Detection and quantification of the human-specific HF183 Bacteroides 16S rRNA genetic marker with real-time PCR for assessment of human faecal pollution in freshwater

The human-specific HF183 Bacteriodes 16S rRNA genetic marker can be used to detect human faecal pollution in water environments. However, there is currently no method to quantify the prevalence of this marker in environmental samples. We developed a real-time polymerase chain reaction (PCR) assay using SYBR Green I detection to quantify this marker in faecal and environmental samples. To decrease the amplicon length to a suitable size for real-time PCR detection, a new reverse primer was designed and validated on human and animal faecal samples. The use of the newly developed reverse primer in combination with the human-specific HF183 primer did not decrease the specificity of the real-time PCR assay but a melting curve analysis must always be included. This new assay was more sensitive than conventional PCR and highly reproducible with a coefficient of variation of less than 1% within an assay and 3% between assays. As the Bacteroides species that carries this human-specific marker has never been isolated, a bacteria real-time assay was used to determine the detection efficiency. The estimated detection efficiency in freshwater ranged from 78% to 91% of the true value with an average detection efficiency of 83+/-4% of the true value. Using a simple filtration method, the limit of quantification was 4.7+/-0.3x10(5) human-specific Bacteroides markers per litre of freshwater. The aerobic incubation of the human-specific Bacteroides marker in freshwater for up to 24 days at 4 and 12 degrees C, and up to 8 days at 28 degrees C, indicated that the marker persisted up to the end of the incubation period for all incubation temperatures.     

Characterization of Brackish Coastal Waters of Different Trophic Levels by Means of Phytoplankton Biomass and Primary Production

Investigations on phytoplankton have been carried out in Baltic coastal waters, which are widely separated from the sea. Corresponding to their distance to the sea they differ in their trophic level. Annual phytoplankton production and a mean biovolume of 100-200 g C · m⁻² and 2-10 mm⁻³ · 1⁻¹ respectively were found for the mesotrophic level, of 200-400 g C · m⁻² and 10-20 mm³ · 1⁻¹ for the eutrophic level, and of 400-600 g C · m⁻² and over 20 mm³ · 1⁻¹ for the polytrophic level. In the course of nearly two decades of investigation a slight increase of phytoplankton biovolume, but no increase of primary production was recorded. Some changes in species composition are to be recognized in Greifswalder Bodden, if old literature is compared with recent data. In the Darss-Zingst boddens a shift from Cyanobacteria dominance towards Chlorophyceae dominance has appeared for at least 5 years. This was on account of the disappearance of Gomphosphaeria pusilla, which is thought to be an indicator species of the mesotrophic level.     

Reverse flow in roots of Sesbania rostrata measured using the constant power heat balance method

This investigation was performed to examine qualitatively and quantitatively the reverse flow in partially dried roots of Sesbania rostrata using the constant power heat balance method. First, a semi-empirical technique for estimating sheath conductance of sap-flow sensors without assuming that sap flow is zero at night was proposed. Sap flow measured with the heat balance method was compared with water uptake as measured by a potometric method. Sap flow was overestimated by 56·1% for a 3·3-mm-diameter root, and by 40·0% for 6·1 mm and 33·3% for 8·8 mm roots. However, high correlation coefficients between the rates of water uptake and sap flow demonstrated that calibration would provide reliable values for root sap flow. To detect reverse flow, a split root experiment was conducted using a S. rostrata plant with its root system divided between dry and wet compartments. Daily sap flow of the drying compartment declined whereas that in ‘wet’ root increased, suggesting that the decrease in water uptake by ‘dry’ roots was offset by the ‘wet’ roots. Reverse flow was observed at night in the root on the dry side of the container when the soil water potential was less than –0·30 MPa. The total amount of water released into the soil during the night period was estimated to be 22·5 g.     

Cost-effectiveness of the use of low- and high-potency statins in people at low cardiovascular risk

Background:

Although statins have been shown to reduce the risk of cardiovascular events in patients at low cardiovascular risk, their absolute benefit is small in the short term, which may adversely affect cost-effectiveness. We sought to determine the long-term cost-effectiveness (beyond the duration of clinical trials) of low- and high-potency statins in patients at low cardiovascular risk and to estimate the impact on Canada’s publicly funded health care system.

