The New York Times, allowed for large courtyards shielded from neighbors’ noise for play and recreation, windows that open onto the courtyards to provide light and air, and thoroughly ventilated wardrobes to dry clothing and maintain circulation. That was a few years ago—in 1901, to be exact. But those long-ago improvements—attention to indoor air quality, ventilation, lighting, and acoustics—now distinguish “high-performance” schools, which are specifically designed to promote better attendance, achievement, and behavior. Throw in energy and water conservation features—which are traditional “green” elements—along with a recycling program, an environmentally preferable purchasing program, nontoxic cleaning products, integrated pest management, a school garden to augment other healthful cafeteria food, and a sustainably developed site, and you have the new ideal for today’s healthy schools and child care centers.The H-shape design planned for New York City’s new Public School 109, as described by But many children attend schools that bear no resemblance to this picture. Numerous studies have demonstrated that schools can be places where kids too often are exposed to toxic chemicals, mold, lead, asbestos, and other harmful agents. Moreover, some schools are located in areas where the outdoor air is so polluted that teachers wouldn’t want to open the windows even if they could. With children spending about one-third of their day at school, healthy school facilities could, if given the support, provide children with the most pollution-free part of their day, experts say.Today there is considerable overlap between green energy efficiency and resource conservation measures and the elements that characterize high-performance schools. For instance, according to the National Renewable Energy Laboratory, increased use of daylighting, which reduces use of artificial lighting, yields both energy savings and better test scores . In the early years of the green school movement, however, agencies and architects focused almost entirely on energy efficiency, says Barbara Sattler, an environmental health professor at the University of Maryland School of Nursing. One of the leaders in the field, the U.S. Green Building Council (USGBC), had recently established its now well-known Leadership in Energy and Environmental Design (LEED®) for New Construction rating system, in which new buildings achieve one of various ratings depending on the number of energy efficiency features they incorporate. But when Sattler would speak up about making buildings healthy as well as energy efficient at early USGBC meetings, “people didn’t always understand what that might mean,” she says.However, policy makers in Los Angeles—one city where the high-performance school movement first flowered and is now in full bloom—did understand. In the late 1990s, faced with severe overcrowding, the Los Angeles Unified School District sought and received funding for the largest new school construction program in the country. Ahead of its time, the LA Board of Education passed a resolution mandating that schools be built to standards outlined by the then–newly formed California-based Collaborative for High Performance Schools (CHPS). The CHPS criteria began with LEED for New Construction and added guidelines for additional elements that more directly related to student health as a means of fostering better performance. Where other green building groups focused primarily on energy and water use efficiencies, the Board’s stated priorities for adopting CHPS were to protect student and staff health and to maximize academic performance by providing a healthy environment.The CHPS rating system certifies schools as being “high-performance” and awards points for energy efficiency, water conservation, natural lighting, thermal comfort, noise control, and ease of operation (to ensure the building is maintained well), among other features. CHPS offers two levels of certification. Schools can have their buildings rated and verified by an outside party, or they can “self-certify,” meaning they use a scorecard to ensure they meet CHPS design criteria.Eleven states—including New York, Texas, Colorado, Washington, and the New England states—have adopted CHPS criteria as a voluntary program for their school districts. In addition, more than 40 districts now require that schools be designed using the CHPS criteria, with 30 of those signing on in the past two years, says Ariel Dekovic, communications manager for CHPS. Temporary or “relocatable” classrooms have their own set of CHPS guidelines for energy conservation, indoor air quality, lighting, and the design of their heating, ventilation, and air conditioning (HVAC) system. CHPS also offers a maintenance and operations manual for keeping high-performance features operating as intended.Greening American’s Schools: Costs and Benefits, by Gregory Kats, and Green Schools: Attributes for Health and Learning, by the National Research Council, both described how the indoor environment affects children’s health and thus academic performance. Moreover, Kats calculated that “green schools” (which he defined to include some high-performance characteristics) cost on average about $3 more per ft2 to build than conventional schools. However, he calculated the direct and indirect health and productivity benefits of these same improvements—which included energy and water cost savings, greater teacher retention, and reductions in colds, flu, and asthma, among other benefits—to be about $74 per ft2.In 2006 two frequently cited reports brought broader attention to the merits of combining “green” with “high-performance” in schools. In spring 2007 USGBC launched its LEED for Schools rating system for new construction and major renovation, adding an acoustic prerequisite, a mold prevention credit, and additional siting criteria to protect the health of both students and surrounding ecosystems, says Rachel Gutter, senior manager of USGBC’s education sector. For instance, schools can develop a master plan for their entire campus to conserve existing habitat, minimize the extent