died on the CAV/EP arm. Response rates after chemotherapy were higher (P =.006) with CODE (87%) than with CAV/EP (70%). However, progression-free survival (median of 0.66 years on both arms) and overall survival (median, 0.98 years for CODE and 0. 91 years for CAV/EP) were not statistically different., Conclusion: The CODE regimen increased two-fold the received dose-intensity of four of the most active drugs in small-cell lung cancer compared with the standard CAV/EP regimen while maintaining an approximately equal total dose. Despite supportive care (but not routine prophylactic use of granulocyte colony-stimulating factor), there was excessive toxic mortality with the CODE regimen. The response rate with CODE was higher than that of CAV/EP, but progression-free and overall survival were not significantly improved. In view of increased toxicity and similar efficacy, the CODE chemotherapy regimen is not recommended for treatment of ESCLC.

A quantitative exposure-estimating algorithm for benzene and total hydrocarbons was developed for a case control study of petroleum marketing and distribution workers. The algorithm used a multiplicative model to adjust recently measured quantitative exposure data to past scenarios for which representative exposure measurement data did not exist. This was accomplished through the development of exposure modifiers to account for differences in the workplace, the materials handled, the environmental conditions, and the tasks performed. Values for exposure modifiers were obtained empirically and through physical/chemical relationships. Dates for changes that altered exposure potential were obtained from archive records, retired employee interviews, and from current operations personnel. Exposure modifiers were used multiplicatively, adjusting available measured data to represent the relevant exposure scenario and time period. Changes in exposure modifiers translated to step changes in exposure estimates. Though limited by availability of data, a validation exercise suggested that the algorithm provided accurate exposure estimates for benzene (compared with measured data in industrial hygiene survey reports); the estimates generally differed by an average of less than 20% from the measured values. This approach is proposed to quantify exposures retrospectively where there are sufficient data to develop reliable current era estimates and where a historical accounting of key exposure modifiers can be developed, but where there are insufficient historic exposure measurements to directly assess historic exposures.

This retrospective mortality study was conducted among 34,597 oil industry workers in diverse operating segments. Employees were traced through Statistics Canada, and overall mortality (SMR = 0.85) was lower than general population rates and similar to other petrochemical cohorts. The most notable finding was a significant excess of malignant melanoma [observed deaths (N) = 16, SMR = 1.87, 95% CI = 1.07, 3.04], which concentrated among upstream workers (N = 6, SMR = 6.00, 95% CI = 2.19, 13.06), and was directly related to employment duration and latency. Specific substances or hydrocarbon (HC) streams could not be implicated, although possible explanations include dermal HC exposure, ultraviolet light exposure, or a synergistic effect between these two factors. Marketing/transportation workers showed a non-significant excess of multiple myeloma (SMR = 1.81), which was also related to employment duration, latency, and commencement of employment before 1950. Lymphatic cancer, skin cancer, and kidney cancer mortality was not elevated in refinery workers, a finding at odds with some previous refinery worker studies. Although the malignant melanoma and possibly the multiple myeloma mortality patterns are consistent with an occupational link, further studies are needed to investigate the relationship of these diseases with particular exposures.

An economic evaluation was undertaken of a previously reported National Cancer Institute of Canada (NCIC) trial of chemotherapy in advanced nonsmall-cell lung cancer (NSCLC). That trial had demonstrated a survival benefit associated with the use of either vindesine and cisplatin (VP) or cyclosphosphamide, doxorubicin, and cisplatin (CAP) in relation to best supportive care (BSC). The economic technique used in this evaluation was cost-effectiveness analysis (CEA). All costs were determined from the viewpoint of two provincial health care plans. When compared with BSC, the survival benefit of 8 weeks in favor of patients receiving CAP chemotherapy was associated with an economic saving of $949.49 (in 1984 Canadian dollars). This translated into a savings of $6,171.69 per year of life gained. The mean survival benefit of 12.8 weeks that was obtained with VP chemotherapy compared with BSC was associated with an increased cost of $3,637.60 per patient, or $14,777.75 per year of life gained. The economic evaluation demonstrated that the majority of costs on each of the three treatment arms was related to hospitalization and not to the use of chemotherapy agents. These results compare favorably with estimates of cost-effectiveness (CE) of commonly used treatments for other diseases and demonstrate that a policy of supportive care is associated with costs that may exceed those of active treatment. It is concluded that economic factors should not adversely affect decisions regarding the use of chemotherapy in advanced NSCLC.