Methods:

Using Markov modelling, we performed a cost-utility analysis in which we compared low-potency statins (fluvastatin, lovastatin, pravastatin and simvastatin) and high-potency statins (atorvastatin and rosuvastatin) with no statins in a simulated cohort of low-risk patients over a lifetime horizon. Model outcomes included costs (in 2010 Canadian dollars), quality-adjusted life-years (QALYs) gained and the cost per QALY gained.

Results:

Over a lifetime horizon, the cost of managing a patient at low cardiovascular risk was estimated to be about $10 100 without statins, $15 200 with low-potency statins and $16 400 with high-potency statins. The cost per QALY gained with high-potency statins (v. no statins) was $21 300; the use of low-potency statins was not considered economically attractive. These results were robust to sensitivity analyses, although their use became economically unattractive when the duration of benefit from statin use was assumed to be less than 10 years.

Interpretation:

Use of high-potency statins in patients at low cardiovascular risk was associated with a cost per QALY gained that was economically attractive by current standards, assuming that the benefit from statin use would continue for at least 10 years. However, the overall expenditure on statins would be substantial, and the ramifications of this practice should be carefully considered by policy-makers.Although statins improve survival and reduce the risk of cardiovascular events in populations at high and moderate risk,¹ their effectiveness and cost-effectiveness in low-risk populations is less certain.² This uncertainly is due in part to low-risk patients being less likely to have cardiovascular events over the short term. For instance, in the recent Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) study³ — a large randomized trial comparing cardiovascular outcomes in low-risk patients randomly assigned to receive either rosuvastatin or placebo — the risk of death or nonfatal myocardial infarction over three years was 2.5% in the rosuvastatin group and 3.5% in the placebo group, which represented a large relative, but small absolute, risk reduction in cardiovascular events.Other cholesterol-lowering interventions are available, such as diet, exercise and the use of other hypolipidemic agents, but the use of statins is the only such intervention known to reduce cardiovascular risk in people with low and high blood cholesterol levels.^4–7 Thus, statins are now primarily indicated for the reduction of cardiovascular risk instead of being used mainly for the management of hypercholesterolemia.⁸With this broadening indication for use, expenditures on statins have increased and represent about 13% of total expenditures by provincial formularies in Canada.⁹ The absolute number of people at low cardiovascular risk who are taking statins has increased substantially over the last decade, driven by the large number of low-risk people in the general population.¹⁰ In addition, statins that are more effective in lowering low-density lipoprotein (LDL) cholesterol levels have become available.^3,11 These high-potency statins (atorvastatin and rosuvastatin) are substantially more expensive than low-potency statins available as generics (pravastatin, simvastatin, fluvastatin and lovastatin), although atorvastatin has recently become available as a generic in Canada.¹² Increasing costs and concerns over the absolute benefit of statins in people at low cardiovascular risk has raised concerns about the cost-effectiveness of statins in this group.We performed an incremental cost-utility analysis comparing low- and high-potency statins with no statins in patients at low cardiovascular risk in a Canadian setting. We used findings from our group’s recent systematic review of the efficacy of statins for primary prevention in low-risk people¹³ as well as observational data from a large provincial registry of patients documenting existing statin use. Our objective was to determine which strategy represents the best use of health care resources for the publicly funded health care system, and what investment would be required to fund statins.     

Stimulatory and Inhibitory Effects of Sucrose Concentration on Xylogenesis in Lettuce Pith Explants; Possible Mediation by Ethylene Biosynthesis

