A controlled trial of the effectiveness of internet continuing medical education.

BACKGROUND: The internet has had a strong impact on how physicians access information and on the development of continuing medical education activities. Evaluation of the effectiveness of these activities has lagged behind their development. METHODS: To determine the effectiveness of a group of 48 internet continuing medical education (CME) activities, case vignette surveys were administered to US physicians immediately following participation, and to a representative control group of non-participant physicians. Responses to case vignettes were analyzed based on evidence presented in the content of CME activities. An effect size for each activity was calculated using Cohen's d to determine the amount of difference between the two groups in the likelihood of making evidence-based clinical decisions, expressed as the percentage of non-overlap, between the two groups. Two formats were compared. RESULTS: In a sample of 5621 US physicians, of the more than 100,000 physicians who participated in 48 internet CME activities, the average effect size was 0.75, an increased likelihood of 45% that participants were making choices in response to clinical case vignettes based on clinical evidence. This likelihood was higher in interactive case-based activities, 51% (effect size 0.89), than for text-based clinical updates, 40% (effect size 0.63). Effectiveness was also higher among primary care physicians than specialists. CONCLUSION: Physicians who participated in selected internet CME activities were more likely to make evidence-based clinical choices than non-participants in response to clinical case vignettes. Internet CME activities show promise in offering a searchable, credible, available on-demand, high-impact source of CME for physicians.

Air emission inventories in North America: a critical assessment.

Although emission inventories are the foundation of air quality management and have supported substantial improvements in North American air quality, they have a number of shortcomings that can potentially lead to ineffective air quality management strategies. Major reductions in the largest emissions sources have made accurate inventories of previously minor sources much more important to the understanding and improvement of local air quality. Changes in manufacturing processes, industry types, vehicle technologies, and metropolitan infrastructure are occurring at an increasingly rapid pace, emphasizing the importance of inventories that reflect current conditions. New technologies for measuring source emissions and ambient pollutant concentrations, both at the point of emissions and from remote platforms, are providing novel approaches to collecting data for inventory developers. Advances in information technologies are allowing data to be shared more quickly, more easily, and processed and compared in novel ways that can speed the development of emission inventories. Approaches to improving quantitative measures of inventory uncertainty allow air quality management decisions to take into account the uncertainties associated with emissions estimates, providing more accurate projections of how well alternative strategies may work. This paper discusses applications of these technologies and techniques to improve the accuracy, timeliness, and completeness of emission inventories across North America and outlines a series of eight recommendations aimed at inventory developers and air quality management decision-makers to improve emission inventories and enable them to support effective air quality management decisions for the foreseeable future.

Modeling the atmospheric transport and deposition of mercury to the Great Lakes.

A special version of the NOAA HYSPLIT_4 model has been developed and used to estimate the atmospheric fate and transport of mercury in a North American modeling domain. Spatial and chemical interpolation procedures were used to expand the modeling results and provide estimates of the contribution of each source in a 1996 anthropogenic US/Canadian emissions inventory to atmospheric mercury deposition to the Great Lakes. While there are uncertainties in the emissions inventories and ambient data suitable for model evaluation are scarce, model results were found to be reasonably consistent with wet deposition measurements in the Great Lakes region and with independent measurement-based estimates of deposition to Lake Michigan. Sources up to 2000 km from the Great Lakes contributed significant amounts of mercury through atmospheric transport and deposition. While there were significant contributions from incineration and metallurgical sources, coal combustion was generally found to be the largest contributor to atmospheric mercury deposition to the Great Lakes.

Modeling the atmospheric transport and deposition of PCDD/F to the Great Lakes.

Atmospheric deposition is a significant loading pathway for polychlorinated dibenzo-p-dioxins and dibenzofurans (dioxin) to the Great Lakes. An innovative approach using NOAA's HYSPLIT atmospheric fate and transport model was developed to estimate the 1996 dioxin contribution to each lake from each of 5,700 point sources and 42,600 area sources in a U.S./Canadian air emissions inventory. These unusually detailed source-receptor modeling results show that deposition to each lake arises from a broad geographical region, with significant contributions from up to 2,000 km away. The source categories contributing most significantly to 1996 dioxin deposition appear to be municipal waste incineration, iron sintering, medical waste incineration, and cement kilns burning hazardous waste. Model-predicted air concentrations and deposition fluxes were consistent with ambient measurement data, within the uncertainties in each, but there may be a moderate tendency toward underestimation using midrange emissions estimates. The most likely reason for this tendency appears to be missing or underestimated emissions sources, but in-situ atmospheric formation of octachlorinated dibenzo-p-dioxin (OCDD) and heptachlorinated dibenzo-p-dioxin (HpCDD) may have also contributed. Despite uncertainties, the findings regarding the relative importance of different sources types and source regions appear to be relatively robust and may be useful in prioritizing pollution prevention efforts.