of impermeable surfaces (which exacerbate stormwater runoff), restore damaged areas, and use naturally pest- and drought-resistant native plants for landscaping. Schools can also earn a credit for making their playing fields and other facilities available for community use—a boon for communities with few public exercise options.With the encouragement of USGBC, CHPS, and other groups and government agencies, many schools are switching to nontoxic cleaning products that produce less indoor air pollution. According to the U.S. Environmental Protection Agency (EPA), the volatile chemicals in many cleaners, floor waxes, disinfectants, and other janitorial supplies can irritate the eyes and respiratory tract and cause headache, even dizziness; mitigating these distracting symptoms helps both students and teachers perform better. Schools are also implementing integrated pest management practices, which replace the routine use of pesticides with specific cleaning and building maintenance measures. As of 2007 more than 70% of California school districts adopted integrated pest management practices.In Washington, DC, schools are being renovated to LEED for Schools standards as part of a 15-year, $3.5-billion campaign to modernize all of the city’s 142 school buildings. The campaign is focused on creating a better environment for learning, says Christopher Dunlavey, program manager for the DC Office of Public Education Facilities Modernization and president of Brailsford & Dunlavey, a facility planning and program management firm. “We tried to home in exactly on what facility conditions are important to supporting academic performance,” he says.But Marni Allen, senior research and policy associate for the 21st Century School Fund, which maintains a database of DC public school buildings, finds “a huge variation” in the condition of the DC schools. Some have been fully modernized, “and then you go look at the ones that haven’t been, and it can be pretty startling,” she says. She and her colleagues are worried the funds will not stretch to meet the needs of all the schools.School Construction News she wrote, “Throughout the country, integrated project teams are building green schools that don’t cost more and sometimes cost less [than conventionally designed facilities].”Green schools don’t have to cost more, some advocates say. “By far the greatest barrier to building green schools . . . is the perception that they cost more,” says Gutter. In a 4 August 2009 article in the online trade publication “The construction cost of a green building does not have to be greater than a traditional one,” agrees Jane Rath, a principal with SMP Architects in Philadelphia and an expert in green design for schools. But some options, such as installing a vegetated “green roof” or one’s own power source, will cost more than the traditional alternative. Also, if LEED certification is pursued, costs can go up by $30,000–50,000, says Rath, who explains that building designers must charge more for the work to meet LEED certification requirements.EHP 116:A24–A31 [2008]).For his part, Dunlavey says incorporating LEED criteria used to add 3% to his design and construction costs, but that’s no longer the case. “Green design practices are becoming so common and expected . . . that those premiums are shrinking.” The premium depends to some degree on the individual builder’s experience with and sources for green building materials  include removing para-dichlorobenzene cake toilet deodorizers; installing “walk-off” mats at all major entries, which keeps schools cleaner and helps prevent pollutants being tracked indoors; ensuring air intakes are clear and open on the outside; prohibiting bus and car idling near the building; and phasing in the use of nontoxic cleaning products and pest control methods. Barnett notes that entities that are going to set guidelines for school design must ensure their advisory committees include advocates for children, teachers, custodians, and other occupants who have actual, not just theoretical, knowledge about how public schools actually operate day to day.Fundamental technical hurdles to building healthy schools still exist, particularly in the area of indoor air quality, researchers say. “We are making good progress . . . with striking that balance between saving energy and improving greening and indoor air quality and moisture management [to prevent mold]. But a lot of research has to be done,” says Thomann. He and his colleagues are revising a position paper for the American Society of Heating, Refrigeration and Air-Conditioning Engineers that addresses the challenge of saving energy and reducing greenhouse gas emissions while maintaining good indoor air quality, which he hopes to publish within a year.Green Schools: Attributes for Health and Learning, asserts that because USGBC and CHPS must develop their criteria with input from many different interest groups that have conflicting concerns, they may be slower to take action on controversial materials such as flame retardants. It’s not that the groups can’t or won’t address these issues, he says, “but the way they are structured makes it a lot more difficult.”A similar overarching question is whether the current rating systems address key environmental health concerns. Harvard University’s John Spengler, chairman of the committee that wrote Orr points out that improvements to the standards are ongoing. “CHPS and its stakeholders have pioneered approaches to daylighting, displacement ventilation, and low-emitting materials, and continue to pioneer the latest strategies in acoustics, indoor air quality, materials, and energy efficiency,” he says. “Sometimes these advances are not quite ready for incorporation, and they are deferred to the later updates of our standards.”