Numbers of tracheary elements differentiating in lettuce pithexplants rose with increase in concentration of sucrose in themedium up to an optimal concentration of 0·2%, and fellwith further increase in concentration to about one-tenth maximalat 3% sucrose. Although a few tracheary elements formed withoutexogenous sucrose, a very low concentration of sucrose (0·001%)was sufficient to stimulate additional xylogenesis. Pretreatmentof explants with 3% sucrose caused a persisting inhibition ofxylogenesis, especially in tissue that had been near the siteof sucrose application (sandwich technique). The requirementfor adequate, but not inhibitory, concentrations of sucrosefor xylogenesis may underlie the development of xylem alongsidethe sucrose-rich phloem in normal apical morphogenesis. For callus growth the response to sucrose was different: theoptimal concentration was 3%, with a broad plateau from 1 to4% sucrose. Sucrose concentrations of 2 to 3%, used in manytissue culture media, are thus roughly optimal for callus growth,but ten times the optimum for xylogenesis in lettuce pith explants. It is surprising that 0·001% (0·03 mM) sucrose,applied exogenously, can stimulate xylogenesis: endogenous sugarconcentrations are normally higher. Perhaps the stimulationis mediated by ethylene biosynthesis, which is known to be xylogenic.Rates of ethylene production per explant rose with increasingsucrose concentration from about 0·1 nl h^-1 at 0% sucroseto a slightly (significantly) higher level at 0·004%sucrose and to about 0·5 nl h^-1 at 3% sucrose. D -glucoseresembled sucrose in its effects on xylogenesis and ethyleneproduction, but L-glucose yielded no xylogenesis and littlestimulation of ethylene biosynthesis.Copyright 1994, 1999 AcademicPress Lactuca sativa, Coleus blumei, Nicotiana tabacum, lettuce pith explants, tracheary element differentiation, sucrose, glucose, ethylene     

The potential economic impact of restricted access to angiotensin-receptor blockers

Background

The use of angiotensin-receptor blockers increased by more than 4000% in Canada from 1996 to 2006. The benefit of these medications over angiotensin-converting-enzyme (ACE) inhibitors has not been proven aside from a reduction in dry cough. We estimated the potential cost savings that might have been achieved had access to angiotensin-receptor blockers been restricted.

Methods

We performed a cost-minimization analysis with a decision-tree model using a societal perspective over a one-year period. Sources of data for model parameters included IMS Health Canada data collected from one-third of all retail pharmacies for the cost and use of angiotensin-receptor blockers and ACE inhibitors in each province, as well as published studies for administrative costs and incidence of dry cough. We used Monte Carlo simulations with 10 000 iterations to test the impact of several model parameters (e.g., drug prices, administrative costs and the incidence of dry cough). All data are in 2006 Canadian dollars.

Results

A policy that would have restricted access to angiotensin-receptor blockers might have saved more than $77 million in Canada in 2006. The simulations yielded similar savings for the year (mean $58.3 million, 95% confidence interval $29.3 million to $90.8 million). Every simulation showed a cost savings.

Interpretation

Had access to angiotensin-receptor blockers been restricted, the potential cost savings to the Canadian health care system might have been more than $77 million in 2006, likely without any adverse effect on cardiovascular health.Costs of cardiovascular drugs in Canada increased by more than 200% from 1996 to 2006. The use of angiotensin-receptor blockers grew at an especially high rate, rising by more than 4000% during that period.¹ Such an increase in the use of these agents is not strongly supported by evidence.¹ Although angiotensin-receptor blockers were effective in reducing mortality and morbidity associated with hypertension in one large trial, patients in the control group were not given an angiotensin-converting-enzyme (ACE) inhibitor.² Instead, they received atenolol, a β-blocker, a drug class whose use is increasingly being questioned in the management of high blood pressure uncomplicated by prior myocardial infarction, heart failure or tachyarrhythmia.^3,4 Although angiotensin-receptor blockers are not associated with dry cough, a side effect reported by 5%–35% of patients taking ACE inhibitors,⁵ this side effect is benign and fully reversible once the drug is stopped. Meta-analyses that included several randomized trials failed to show superiority of angiotensin-receptor blockers over ACE inhibitors for the treatment of hypertension,⁶ heart failure⁷ or the secondary prevention of coronary artery disease.⁸Innovative policies are needed to offset the ever-increasing costs of cardiovascular drugs in Canada. Currently, British Columbia is the only province that restricts access to angiotensin-receptor blockers. Given that these agents can safely be substituted by ACE inhibitors and still yield similar clinical outcomes,^6–8 restricting their access is expected to lead to cost savings without adversely affecting patient heath. We estimated the potential cost savings that might have been achieved had access to angiotensin-receptor blockers been restricted in Canada in 2006.     

