Occupational cancer: experience in Ontario.

This paper reviews the experience of the Workmen''s Compensation Board of Ontario in identifying cases of cancer that could be attributed to occupational hazards. Worker''s claims for compensation are allowed if there is reasonable medical evidence that their cancer was caused by exposure to risk factors associated with their occupation. Details of the types of cancer associated with specific carcinogens or fields of employment are discussed. About 50% of the cases were related to exposure in particular industrial operations that functioned for relatively brief periods. The number of deaths from cancer identified as being caused by occupational factors is compared with the total for cancer from all causes in Ontario during the period 1971 through 1975. Although all workers eligible for compensation may not have been identified, the data suggest that less than 1% of cancer is presently caused by occupational factors.     

Breast Cancer at the Ontario Cancer Clinics, 1938-1956: A Statistical Review

In Ontario, breast cancer accounts for one death in every 27 among females. In 1938-1956 some 40% of all new cases were registered at the Ontario Cancer Foundation''s regional clinics. The five-year crude survival rate for 11,393 women was 45.4%, and for 91 men, 36.3%. Survival rates were strongly affected by extent of disease; when this was allowed for, pregnancy and treatment method were also found to influence survival rate. Simple mastectomy with radiotherapy gave results that appeared comparable to those after radical mastectomy, alone or with radiotherapy. There was a 20% improvement in the crude five-year survival rate over the period of the survey. The need for great caution in interpreting these findings is stressed.     

Gender sensitivity in medical curricula

Both sex--the biologic aspects of being female or male--and gender--the cultural roles and meanings ascribed to each sex--are determinants of health. Medical education, research and practice have all suffered from a lack of attention to gender and a limited awareness of the effects of the sex-role stereotypes prevalent in our society. The Women''s Health Interschool Curriculum Committee of Ontario has developed criteria for assessing the gender sensitivity of medical curricula. In this article, the effects of medicine''s historical blindness to gender are explored, as are practical approaches to creating curricula whose content, language and process are gender-sensitive. Specific areas addressed include ensuring that women and men are equally represented, when appropriate, that men are not portrayed as the prototype of normal (and women as deviant), that language is inclusive and that women''s health and illness are not limited to reproductive function. By eliminating or at least addressing the subtle and often unintentional gender stereotyping in lecture material, illustrations and problems used in problem-based learning, medical educators can undertake a much-needed transformation of curriculum.     

Mother-child separation: a study in a remote health care setting.

The literature indicates that the birth of a sibling and the consequent temporary separation from the mother is usually a stressful experience for a child. It was hypothesized that this stress would result in an increased number of visits by the child to health care facilities because of new health problems. In a controlled study of 89 matched pairs of Indian families in a remote region of northwestern Ontario this hypothesis was not supported. During the intervals studied - the anticipatory period before delivery, the separation itself and the period immediately following the mother''s return home - the number of diagnoses of new medical problems was significantly less for the children who were separated from their mothers for the birth of a sibling. As well, the number of diagnoses of new medical problems in the children separated form their mothers decreased over the three intervals. The fathers'' reluctance to seek health care probably played a major role in this decrease.     

Cost analysis of the Kozak protocol as used in an Ontario hospital in the treatment of children with epidermolysis bullosa.

Conventional treatment of epidermolysis bullosa is often unsuccessful. The Kozak protocol is an alternative that has been given considerable public support in Ontario. The incremental cost of this treatment program at the Hospital for Sick Children, Toronto, was examined. The departments of nursing, pharmacy and food services each kept records of salaries and supply costs applicable to the care of nine patients with epidermolysis bullosa who were treated in the fiscal year 1982-83. The selected direct costs to the hospital were compared with the projected costs if these patients had been treated in Dr. Kozak''s clinic in West Germany or under the financial arrangements offered to Dr. Kozak by the Ontario minister of health. At a total incremental cost of +255.92 per patient-day, care at the Hospital for Sick Children may not currently be the least expensive means of offering the Kozak protocol to Ontario children. However, the major expense of the program, the nurses'' salaries, could be reduced if the patients'' parents were to assume many of the nursing tasks; this would make the hospital''s program the most cost-effective method of treating children with epidermolysis bullosa.     