“To increase adoption of guidelines, these groups have to strike a balance between what is ideal and what is pragmatic,” notes Axelrad. The EPA is attempting to do just this by creating new guidelines on all aspects of school environmental health, from how to get rid of unnecessary toxic chemicals to managing mold and moisture and indoor air quality. The EPA created the comprehensive Healthy School Environments Assessment Tool  software program to help states and districts assess and manage their schools’ environmental and safety conditions. Many schools use HealthySEAT to develop indoor air management programs, says Axelrad. CHPS is also developing an operations report card for all schools to assess the major facets of operation.Once measures are in place, however, realizing the benefits depends on proper building maintenance. “If you don’t have a trained workforce that is able to understand and manage and operate it, then you’ve really lost all the advantages of going through a rating system,” says Spengler.When staff members from custodians to teachers aren’t properly trained, numerous problems can erupt. For instance, Thomann says, schools will shut down the HVAC system at night to save money but create another form of greening—mold growth. And in one North Carolina classroom, the teacher had filled the special “light shelves,” designed to bounce daylight further into the classroom, with her supplies, says Gutter. No one had told her what the shelves were for.“We’ve seen so many times that the facility operators—the custodial services—can’t operate complex systems,” Spengler says. Building facilities have become unnecessarily complicated and high-tech, he and others say, and Barnett stresses that school facilities must be designed to be easy to maintain for indoor health. She also points out that schools facing steep budget cuts are reducing their facility and custodial staff.Support for schools needs to come from the federal government, and no federal guidelines or legislation exist to fully support the healthy school movement, experts say. The principles of high-performance school design are spelled out in the No Child Left Behind Act of 2001, but Congress has not appropriated funds to help school districts implement these, says Barnett.Members of Congress are considering school funding legislation that some advocates say is necessary for schools across the country to get healthier. In May 2009, the House of Representatives passed the 21st Century Green High-Performing Public Schools Facilities Act. The bill would allow the Department of Education to authorize billions of dollars for state and local educational agencies to conduct high-performance and green school projects. The Senate is still debating its version of the bill.Advocates looked last winter to the federal stimulus package for support for high-performance schools. The American Recovery and Reinvestment Act was passed with $39.5 billion of its State Fiscal Stabilization Fund earmarked for uses including “modernization,” which could include green building renovations. Yet an August 2009 survey by the American Association of School Administrators revealed that only 12% of respondents were using the funds for modernization, whereas more than half were using the money to save personnel positions. “By next year,” Barnett says, “we will all know more about how [stimulus funds were] spent by local schools and states.”Barnett notes there are also bond funds newly available as well as federal funds that go directly to local schools for use in renovations and repairs (but not new construction). Schools nationwide spend $20–30 billion per year on facility projects, she says, but still have decades’ worth of deferred repairs.“We all know that budgets are zero-sum most of the time—if money has to go to [school improvements] it has to be taken from somewhere else, and the question is where?” says Sattler. As a society, she says, “we need to decide where our funding will go. It seems to me that taking care of our children by creating learning spaces that are healthy and safe would be a good reflection of our values.”Creating Safe Learning Zones showed that more than 1,100 schools in New York, New Jersey, Massachusetts, California, and Michigan fell within a half-mile of a Superfund site. Moreover, in the September 2008 issue of the Journal of Environmental Planning and Management, Sergey Grinshpun and colleagues reported that about one-third of U.S. public schools are located within 400 m of a major roadway, and about one-tenth are within 100 m, exposing children to potentially hazardous traffic-related pollutants. The EPA is mandated to develop federal guidelines for the siting of schools, taking into consideration proximity to toxics and the availability of safe routes to schools. Draft school siting guidelines will be available for public comment in late 2009 or early 2010.A key school-related environmental health issue now on the EPA’s agenda is the siting of schools. “Without careful attention, building a great energy-efficient school near polluting facilities isn’t really doing anything for the health and safety of students,” says Renee Blanchard, campaign coordinator for the Virginia-based Center for Health, Environment and Justice (CHEJ), which is working to strengthen school siting policies. A 2002 CHEJ study documented in the report http://www.epa.gov/schoolair.Meanwhile, on 31 March 2009, the EPA announced it would monitor the air quality outside 62 schools in 22 states as part of an initiative to better characterize risks posed to schoolchildren by air pollution. Since then, two tribal nation schools have been added to the list. Once the air toxics data for a school are confirmed, the EPA will estimate potential exposures and health effects. If a school is found to have low potential for long-term health effects, the agency may cease monitoring at that site. At sites where estimated health risks are high, the EPA will seek to mitigate the sources of pollution. The first monitoring data were posted in August 2009 at www.chps.netCollaborative for High Performance Schools, https://http://www.usgbc.org/U.S. Green Building Council, http://www.epa.gov/schools/healthyseat/HealthySEAT,