Isolation and characterisation of subribosomal ribonucleoprotein particles from radish seeds and seedlings

Ribonucleoprotein (RNP) particles were isolated from the postribosomal supernatant of radish seeds and seedlings. Most of them sediment at about 20 S and have a buoyant density in CsCl of 1.38 g · cm⁻³. A minor fraction appears as a shoulder on the heavy side of the 20 S peak; it bands at 1.41 – 1.43 g · cm⁻³. Two types of RNA families have been identified in the particulate fraction : heterogenous RNA (18-4 S) and RNA comigrating with 4 S tRNA. Poly(A) has been found in this RNA but it accounts for less than 10% of total stored poly(A). The polypeptide moiety of the particles was analysed and compared with ribosomal and soluble proteins. It was shown that the 20 S RNP gradually disappears during germination. These results indicate that the post-ribosomal supernatant of seeds contains some mRNA (or nuclear precursor) associated with proteins and a large amount of another type of RNP in which tRNA is associated with proteins.     

Recent epidemiologic trends of diabetes mellitus among status Aboriginal adults

Background:

Little is known about longitudinal trends in diabetes mellitus among Aboriginal people in Canada. We compared the incidence and prevalence of diabetes, and its impact on mortality, among status Aboriginal adults and adults in the general population between 1995 and 2007.

Methods:

We examined de-identified data from Alberta Health and Wellness administrative databases for status Aboriginal people (First Nations and Inuit people with treaty status) and members of the general public aged 20 years and older who received a diagnosis of diabetes mellitus from Apr. 1, 1995, to Mar. 31, 2007. We calculated the incidence and prevalence of diabetes and mortality rate ratios by sex and ethnicity in 2007. We examined the average relative changes per year for longitudinal trends.

Results:

The average relative change per year in the prevalence of diabetes showed a smaller increase over time in the Aboriginal population than in the general population (2.39 v. 4.09, p < 0.001). A similar finding was observed for the incidence of diabetes. In the Aboriginal population, we found that the increase in the average relative change per year was greater among men than among women (3.13 v. 1.88 for prevalence, p < 0.001; 2.60 v. 0.02 for incidence, p = 0.001). Mortality among people with diabetes decreased over time to a similar extent in both populations. Among people without diabetes, mortality decreased in the general population but was unchanged in the Aboriginal population (−1.92 v. 0.11, p = 0.04). Overall, mortality was higher in the Aboriginal population than in the general population regardless of diabetes status.

Interpretation:

The increases in the incidence and prevalence of diabetes over the study period appeared to be slower in the status Aboriginal population than in the general population in Alberta, although the overall rates were higher in the Aboriginal population. Mortality decreased among people with diabetes in both populations but was higher overall in the Aboriginal population regardless of diabetes status.The health of Aboriginal people in Canada is generally poorer than their non-Aboriginal counterparts, and diabetes mellitus is a significant contributor.^1,2 Studies have shown that type 2 diabetes and its complications occur at rates two to five times higher in Canada’s Aboriginal population than in the general population.^3–7 In response, diverse diabetes programs have materialized, including various community-based prevention and screening projects.^8–10 The federally funded Aboriginal Diabetes Initiative was created to emphasize health promotion and diabetes prevention.¹¹ In addition, numerous Aboriginal communities have established their own diabetes and health programs.¹²Accurate diabetes surveillance data are essential for governments and health care organizations to plan health care delivery and translate knowledge into policy and funding decisions. However, research into the longitudinal trends of diabetes in Aboriginal populations is scarce. For the most part, data have come from small, community-based studies and self-reported surveys. Population-based studies of primary data are few and have been conducted only for limited periods. Even less is known about outcomes, mortality in particular, among Aboriginal individuals with diabetes.The use of administrative data is becoming more common for tracking diabetes in Canada.¹³ The National Diabetes Surveillance System uses administrative health data to document the burden of the disease, but it has little information on Aboriginal people. Dyck and colleagues recently used the methodology of the National Diabetes Surveillance System to examine the incidence and prevalence of diabetes among Aboriginal people in the province of Saskatchewan,¹⁴ and similar analyses were conducted in Manitoba and Ontario.^15,16As part of the Alberta Diabetes Surveillance System, we conducted this study to compare the incidence and prevalence of diabetes among people 20 years and older in the status Aboriginal population (First Nations and Inuit people with treaty status) and the general population in the province of Alberta between 1995 and 2007. We also compared trends in mortality in the two populations among people with and without diabetes.     

