Designing systems for the care we need: A transformation journey in Southwestern Ontario.

Primary care is considered the foundation of any health system. In Ontario, Canada Bills 41 and 74 introduced in 2016 and 2019, respectively, aimed to move towards a primary care-focused and sustainable integrated care approach designed around the needs of local populations. These bills collectively set the stage for integrated care and population health management in Ontario, with Ontario Health Teams (OHTs) introduced as a model of integrated care delivery systems. OHTs aim to streamline patient connectivity through the healthcare system and improve outcomes aligned with the Quadruple Aim. When Ontario released a call for health system partners to apply to become an OHT, providers, administrators, and patient/caregiver partners from the Middlesex-London area were quick to respond. We highlight the critical elements and journey of the Middlesex-London Ontario Health Team since its start.

A cluster of patients infected with I221V influenza b virus variants with reduced oseltamivir susceptibility--North Carolina and South Carolina, 2010-2011.

BACKGROUND: During 2010-2011, influenza B viruses with a novel neuraminidase substitution, denoted I221V (B/I221V), associated with reduced in vitro oseltamivir susceptibility were detected in North Carolina. METHODS: We determined the prevalence of I221V among B viruses submitted to the Centers for Disease Control and Prevention for antiviral resistance surveillance, including all B viruses submitted to North Carolina and South Carolina state laboratories, during October 2010-September 2011.We conducted chart reviews and telephone interviews to characterize North Carolina and South Carolina patients with B/I221V vs wild-type B virus infection (B/WT). RESULTS: We detected I221V in 45 (22%) of 209 B viruses from North Carolina and 8 (10%) of 82 B viruses from South Carolina. We detected I221V in 3 (0.3%) of 881 B viruses tested from 45 other states. B/I221V infection was not associated with differences in underlying conditions or illness severity, compared with B/WT infection. No patients with B/I221V infection received oseltamivir prior to specimen collection. Among patients who completed oseltamivir, those with B/I221V infection reported a longer duration until illness resolution (5 vs 3 days; P = .02). CONCLUSIONS: B/I221V cocirculated with B/WT in North Carolina and South Carolina during 2010-2011. I221V did not alter illness severity but may have reduced oseltamivir effectiveness. Thus, global surveillance for I221V is important.

Variability of urinary concentrations of bisphenol A in spot samples, first morning voids, and 24-hour collections.

BACKGROUND: Human exposure to bisphenol A (BPA) is widespread. After exposure, BPA is rapidly metabolized and eliminated in urine. Therefore, there is considerable within-person and between-person variability of BPA concentrations in spot urine samples. However, no information exists on the within-day variability of urinary BPA concentrations. OBJECTIVES: We examined the between-person and within-person and between-day and within-day variability in the urinary BPA concentrations of eight adults who collected all voids for 1 week to investigate the impact of sampling strategy in the exposure assessment of BPA using spot, first morning, or 24-hr urine collections. METHODS: We determined the urinary concentrations of BPA using on-line solid-phase extraction coupled to isotope dilution high-performance liquid chromatography/tandem mass spectrometry. RESULTS: The between-day and within-person variability was the primary contributor to the total variance both for first morning voids (77%) and 24-hr urine collections (88%). For the spot collections, we observed considerable within-day variance (70%), which outweighed the between-person (9%) and between-day and within-person (21%) variances. CONCLUSIONS: Regardless of the type of void (spot, first morning, 24-hr collection), urinary BPA concentrations for a given adult changed considerably--both within a day and for the 7 days of the study period. Single 24-hr urine collections accurately reflect daily exposure but can misrepresent variability in daily exposures over time. Of interest, when the population investigated is sufficiently large and samples are randomly collected relative to meal ingestion times and bladder emptying times, the single spot-sampling approach may adequately reflect the average exposure of the population to BPA.

Surveillance for influenza during the 2009 influenza A (H1N1) pandemic-United States, April 2009-March 2010.

The emergence in April 2009 and subsequent spread of the 2009 pandemic influenza A (H1N1) virus resulted in the first pandemic of the 21st century. This historic event was associated with unusual patterns of influenza activity in terms of the timing and persons affected in the United States throughout the summer and fall months of 2009 and the winter of 2010. The US Influenza Surveillance System identified 2 distinct waves of pandemic influenza H1N1 activity--the first peaking in June 2009, followed by a second peak in October 2009. All influenza surveillance components showed levels of influenza activity above that typically seen during late summer and early fall. During this period, influenza activity reached its highest level during the week ending 24 October 2009. This report summarizes US influenza surveillance data from 12 April 2009 through 27 March 2010.

Does the composition of urine change when collected from disposable diapers and other absorbent materials?