Trisha Greenhalgh and Jill Russell discuss the relative merits of “scientific” and “social practice” approaches to evaluation and argue that eHealth evaluation is in need of a paradigm shift. We argue that the assumptions, methods, and study designs of experimental science, whilst useful in many contexts, may be ill-suited to the particular challenges of evaluating eHealth programs, especially in politicised situations where goals and success criteria are contested.We offer an alternative set of guiding principles for eHealth evaluation based on traditions that view evaluation as social practice rather than as scientific testing, and illustrate these with the example of England's controversial Summary Care Record program.PLoS Medicine readers to join a debate on the relative merits of “scientific” and “social practice” approaches to evaluation and consider the extent to which eHealth evaluation is in need of a paradigm shift.We invite evaluations of such initiatives fail to deliver the insights expected of them. PLoS Medicine has published three papers offering a “robust” and “scientific” approach to eHealth evaluation Much has been written about why electronic health  initiatives fail PLoS Medicine series rests on a set of assumptions that philosophers of science call “positivist” The approach to evaluation presented in the previous Alternative approaches to eHealth evaluation are based on very different philosophical assumptions “interpretivist” approaches assume a socially constructed reality —hence, reality is never objectively or unproblematically knowable—and that the identity and values of the researcher are inevitably implicated in the research process “critical” approaches assume that critical questioning can generate insights about power relationships and interests and that one purpose of evaluation is to ask such questions on behalf of less powerful and potentially vulnerable groups (such as patients) Catwell and Sheikh argue that “health information systems should be evaluated with the same rigor as a new drug or treatment program, otherwise decisions about future deployments of ICT in the health sector may be determined by social, economic, and/or political circumstances, rather than by robust scientific evidence” , page 1.social practice—that is, as actively engaging with a social situation and considering how that situation is framed and enacted by participants reflexivity—consciously thinking about issues such as values, perspectives, relationships, and trust. These traditions reject the assumption that a rigorous evaluation can be exclusively scientific. Rather, they hold that as well as the scientific agenda of factors, variables, and causal relationships, the evaluation must also embrace the emotions, values, and conflicts associated with a program In contrast to this view of evaluation as scientific testing, scholars in critical-interpretivist traditions view evaluation as Kushner observes that “The [positivist evaluation] model is elegant in its simplicity, appealing for its rationality, reasonable in asking little more than that people do what they say they will do, and efficient in its economical definition of what data count” , page 16The first problem with scientific evaluation, suggests Kushner, is that programs typically have multiple and contested goals; hence, no single set of goals can serve as a fixed referent for comparison. An early finding of our evaluation was that the SCR program had numerous goals  Second, outcomes are not stable; they erode and change over time and across contexts. In the SCR program, it was originally planned that patients would access their electronic record from home via linked software called HealthSpace, thereby becoming “empowered”. But HealthSpace was subsequently uncoupled from the SCR program because it was deemed “high risk” by civil servants Third, Kushner suggests, the causal link between process and outcome is typically interrupted by so many intervening variables as to make it unreliable. In the SCR evaluation, we documented 56 such variables—including training, permissions, physical space, technical interoperability, local policies and protocols, professional sanction, and point-of-care consent Fourth, key characteristics of program success may not be articulated in the vocabulary of outcomes and may not yield to measurement. One such dimension of the SCR program was the variable culture of e-governance across different organisations .Finally, program learning that leads away from initial objectives threatens failure against outcome criteria. In the SCR program, an early finding was that predefined milestones  were sometimes counterproductive since implementation teams were required to push forward in the absence of full clinical and patient engagement, which sometimes led to strong local resistance. We recommended that these milestones be made locally negotiable. But because critics of the program interpreted missed milestones as evidence of “failure”, policymakers took little heed of this advice.explaining the phenomenon under study. Controlled, feature-at-a-time comparisons are vulnerable to repeated decomposition: there are features within features, contingencies within contingencies, and tasks within tasks “Scientific” evaluation aims to produce statistical statements about the relationship between abstracted variables such as “IT response times”, “resource use”, and “morbidity/mortality” Expressing findings as statistical relationships between variables may draw attention away from people taking action “Substance”  and “verisimilitude” (something that rings true) are linked to the narrative process, which Karl Weick called “sensemaking” PLoS Medicine series MacDonald and Kushner identify three forms of evaluation of government-sponsored programs: bureaucratic, autocratic, and democratic, which represent different levels of independence from the state In sum, critical-interpretivist approaches to evaluation have different quality criteria and generate different kinds of knowledge than “scientific”  approaches. These differences are summarised in Lilford et al. identify four “tricky questions” in eHealth evaluation  and resolve these by recommending mixed-method, patient-and-system studies in which internal evaluations (undertaken by practitioners and policymakers) are