模拟氮沉降对杉木幼苗养分平衡的影响

为研究氮沉降对植物养分平衡的影响,对1a生杉木（Cunninghamia lanceolata（Lamb.）Hook.）幼苗进行了室内模拟试验。以NH4NO3作为外加氮源,设计了N0（0 g N m-2?a-1）、N1（6 g N m-2?a-1）、N2（12 g N m-2?a-1）、N3（24 g N m-2?a-1）和N4（48g N m-2?a-1）等5种氮沉降水平,每处理重复6次。通过1a的试验发现,杉木幼苗叶、茎、粗根和细根中的N、K、Mg含量随氮处理水平的增加而上升,但Ca在各器官中的含量则呈下降趋势;中低氮（N1,N2）对叶、茎和粗根中P的含量表现为促进作用,而高氮（N3,N4）则表现为抑制作用。幼苗各器官中的N与其他养分元素的比值随氮处理水平的增加而普遍升高,但粗根中的N/K、N/Mg则表现为下降。与对照（N0）相比,在N1、N2、N3、N4处理中,幼苗对外加氮素的表观利用率分别为60.7%、57.9%、43.3%和27.9%,随氮处理水平增加,利用率呈明显下降趋势。随着氮处理水平的增加,幼苗体内的氮分配到叶和细根中的比例增加,而分配到茎和粗根中的比例下降。因此,氮沉降明显增加了杉木幼苗各器官的氮含量,影响了幼苗的养分平衡。     

Interactions of superoxide anion with enzyme radicals: Kinetics of reaction with lysozyme tryptophan radicals and corresponding effects on tyrosine electron transfer

The kinetics of O^·-₂ reaction with semi-oxidized tryptophan radicals in lysozyme, Trp^·(Lyz) have been investigated at various pHs and conformational states by pulse radiolysis. The Trp^·(Lyz) radicals were formed by Br^·-₂ oxidation of the 3–4 exposed Trp residues in the protein. At pH lower than 6.2, the apparent bimolecular rate is about 2 × 10⁸M^-1s^-1; but drops to 8 × 10⁷M^-1s^-1 or less above pH 6.3 and in CTAC micelles. Similarly, the apparent bimolecular rate constant for the intermolecular Trp^·(Lyz) + Trp^·(Lyz) recombination reaction is about (4-7 × 10⁶M^-1s^-1) at/or below pH 6.2 then drops to 1.3-1.6 × 10⁶M^-1s^-1 at higher pH or in micelles. This behavior suggests important conformational and/or microenvironmental rearrangement with pH, leading to less accessible semioxidized Trp^· residues upon Br^·-₂ reaction. The kinetics of Trp^·(Lyz) with ascorbate, a reducing species rather larger than O^·-₂ have been measured for comparison. The well-established long range intramolecular electron transfer from Tyr residues to Trp radicals-leading to the repair of the semi-oxidized Trp^·(Lyz) and formation of the tyrosyl phenoxyl radical is inhibited by the Trp^·(Lyz)+O^·-₂ reaction, as is most of the Trp^·(Lyz)+Trp^·(Lyz) reaction. However, the kinetic behavior of Trp^·(Lyz) suggests that not all oxidized Trp residues are involved in the intermolecular recombination or reaction with O^·-₂. As the kinetics are found to be quite pH sensitive, this study demonstrates the effect of the protein conformation on O^·-₂ reactivity. To our knowledge, this is the first report on the kinetics of a protein-O^·-₂ reaction not involving the detection of change in the redox state of a prosthetic group to probe the reactivity of the superoxide anion.     

RNA synthesis in imaginal disks of Galleria mellonella: Effects of alpha- and beta-ecdysone and fat body in vitro

The effects of alpha-ecdysone (α-E), beta-ecdysone (β-E), and larval fat body on morphogenesis and total RNA synthesis in wing imaginal disks of Galleria mellonella were studied. Both ecdysones induce morphogenesis of disks in vitro. Alpha-ecdysone and β-E (0·3–3·0 μg/ml) stimulate RNA synthesis 30 and 60 per cent above control levels, respectively. While less α-E (0·3 μg/ml) is required to increase RNA synthesis than to induce morphogenesis, the reverse is true for β-E. Morphogenesis (i.e. tracheole migration and evagination) can proceed in the presence of concentrations of β-E (0·03 μg/ml) that are subthreshold for the induction of RNA synthesis (0·3 μg/ml). We conclude, therefore, that the increase in total RNA (presumbly ribosomal) is unrelated to and not a prerequisite for tracheole migration or evagination. If morphogenically active preconditioned medium (i.e. medium in which α-E and fat body have been incubated for 48 hr and the fat body then removed) is added to disk cultures, RNA synthesis is not stimulated. Apparently, increases in total RNA caused by both ecdysones may not be necessary for early in vitro disk development. The independent nature of some ecdysone-induced events and implications of our conclusions are discussed.     