MEETING COMMUNITY HEALTH NEEDS—The Combined Role of the Physician,Health Department and Hospital

Social and economic changes—the lengthening life span, the shift of population from rural to urban areas, the growth of industry and other factors—have brought about radical changes in the nation''s health needs. Our greatest health problem today is chronic illness. To cope with these problems public health, medical care and hospital services, which are at present geared primarily for acute illness, must be revised.Immediate and specific steps which physicians, health departments and hospitals can take to accomplish this are to define the problem and to initiate studies in several areas: To determine the incidence and prevalence of disease, injuries and impairments; the nature, degree and duration of resulting disability; and the type of care received.The basic approach to chronic illness is prevention. To accomplish this, more emphasis needs to be placed upon health education. Good health cannot be forced upon the public, but educated and enlightened citizens can and do solve their own health problems and those of their families and communities.Due to the complex nature of today''s health problems, they must be approached jointly by physicians, local health services, hospitals and the public. The efforts of those groups must be coordinated and aimed, directly and indirectly, at preventing disease and disability.     

Problems in determining the incidence of cervical cancer.

Since cancer registries have different recording practices, the incidence rates that they report must be compared with caution. Indexes of reliability of recording indicated that in 1971 the reported incidence of cervical cancer in Ontario was too high. In 1971 Ontario used a method of passive reporting of cancer cases: the Ontario Cancer Registry linked hospital reports, death certificates and reports from the Ontario Cancer Treatment and Research Foundation''s treatment centres to produce a single record for each case. Pathological confirmation was requested for cases thus recorded by the registry. In 26% of cases a diagnosis other than cervical cancer was indicated. With these cases omitted, the incidence rate became 15.1/100 000, as opposed to the 20.5/100 000 reported by the registry.     

Time and money in pediatric practice

The types of services provided by pediatricians in Ontario and the payment they received from OHIP for a three-month period in 1972 are examined. Pediatricians provided 4.8% of the total of 16.3 million services and received 3.3% of the total $117.7 million payment. Most of the services were provided in ambulatory settings. Skin testing for allergy and hyposensitization accounted for 42% of the total of pediatric services. More than two thirds of pediatricians were engaged in provision of services which could be classified as primary care. Indeed, most of the services provided were of a primary care nature.There is a pressing need for redifining the pediatrician''s role in our health-care delivery system and for a new look at his education.     

The Development and Organization of a Children's Psychiatric Hospital

Thistletown Hospital is a children''s psychiatric hospital which was established by the Department of Health of the Province of Ontario. Special legislation permitting control of the admissions procedures was enacted. The administrative organization consists of a series of committees made up of the heads of hospital departments. An advisory board of distinguished psychiatrists and psychologists advises the Minister of Health directly on major policy changes or innovations envisaged for the hospital. Clinical organization is related to four functions: (1) service (treatment and assessment), (2) research, (3) training of staff, and (4) community education.The basic units of the hospital are related to the treatment or research design necessary in special diagnostic categories. A children''s psychiatric hospital should not be restricted to in-patient facilities but should consist of a totally community-oriented service.     

Containing Ontario's hospital costs under universal insurance in the 1980s: what was the record?

In recent years the Ontario government has been concerned that the proportion of public expenditures devoted to health care is at an all-time high. In addition, the media have devoted considerable attention to specific incidents that may represent inadequate funding of hospital services. To shed light on the debate on health care expenditures we analysed the trend in expenditures of Ontario''s hospital sector in the 1980s in terms of the amount of inputs (e.g., labour) used to produce hospital services (e.g., a patient-day or admission) and after adjustment for general inflation. As in the 1970s the number of inputs grew relatively slowly during the 1980s. Inputs per patient-day grew at an annual rate of 0.46% and inputs per admission at an annual rate of 2.4%. Cost increases were largely accounted for by hospital wage increases; this could have been due to Ontario''s rapidly expanding economy. These findings indicate that Ontario has continued to be successful in containing the number of inputs used in the hospital sector. However, after two decades of substantial success with publicly acceptable cost control, the government faces increased scrutiny as the media and the public focus attention on several areas of perceived inadequate funding in health care services.     