formative and external ones  are summative We offer below an alternative  set of principles, initially developed to guide our evaluation of the SCR program First, think about your own role in the evaluation. Try to strike a balance between critical distance on the one hand and immersion and engagement on the other. Ask questions such as What am I investigating—and on whose behalf? How do I balance my obligations to the various institutions and individuals involved? Who owns the data I collect? Second, put in place a governance process (including a broad-based advisory group with an independent chair) that formally recognises that there are multiple stakeholders and that power is unevenly distributed between them. Map out everyone's expectations of the program and the evaluation. Be clear that simply because a sponsor pays for an evaluation it does not have special claim on its services or exemption from its focus Third, provide the interpersonal and analytic space for effective dialogue . Conversation and debate is not simply a means to an end, it can be an end in itself. Learning happens more through the processes of evaluation than from the final product of an evaluation report Fourth, take an emergent approach. An evaluation cannot be designed at the outset and pursued relentlessly to its conclusions; it must grow and adapt in response to findings and practical issues which arise in fieldwork. Build theory from emerging data, not the other way round .Fifth, consider the dynamic macro-level context  in which the eHealth innovation is being introduced Sixth, consider the different meso-level contexts , how action plays out in these settings  and how this changes over time. Include reflections on the research process  in this dataset.Seventh, consider the individuals  through whom the eHealth innovation(s) will be adopted, deployed, and used. Explore their backgrounds, identities and capabilities; what the technology means to them and what they think will happen if and when they use it.Eighth, consider the eHealth technologies, the expectations and constraints inscribed in them  and how they “work” or not in particular conditions of use. Expose conflicts and ambiguities .Ninth, use narrative as an analytic tool and to synthesise findings. Analyse a sample of small-scale incidents in detail to unpack the complex ways in which macro- and meso-level influences impact on technology use at the front line. When writing up the case study, the story form will allow you to engage with the messiness and unpredictability of the program; make sense of complex interlocking events; treat conflicting findings  as higher-order data; and open up space for further interpretation and deliberation.Finally, consider critical events in relation to the evaluation itself. Document systematically stakeholders' efforts to re-draw the boundaries of the evaluation, influence the methods, contest the findings, amend the language, modify the conclusions, and delay or suppress publication.eHealth initiatives often occur in a complex and fast-moving socio-political arena. The tasks of generating, authorising, and disseminating evidence on the success of these initiatives do not occur in a separate asocial and apolitical bubble. They are often produced by, and in turn feed back into, the political process of deciding priorities and allocating resources to pursue them Differences in underlying philosophical position may lead to opposing quality criteria for “robust” evaluations. Some eHealth initiatives will lend themselves to scientific evaluation based mainly or even entirely on positivist assumptions, but others, particularly those that are large-scale, complex, politically driven, and differently framed by different stakeholders, may require evaluators to reject these assumptions and apply alternative criteria for rigour


This paper examines the relative importance of family socioeconomic status (SES) and school-based peer hierarchies for young people's psychoneuroendocrine response, represented by cortisol level. Data are drawn from a study of 2824, 15-year-olds in 22 Scottish secondary schools in 2006 who provided information on family SES  and social position in school hierarchies, together with two morning salivary cortisol samples. School social position was assessed by participants placing themselves on seven ‘ladders’, from which three factors were derived, termed scholastic, peer and sports hierarchies. Controlling for confounds, there was little or no variation in cortisol by any SES measure. By contrast, each school hierarchy was independently associated with cortisol, but in different ways. For the scholastic hierarchy, an inverse linear relationship was found for females, cortisol increasing with lower position. For peer hierarchy, an opposite (direct) linear relationship occurred for males, while for females elevated cortisol was associated only with ‘top’ position. For sports, elevated cortisol among males was associated with ‘bottom’ position, among females with all except the ‘top’. These results are interpreted in the context of Sapolsky's  predicti All social systems are characterised by social hierarchies, a characteristic that applies as much to institutions within societies as it does to whole societies . WhetherIn society as a whole, an individual's position in the social hierarchy is typically represented by socioeconomic status (SES) measured by various indicators such as income, deprivation and social class. There is now a substantial evidence-base demonstrating that SES in adulthood is systematically related to both physical and mental health , those aWhile the causes of ‘health inequalities’ remain a matter of debate, recent work has emphasized psychosocial explanations, and particularly the role of ‘stress’ variously defined as differential exposure to cumulative environmental stressors , perceivWhile the ‘stress’ explanation appears to fit in the case of adult health in stable societies, it is less obvious how it fits with that relating to the SES patterning of health in youth. At this stage in the life-course, when position in