The responses of Aboriginal Canadians to adjuvanted pandemic (H1N1) 2009 influenza vaccine

Background:

Because many Aboriginal Canadians had severe cases of pandemic (H1N1) 2009 influenza, they were given priority access to vaccine. However, it was not known if the single recommended dose would adequately protect people at high risk, prompting our study to assess responses to the vaccine among Aboriginal Canadians.

Methods:

We enrolled First Nations and Métis adults aged 20–59 years in our prospective cohort study. Participants were given one 0.5-mL dose of ASO3-adjuvanted pandemic (H1N1) 2009 vaccine (Arepanrix, GlaxoSmithKline Canada). Blood samples were taken at baseline and 21–28 days after vaccination. Paired sera were tested for hemagglutination-inhibiting antibodies at a reference laboratory. To assess vaccine safety, we monitored the injection site symptoms of each participant for seven days. We also monitored patients for general symptoms within 7 days of vaccination and any use of the health care system for 21–28 days after vaccination.

Results:

We enrolled 138 participants in the study (95 First Nations, 43 Métis), 137 of whom provided all safety data and 136 of whom provided both blood samples. First Nations and Métis participants had similar characteristics, including high rates of chronic health conditions (74.4%–76.8%). Pre-existing antibody to the virus was detected in 34.3% of the participants, all of whom boosted strongly with vaccination (seroprotection rate [titre ≥ 40] 100%, geometric mean titre 531–667). Particpants with no pre-existing antibody also responded well. Fifty-eight of 59 (98.3%) First Nations participants showed seroprotection and a geometric mean titre of 353.6; all 30 Métis participants with no pre-existing antibody showed seroprotection and a geometric mean titre of 376.2. Pain at the injection site and general symptoms frequently occurred but were short-lived and generally not severe, although three participants (2.2%) sought medical attention for general symptoms.

Interpretation:

First Nations and Métis adults responded robustly to ASO3-adjuvanted pandemic (H1N1) 2009 vaccine. Virtually all participants showed protective titres, including those with chronic health conditions.

Trial registration:

ClinicalTrials.gov trial register no. NCT.01001026.During the first wave of the H1N1 pandemic in Canada in 2009, some First Nations communities were severely affected, with younger adults and children most at risk for severe disease.^1,2 Whereas Aboriginal Canadians make up 3.4% of the population (with 1.14 million people), they accounted for 16% of admissions to hospital during the first wave of the pandemic, and 43% of Aboriginal patients had underlying medical conditions.³ The increased rate of severe disease might have resulted from residential crowding, prevalence of chronic health conditions, delayed access to health care or suboptimal immune responses to infection.⁴ When a federally funded, ASO3-adjuvanted (squalene/tocopherol) pandemic vaccine became available for Canadians later in 2009,⁵ Aboriginal people were given priority access to it.³ However, dosing requirements at the time were tentative. Previous studies of an ASO3-adjuvanted influenza A (H5N1) vaccine established that two doses were needed for immunity in adults.⁶ Because the 2009 influenza (H1N1) pandemic occurred without warning, no prepandemic studies had been done with vaccines based on this novel swine-derived virus.⁷The ASO3-adjuvanted pandemic (H1N1) 2009 vaccine manufactured in Canada (Arepanrix, GlaxoSmithKline, Laval, Quebec) was released for public use as soon as it was available, unstudied, to mitigate morbidity during the pandemic’s second wave, which was already in progress. A single 3.75-μg dose of hemagglutinin was recommended for adults using the preliminary results of a European trial of another ASO3-adjuvanted vaccine (Pandemrix, GlaxoSmithKline, Rixensart, Belgium) given to 65 adults aged 18–60 years.⁸ The European product was believed to be equivalent to the Canadian-made vaccine, but this had not yet been shown.We wondered if the recommended single dose would be adequate for Aboriginal Canadian adults given their heightened risk of severe influenza during the first wave. We were unable to identify any previous studies of influenza vaccines involving Aboriginal Canadians to determine if their responses would be similar to other Canadians or to the healthy European study participants on whom the dosing recommendation was based. Consequently, we undertook a study involving First Nations and Métis adults to assess their responses to the pandemic vaccine.     