The free and conjugated urinary species of non-persistent environmental chemicals or their breakdown products are valid human exposure biomarkers. For convenience, disposable diapers and other absorbent materials are widely used to collect urine specimens from infants and young toddlers. However, the extent to which the different urinary species of the target analytes and other components are recovered after the urine is extracted from these absorbent materials is unknown. In this proof-of-concept study, we investigated the extraction recovery from disposable diapers, cotton pads, and gauzes of the free versus glucuronidated urinary species of three example chemicals: bisphenol A, triclosan, and 4-methylumbelliferone. Although the glucuronides were almost fully recovered, the free species were not. Our results suggest that, in addition to other sampling considerations, the binding affinity and extraction recovery of the target biomarkers to the material used to collect the urine should be considered. Alternative collection approaches that do not require such an extraction (e.g., urine bags routinely used in hospitals) may be worth exploring. Despite its shortcomings, having urinary concentrations for biomonitoring considerably strengthens the exposure assessment, particularly for infants and young toddlers, and the benefits of including biomonitoring data outweigh their potential limitations.

Urinary concentrations of four parabens in the U.S. population: NHANES 2005-2006.

BACKGROUND: Parabens are widely used as antimicrobial preservatives in cosmetics, -pharmaceuticals, and food and beverage processing. OBJECTIVES: We assessed exposure to methyl, ethyl, propyl, and butyl parabens in a representative sample of persons >or= 6 years of age in the U.S. general population from the 2005-2006 National Health and Nutrition Examination Survey. METHODS: We analyzed 2,548 urine samples by using online solid-phase extraction coupled to isotope dilution-high-performance liquid chromatography/tandem mass spectrometry. RESULTS: We detected methyl paraben (MP) and propyl paraben (PP) in 99.1% and 92.7% of the samples, respectively. We detected ethyl (42.4%) and butyl (47%) parabens less frequently and at median concentrations at least one order of magnitude lower than MP (63.5 microg/L) and PP (8.7 microg/L). Least-square geometric mean (LSGM) concentrations of MP were significantly higher (p or= 60 years). Adolescent and adult females had significantly higher (p < 0.01) LSGM concentrations of MP and PP than did adolescent and adult males. Females were more likely than males [adjusted odds ratios (ORs) and 95% confidence intervals (CIs): MP, 3.2 (2.99-5.27); PP, 4.19 (2.34-7.49)] and non-Hispanic blacks were more likely than non-Hispanic whites [MP, 4.99 (2.62-9.50); PP, 3.6 (1.86-7.05)] to have concentrations above the 95th percentile. CONCLUSIONS: The general U.S. population was exposed to several parabens during 2005-2006. Differences in the urinary concentrations of MP and PP by sex and race/ethnicity likely reflect the use of personal care products containing these compounds.

Automated on-line column-switching HPLC-MS/MS method with peak focusing for measuring parabens, triclosan, and other environmental phenols in human milk.

Parabens (esters of p-hydroxybenzoic acid) and triclosan are widely used as preservatives and antimicrobial agents, respectively, in personal care products, pharmaceuticals, and food processing. Because of their widespread use and potential risk to human health, assessing human exposure to these compounds in breastfed infants is of interest. We developed a sensitive method, using a unique on-line solid-phase extraction-high performance liquid chromatography-tandem mass spectrometry system with peak focusing feature, to measure in human milk the concentrations of five parabens (methyl-, ethyl-, propyl-, butyl-, and benzyl parabens), triclosan, and six other environmental phenols: bisphenol A (BPA); ortho-phenylphenol (OPP); 2,4-dichlorophenol; 2,5-dichlorophenol; 2,4,5-trichlorophenol; and 2-hydroxy-4-methoxybenzophenone (BP-3). The method, validated by use of breast milk pooled samples, shows good reproducibility (inter-day coefficient of variations ranging from 3.5% to 16.3%) and accuracy (spiked recoveries ranging from 84% to 119% at four spiking levels). The detection limits for most of the analytes are below 1 ng mL(-1) in 100 microL of milk. We tested the usefulness of the method by measuring the concentrations of these twelve compounds in four human milk samples. We detected methyl paraben, propyl paraben, triclosan, BPA, OPP, and BP-3 in some of the samples tested. The free species of these compounds appear to be the most prevalent in milk. Nevertheless, to demonstrate the utility of these measures for exposure and risk assessment purposes, additional data about sampling and storage of the milk, and on the stability of the analytes in milk, are needed.

Temporal stability of the conjugated species of bisphenol A, parabens, and other environmental phenols in human urine.

Human exposure to environmental phenols can be assessed by measuring the urinary concentrations of these compounds or their metabolites. Total concentrations, which include both free and conjugated (i.e., glucuronide and sulfated) species, are usually reported. Because conjugation may reduce the potential bioactivity of the compounds, measuring separately both the concentrations of free and conjugated species can be of interest. Data on the stability of these conjugated species in urine is critical if the concentrations of free and conjugated species are to be compared. Over a period of 6 months, we investigated the stability of the urinary conjugates of eight environmental phenols (bisphenol A, 2-hydroxy-4-metoxybenzophenone or benzophenone-3, triclosan, 2,5-dichlorophenol, methyl paraben, ethyl paraben, propyl paraben, and butyl paraben) at three storage conditions (room temperature, 4 degrees C, and -70 degrees C). After collection, conjugated species appeared to be stable for at least 7 days when the urine was stored at 4 degrees C, and for at least 180 days at -70 degrees C. By contrast, some of the environmental phenol conjugates commenced to degrade within 24 h after collection when the urine was stored at room temperature although the total concentrations remained relatively constant for at least 30 days. These results suggest that if the concentrations of free and conjugated species will be used for exposure assessment purposes, urine specimens collected for analysis of environmental phenols should be kept at room temperature for the shortest possible time after collection.