the wider social hierarchy is ascribed by family SES, most studies find little or no SES variation in a range of subjective health indicators e.g. , a patteThe lack of relationship between family SES and health raises questions about the salience of the SES hierarchy as a source of stress in youth and directs attention to other social institutions in which young people are located. Chief among these is the school, which is quintessentially hierarchical in nature. Within any school, pupils are differentiated by school year, ability and academic achievement, either formally in groups or by individual test results or grades. Schools also have a regulative purpose, differentially rewarding pupils for ‘good’ behaviour. In combination with academic success, this defines what makes a ‘good’ pupil, placing them on a hierarchy we have termed ‘scholastic’ . FurtherThe school, however, is not simply comprised of a single ‘official’ hierarchy but constitutes an arena within which peer group structures and related hierarchies are developed. Such hierarchies refer to a range of attributes with particular salience for young people as desirable youth identities, typically involving judgments about physical appearance, body shape, clothing and style. A voluminous literature testifies to the important role such attributes play as signifiers of group membership, youth subculture, and position in the peer social hierarchy . The eviSchool-based peer groups are, therefore, unlikely to be unidimensional either in respect of social hierarchy, or the direction of associated effects on the PSR. To date, however, there are few studies which have directly investigated school hierarchies. One , which bThe most widely used measure of the PSR is salivary cortisol. In addition to responding to stressors, cortisol is governed by the hypothalamic–pituitary–adrenal (HPA) system and follows a daily circadian rhythm in most people. Levels are generally lowest around midnight and begin to rise before waking, thereafter rising sharply for 30–40 min as part of the cortisol awakening response . This isWhile cortisol levels typically return to normal quite quickly after exposure to acute stressors, exposure to chronic stressors, such as those associated with lower SES position, is thought to cause dysregulation of the HPA system, typically resulting in repeatedly elevated levels  though iAmong studies of adults, while a few have reported no association with SES  or even Against this background, the overall aim of this paper is to assess the relative importance of family SES and school-based hierarchies for the PSR, as measured by a morning cortisol sample. In the absence of a strong evidence-base relating to the SES patterning of cortisol in youth, and none at all for school hierarchies, it is difficult to derive specific hypotheses. Hence, the study reported here is exploratory. However, a number of tentative predictions can be made which principally involve the distinction between more and less stable social systems and related effects on cortisol.First, inasmuch as a young person's position in the SES hierarchy refers to a relatively stable social system, there is no a-priori reason to expect the relationship with cortisol should differ from that in adulthood. Although such evidence as there is suggests this may not be the case, it is possible the social patterning of cortisol might vary by SES measure. If social comparisons are involved as a mechanism, we might expect greater variation by FAS than either parental social class or material deprivation.Second, while any school clearly has the potential for instability, within schools the implications for pupil ‘stress’ of formal (scholastic) and informal (peer) school hierarchies may be different. Following Third, much of the work on social hierarchy and ‘stress’ assumes a generic effect, the clear prediction being a linear relationship with cortisol. An alternative view is that stress is concentrated in particular social positions, notably the bottom of a hierarchy. It is possible, however, in unstable social systems such as the peer group that this might also characterize ‘top’ positions. It is important, then, to consider the shape of the relationship between social hierarchies and cortisol.Taking account of previously validated confounds , includiData are derived from the ‘Peers and Levels of Stress’ (PaLS) study, a cross-sectional survey of 15-year-olds in 2006 in their final year of statutory education (Scottish S4) in 22 mainstream secondary schools situated in and around Glasgow. The sampling scheme is fully described elsewhere , but briThe survey took place in schools during the first morning class , representing the best compromise between the study's aim to capture the morning decline in cortisol with the practicalities of the school timetable. Pupils filled in a questionnaire, completed a brief interview, had their height and weight measured, and provided two salivary cortisol samples. Of the eligible sample of 3950 pupils, 3194 (81%) completed a questionnaire (including 137 absentees who returned their questionnaires by post). Of 3057 participants completing in school, 2995 provided two useable cortisol samples, representing 76% of the eligible sample. Missing data on confounds, together with that on one SES measure (deprivation), reduces the sample used here to 2824  with mean age 15.4 years (S.D. 0.4 years). Although the sample of schools is representative, among those completing questionnaires and providing cortisol samples there are a number of biases, including an over-representation of pupils from higher SES backgrounds. However, there were no biases according to ethnicity, the proportion self-identifying as from ‘non-white’ groups being very small (8%), reflecting the local population . Probabiocial class of the head of household, derived from data about parental occupation obtained in the brief interview, and based on father's current occupation or, if absent or not working, mother's occupation, and coded according to the UK Registrar General's classification system (n = 278 [10%]); (2) Area deprivation, based