Diagnoses and factors associated with medical evacuation and return to duty among nonmilitary personnel participating in military operations in Iraq and Afghanistan

Background

Nonmilitary personnel play an increasingly critical role in modern wars. Stark differences exist between the demographic characteristics, training and missions of military and nonmilitary members. We examined the differences in types of injury and rates of returning to duty among nonmilitary and military personnel participating in military operations in Iraq and Afghanistan.

Methods

We collected data for nonmilitary personnel medically evacuated from military operations in Iraq and Afghanistan between 2004 and 2007. We compared injury categories and return-to-duty rates in this group with previously published data for military personnel and identified factors associated with return to duty.

Results

Of the 2155 medically evacuated nonmilitary personnel, 74.7% did not return to duty. War-related injuries in this group accounted for 25.6% of the evacuations, the most common causes being combat-related injuries (55.4%) and musculoskeletal/spinal injuries (22.9%). Among individuals with non–war-related injuries, musculoskeletal injuries accounted for 17.8% of evacuations. Diagnoses associated with the highest return-to-duty rates in the group of nonmilitary personnel were psychiatric diagnoses (15.6%) among those with war-related injuries and noncardiac chest or abdominal pain (44.0%) among those with non–war-related injuries. Compared with military personnel, nonmilitary personnel with war-related injuries were less likely to return to duty (4.4% v. 5.9%, p = 0.001) but more likely to return to duty after non–war-related injuries (32.5% v. 30.7%, p = 0.001).

Interpretation

Compared with military personnel, nonmilitary personnel were more likely to be evacuated with non–war-related injuries but more likely to return to duty after such injuries. For evacuations because of war-related injuries, this trend was reversed.In modern warfare, injuries sustained in combat have never been the leading source of attrition among soldiers. In World War I, World War II and the Korean War, respiratory and infectious diseases were the top reasons for hospital admissions among service members. By the Vietnam Conflict, non-battle injuries had supplanted respiratory illness as the leading cause of hospital admissions and have remained the leading cause ever since.^1,2The principal causes for medical evacuation of military personnel from US operations in Iraq and Afghanistan were recently described in a large four-year epidemiologic study.³ In descending order, the leading reasons were musculoskeletal conditions, combat-related injuries, neurologic symptoms and psychiatric disorders; the last category surpassed combat-related injuries as the number two reason in the latter half of both engagements. However, nonmilitary personnel were not included in that study. Over the past three years, nonmilitary members, including US Department of Defense civilians, private contractors and diplomats, have comprised about 50% of personnel serving in Iraq and about two-thirds of those serving in Afghanistan.^4,5Several reasons may explain why the types of injury and the return-to-duty rates differ between military and nonmilitary personnel. First, the motivations for overseas deployment might differ between the groups. Whereas some civilian personnel (e.g., diplomats) may be assigned to positions in Iraq and Afghanistan, virtually all private contractors volunteer for their jobs. In contrast, most military members have little choice in their deployment. Second, military and nonmilitary members assigned to war zones have different occupational specialties, living conditions and regulations to which they must adhere. Especially for junior military personnel, jobs tend to be more dangerous, living environments more austere and regulations more stringent. Finally, unlike military personnel, who are paid regardless of deployment status, most contractors’ pay is contingent upon continued employment in theatres of operation. In addition, nonmilitary personnel are generally compensated with higher salaries than service members in comparable occupational specialties.In civilian cohorts, many of these factors have been shown to influence return-to-work rates in a variety of contexts. Studies of the effect of financial compensation on work status after injury have generally shown a direct correlation between return-to-work rates and higher income levels.^6,7 Similar associations have also been found between return-to-work rates and job satisfaction and coping mechanisms, factors that may be influenced by work conditions and perceived control over one’s environment.^8–10The objectives of our study were threefold: to ascertain whether the reasons for medical evacuation from military operations differed between military and nonmilitary personnel; to determine whether return-to-duty rates differed between the two groups; and to identify factors that influence return-to-duty rates among nonmilitary members.