Identification of metabolites of 4-nonylphenol isomer 4-(3',6'-dimethyl-3'-heptyl) phenol by rat and human liver microsomes.

Nonylphenol (NP) has been widely used for more than 50 years in the synthesis of NP ethoxylates, which are important nonionic surfactants. NP is considered an endocrine disruptor based on in vitro and in vivo animal studies. However, the toxic effects of NP in humans are unknown. Information regarding the metabolic fate of 4-t-nonylphenol (4-tNP), a mixture of commercial NP branched isomers, in mammalian species is limited. This information is critical for the identification of adequate biomarkers of exposure to NP that could be used for exposure and risk assessment. We identified metabolites of one 4-tNP isomer, namely, 4-(3',6'-dimethyl-3'-heptyl) phenol (P363-NP), using rat and human liver microsomes. The P363-NP metabolites were extracted by on-line solid-phase extraction and then separated and detected using high-performance liquid chromatography/tandem mass spectrometry. Using the genuine standard, we unambiguously identified 4-(3',6'-dimethyl-3'-heptyl) catechol (P363-NC) as the main P363-NP metabolite when using human liver microsomes. Based on their chromatographic behavior and mass spectral fragmentation patterns, several other metabolites were tentatively identified, including a hydroxylated P363-NP with the alcohol functional group on the branched alkyl chain and its oxidative metabolite, a catechol with a hydroxylated alkyl side chain. Furthermore, the metabolite profile of P363-NP using rat and human enzymes was compared. Our findings suggest that P363-NC could be used as a biomarker to assess exposure to 4-tNP, although additional research to evaluate its suitability as a biomarker is warranted.

Parabens as urinary biomarkers of exposure in humans.

BACKGROUND: Parabens appear frequently as antimicrobial preservatives in cosmetic products, in pharmaceuticals, and in food and beverage processing. In vivo and in vitro studies have revealed weak estrogenic activity of some parabens. Widespread use has raised concerns about the potential human health risks associated with paraben exposure. OBJECTIVES: Assessing human exposure to parabens usually involves measuring in urine the conjugated or free species of parabens or their metabolites. In animals, parabens are mostly hydrolyzed to p-hydroxybenzoic acid and excreted in the urine as conjugates. Still, monitoring urinary concentrations of p-hydroxybenzoic acid is not necessarily the best way to assess exposure to parabens. p-hydroxybenzoic acid is a nonspecific biomarker, and the varying estrogenic bioactivities of parabens require specific biomarkers. Therefore, we evaluated the use of free and conjugated parent parabens as new biomarkers for human exposure to these compounds. RESULTS: We measured the urinary concentrations of methyl, ethyl, n-propyl, butyl (n- and iso-), and benzyl parabens in a demographically diverse group of 100 anonymous adults. We detected methyl and n-propyl parabens at the highest median concentrations (43.9 ng/mL and 9.05 ng/mL, respectively) in nearly all (> 96%) of the samples. We also detected other parabens in more than half of the samples (ethyl, 58%; butyl, 69%). Most important, however, we found that parabens in urine appear predominantly in their conjugated forms. CONCLUSIONS: The results, demonstrating the presence of urinary conjugates of parabens in humans, suggest that such conjugated parabens could be used as exposure biomarkers. Additionally, the fact that conjugates appear to be the main urinary products of parabens may be important for risk assessment.

Quantification of the urinary concentrations of parabens in humans by on-line solid phase extraction-high performance liquid chromatography-isotope dilution tandem mass spectrometry.

Parabens (alkyl esters of p-hydroxybenzoic acid) are widely used as antimicrobial preservatives in cosmetic products, pharmaceuticals, and food processing. However, weak estrogenicity of some parabens has been revealed from several studies. Human exposure to parabens may be assessed by measuring the conjugated or free species of these compounds or their metabolites in urine. We have developed a method using on-line solid phase extraction-high performance liquid chromatography-isotope dilution tandem mass spectrometry with peak focusing to measure the urinary concentrations of methyl, ethyl, propyl, n- and iso- butyl, and benzyl parabens. This method has good reproducibility and accuracy with detection limits for all analytes below 0.2ng/mL in 100microL of urine, and permits quick and accurate analysis of a large number of samples in epidemiologic studies for assessing the prevalence of human exposure to parabens. Using this method, we detected methyl, ethyl, and propyl parabens, mostly as conjugated species, in 22 urine samples collected from anonymous adults.