A new primary care rostering and capitation system in Norway: Lessons for Canada?

Providing every patient with a personal primary care physician or, from the physician''s perspective, establishing a stable roster or list of patients is currently being actively debated in Canada. Norway''s system of primary care medicine, similar to Canada''s, faces many of the same problems. In 1992 a trial rostering system with blended funding (capitation, fee-for-service and user fees) was established in 4 Norwegian municipalities. After 3 years of close monitoring, the results of system evaluations have attracted strong interest. This article reports on the benefits and problems encountered with the new rostering system in Norway. If Canada is moving in the same direction, some of the lessons learned may be helpful.     

Chronic illness and functional limitation in Ontario children: findings of the Ontario Child Health Study.

The Ontario Child Health Study (OCHS) was based on interviews of 1869 Ontario families who were selected by means of a stratified, multistaged sampling method from the 1981 census of Canada. Its primary purpose was to determine the prevalence and distribution of mental health problems in Ontario children aged 4 to 16 years and their families, but it also allowed an estimate of other significant medical conditions and provided an overview of these children''s use of health care, education and social services. Our results are based on questionnaire responses concerning 3294 children. Limitation of function without a chronic illness or medical condition was reported in 1.9%, the converse in 14.0%, and a chronic illness or medical condition with limitation of function in 3.7%. When the three groups are considered together, 19.6% of Ontario children had a chronic health problem. Children of lower socioeconomic status were much more likely to have chronic health problems. Overall, children with chronic health problems were more likely to use physician, special education, social and mental health services. These findings have implications for those who provide services for children, plan community programs or train professionals in caring for children.     

Do you have any regrets about entering medicine?

Do today''s students have any second thoughts about their decision to pursue a career in medicine? Gabriel Leung, who graduates in June from the University of Western Ontario, considers the problems and dilemmas that have confronted him and his classmates during their short careers and muses on the uncertain future today''s physicians face.     

Economic Appraisal of Ontario's Universal Influenza Immunization Program: A Cost-Utility Analysis

Background

In July 2000, the province of Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free seasonal influenza vaccines for the entire population. This is the first large-scale program of its kind worldwide. The objective of this study was to conduct an economic appraisal of Ontario''s UIIP compared to a targeted influenza immunization program (TIIP).

Methods and Findings

A cost-utility analysis using Ontario health administrative data was performed. The study was informed by a companion ecological study comparing physician visits, emergency department visits, hospitalizations, and deaths between 1997 and 2004 in Ontario and nine other Canadian provinces offering targeted immunization programs. The relative change estimates from pre-2000 to post-2000 as observed in other provinces were applied to pre-UIIP Ontario event rates to calculate the expected number of events had Ontario continued to offer targeted immunization. Main outcome measures were quality-adjusted life years (QALYs), costs in 2006 Canadian dollars, and incremental cost-utility ratios (incremental cost per QALY gained). Program and other costs were drawn from Ontario sources. Utility weights were obtained from the literature. The incremental cost of the program per QALY gained was calculated from the health care payer perspective. Ontario''s UIIP costs approximately twice as much as a targeted program but reduces influenza cases by 61% and mortality by 28%, saving an estimated 1,134 QALYs per season overall. Reducing influenza cases decreases health care services cost by 52%. Most cost savings can be attributed to hospitalizations avoided. The incremental cost-effectiveness ratio is Can$10,797/QALY gained. Results are most sensitive to immunization cost and number of deaths averted.

Conclusions

Universal immunization against seasonal influenza was estimated to be an economically attractive intervention. Please see later in the article for the Editors'' Summary     

Demand-side medical education: educating future physicians for Ontario.

Initiated by Associated Medical Services (AMS), Educating Future Physicians for Ontario is a 5-year collaborative project whose overall goal is to make medical education in Ontario more responsive to that province''s evolving health needs. It is supported by AMS, the five universities with medical schools or academic health sciences centres and the Ontario Ministry of Health. The project''s five objectives are to (a) define the health needs and expectations of the public as they relate to the training of physicians, (b) prepare the educators of future physicians, (c) assess medical students'' competencies, (d) support related curricular innovations and (e) develop ongoing leadership in medical education. There are several distinctive features: a focus on "demand-side" considerations in the design of curricula, collaboration within a geopolitical jurisdiction (Ontario), implementation rather than recommendation, a systematic project-evaluation plan and agreement as to defined project outcomes, in particular the development of institutional mechanisms of curriculum renewal as health needs and expectations evolve.     

Carcinoma of the Lung: The Changing Pattern of Mortality in Ontario

Study of the mortality rates for carcinoma of the lung in men in Ontario between 1931 and 1959 reveals a rise from 3.7 in the early 1930''s to 26.7 per 100,000 in the late 1950''s. Analysis of age-specific mortality rates in five-year cohorts (groups of men born within five-year periods) shows that (1) mortality rates in each cohort rise rapidly after the age of 40, ascending in the later years of life almost as a straight line; (2) each succeeding cohort experiences an appreciably higher mortality rate than the preceding one. Mortality rates in individual cohorts in Ontario are compared with those in England; the shape of the cohort curves, and the rate of the increase in mortality from cohort to cohort, are almost identical. However, the picture in Ontario appears to be lagging some 10 years behind. The mortality rates for men in Ontario born around the year 1890 are almost identical with those shown by men born in England around 1880. The rates for carcinoma of the lung will almost inevitably continue to rise in Ontario for at least the next 10 to 20 years.     

Involuntary commitment in Ontario: some barriers to the provision of proper care.

The Ontario Mental Health Act, as amended in November 1978, provides strictly defined criteria for involuntary commitment for psychiatric assessment; the assessment can last up to 5 days. These criteria fail to cover a number of patients who are, in the author''s opinion, in need of compulsory assessment or treatment. Four cases in which there was serious difficulty in giving proper care are described in this paper. The difficulties are discussed and improvements in the criteria for involuntary assessment recommended.     

MicroRNA sponges: Progress and possibilities

The microRNA (miRNA) “sponge” method was introduced three years ago as a means to create continuous miRNA loss of function in cell lines and transgenic organisms. Sponge RNAs contain complementary binding sites to a miRNA of interest, and are produced from transgenes within cells. As with most miRNA target genes, a sponge''s binding sites are specific to the miRNA seed region, which allows them to block a whole family of related miRNAs. This transgenic approach has proven to be a useful tool to probe miRNA functions in a variety of experimental systems. Here we will discuss the ways sponge and related constructs can be optimized and review recent applications of this method with particular emphasis on stable expression in cancer studies and in transgenic animals.     

The Otavalo trade diaspora: social capital and transnational entrepreneurship

This article examines the role of historical social resources in the development of a transnational trade diaspora of Ecuador's indigenous Otavalan merchants. The Otavalans are well known for their production of handicrafts, using pre-industrial and industrial technologies, and for their far-flung trips in search of foreign buyers. In this account, the role of 'social capital', typically defined as a 'public good', is highlighted to better gauge its usefulness to other migrant and indigenous groups. I conclude that the Otavalo case suggests that in-group 'social capital' is: (a) not sufficient or necessary for 'grass-roots' transnational entrepreneurship; (b) the political origins of an ethnic group's 'trust-worthiness' reveal a more diverse set of symbolic and cultural 'capitals', which may then be used by an emergent merchant class to gain financial capital for a business venture; and (c) 'globalization' notwithstanding, contemporary trade diasporas may rise and fall due to similar causal dynamics found among much older and ubiquitous 'cross-cultural trade diasporas'.