on pupils' home postcodes available from school lists, these being coded by reference to 2001 Census ‘Carstairs’ scores , using the most recent version (n = 84 [3%]).This is represented by three measures: (1) Sn system . We use ’ scores  and conv version  comprisir = 0.35; social class/FAS r = −0.32; deprivation/FAS r = −0.34, excluding missing), supporting the view that they comprise different dimensions of family SES.In common with other studies , each ofn = 2748) provided complete data.Following The ‘ladders’ data were factor analysed (varimax), which revealed three main factors accounting for 77% of the total variance of items. The dominant factor (50% of the variance) comprised items relating to popularity, power, respect and attractiveness (each with similar high loadings) together with a smaller component of trouble-making; the second (17%) comprised two items, academic progress (the highest loading) and (not) trouble-making; the third (10%) was dominated by the single item, sportiness. Reflecting these results, the factors are labeled peer, scholastic and sports hierarchies and grouped into quintiles, the highest quintile (Q5) representing ‘top’ position in each hierarchy, those with missing data being represented by a dummy variable. Full details of the ‘ladders’, the factor analysis, and their validation are available elsewhere . AnalysiDetails of procedures for obtaining and assaying cortisol are fully described elsewhere . BrieflyThe rationale for taking two measures was that taking part in the survey  might constitute an acute stressor which would be reflected in the T2 measure. The fact that 73% of participants exhibited a decline in cortisol levels between T1 and T2 suggests this was not the case . BecauseSince cortisol is governed by a diurnal rhythm and is affected by various states and activities, we take account of known confounds which may mediate any relationship with family SES or school hierarchies. Here, we distinguish between biological and other confounds, all fully described elsewhere . BiologiGiven the clustered nature of the sample, all analyses were conducted within a multilevel framework, using MLwin software  to allowp < 0.001). Females were assessed as more mature (p < 0.001) though there was no gender difference in BMI categories. A majority (64%) reported eating something in the previous hour, otherwise the proportions engaging in behaviours linked to cortisol were small, and with the exception of smoking  similar between the sexes. With respect to school hierarchies, females rated themselves higher on the scholastic hierarchy, males higher on both peer and sports hierarchies .p = 0.024) linear trend is observed in models adjusted first for biological and second for all confounds . In the fully adjusted model, however, the trend is no longer significant. Among females, there is no significant association with social class, what little evidence of linear trends going in opposite directions for class and deprivation.p = 0.006) for females remains.The lack of relationship between SES and cortisol contrasts with that for school-based hierarchies. For the scholastic hierarchy, adjusting only for biological confounds, there is a significant inverse gradient in both sexes, cortisol increasing with lower position and being particularly elevated in those at the ‘bottom’ (Q1). In males, this trend becomes non-significant when further adjusted for all other confounds  while in females the effect is less marked. In the fully adjusted model, the significant linear gradient (p = 0.006). Among females, there is no evidence of a gradient in any model; rather all positions except the ‘top’ (Q5) have lower cortisol. For sports hierarchy, among males although there is some evidence of a gradient in the first model, the clearest pattern throughout is that which distinguishes those at the ‘bottom’ as having higher cortisol. Among females, evidence of a persistent gradient obscures the fact that the major difference is between ‘top’ position and all lower positions, those with highest status having lower cortisol.With respect to the other hierarchies, a different relationship is observed, which also varies by sex. For peer hierarchy, among males there is a direct linear relationship, which is barely affected by progressive adjustment, the full model showing cortisol decreasing with each quintile  confounds. Most importantly, the fully adjusted model demonstrates the independence of their effects both within school and with respect to family SES. The different patterns for peer and sports hierarchies between the sexes are also reflected in significant or near significant interaction terms in models conducted on the total sample (see Although there are many studies investigating family SES and the peer group as separate domains, very few examine their effects together. Our findings provide new evidence on the issue, demonstrating different associations between family SES and school-based social hierarchies and the PSR, as represented by cortisol. The overall conclusion is that school hierarchies are a more important source of ‘stress’ at this age than family SES, however, measured. The strength of this conclusion is enhanced by the finding of independent effects of three distinct school hierarchies, each with a different relationship to cortisol, standing in contrast to, and validating, the finding of little or no SES variation.From a life-course perspective , the lacFollowing Given the potential for instability associated with peer hierarchies, the expectation deriving from Sapolsky's work, is that the relationship with cortisol might be reversed; higher levels being associated with higher status. The results for peer hierarchy are only partially consistent with the prediction. While in males there is a clear gradient, in females it is those at the ‘top’ who are distinguished from other positions as having higher cortisol. Why this might be is uncertain, but it could be that competition for status among males is experienced at all levels while for females it is stressors associated with the position of ‘top girl’ that matter .Arguably, the sports hierarchy occupies mid position between scholastic and peer hierarchies. As with peer hierarchy, our results are only partially consistent with predictions, neither sex exhibiting a clear gradient. However, the relationship differs between them. In males, only those at the bottom of the hierarchy have elevated cortisol; in females it is all those except the ‘top’ who have higher levels. Interpretation is difficult, the absence of a gradient suggesting it does not reflect the official school system in a similar way to the scholastic hierarchy. It seems more likely it is interpretable as another dimension of peer status which strongly distinguishes the sexes. Thus, given the importance of athletic prowess for males, it may be that doing something is better than doing nothing, only those in the lowest position experiencing negative reactions and associated ‘stress’. For females, doing little or nothing may matter much less, only those at the ‘top’ being distinguished as different, their lower cortisol possibly being a direct result of higher levels of physical activity. An alternative explanation in terms of selection seems less likely given that the results control for factors relating to fitness, notably BMI.Understanding these relationships between school-based hierarchies and cortisol requires further investigation of the processes by which status is allocated. Unfortunately, no data were collected on the salience of scholastic, peer and sports dimensions, which would have aided interpretation of the different patterns for males and females. It is clear though, that the three hierarchies are separate from one another and that the effects on cortisol are hierarchy specific. Thus, the cumulative effect of different positions in these social hierarchies may reduce or elevate cortisol, but they may also cancel each other out. For example, being at the top of the scholastic, but the bottom of the peer hierarchy may be protective. Focussing on the extremes of social hierarchies, however, detracts from a key finding, which is that for the scholastic hierarchy in both sexes, and peer hierarchy in males, the relationship with cortisol takes the form of a gradient. As with evidence relating to the SES patterning of health in adulthood , this suThere are several caveats to these conclusions arising from limitations of the study. First, and most important, the measures of cortisol obtained in ‘PaLS’ were necessarily restricted by the school timetable. Ideally, it would have been desirable to get a fuller picture of participants' diurnal rhythms, particularly the cortisol awakening response since there is evidence it is regulated by a distinct mechanism . The absSecond, following Sapolsky, the underlying assumption in our analyses is that exposure to stressors results in elevated cortisol levels. However, this is not the only possible indicator of PSR dysregulation, recent studies emphasizing the importance of very low levels following exposure to chronic stressors . In justThird, while our analyses provide no support for the postulated blunted cortisol response associated with low SES, it is important to acknowledge another limitation relating to the sample. Although the weighting procedure developed for the study corrects for known biases, we cannot rule out the possibility that young people most exposed to chronic stressors were excluded from the study.Fourth, the study is cross-sectional, ruling out any consideration of the impact of changing social position on cortisol. This is particularly important in relation to peer hierarchy, since predictions about the direction of the effect on cortisol are premised on the notion that peer group processes are dynamic, and that it represents an unstable social system. It also limits conclusions about the direction of causality between school hierarchies and cortisol, in particular making it difficult to evaluate the role of selection. The absence of data on cognitive ability and personality are particularly important in this respect. However, the specificity of the results for each of the social hierarchies would not be expected if selection were the major explanation. In addition, controlling for confounds, notably BMI in relation to the sports hierarchy, suggests an effect of social position on the PSR rather than the reverse.Finally, underpinning the analysis is the assumption that the measures used in ‘PaLS’, which refer to subjective social status, are good measures of objective social hierarchies with real effects on ‘stress’. In a related paper , we haveNotwithstanding these caveats, the findings strongly support the conclusion that young people's school-based peer groups are largely separate domains of influence from their social background; that there is not a single school hierarchy but multiple hierarchies; that each is more important for PSR than family SES; and that the manner in which this plays out as an effect on cortisol depends both on the position occupied, and in which hierarchy.


Frida Kahlo was born in Mexico City, the third daughter of a German father and a Spanish and Native American mother. Her life was marred by physical trauma—from childhood polio that left her with a limp, to serious injury in 1926, when a bus she was riding collided with a streetcar. Lifelong pain and its psychological aftermath had a profound effect on her artistic development , Kahlo worked alongside the surrealists, yet she denied any connection with them: “They thought I was a surrealist…but I wasn’t. I never painted dreams, I painted my own reality” (From her vivid self-portrait on the cover of this month’s Emerging Infectious Diseases, Frida Kahlo casts a pensive but challenging look at a world that denied her the comforts of health. Like an exotic flower, she embellishes the luscious tropical tableau. Yet, in spite of her regal demeanor and the scene’s vibrant hues, something is troubling about the picture. Menace lurks in nature itself, which though seemingly embracing, is not unqualifiedly benign. The enigmatic presence of the monkey heightens the portrait’s uneasiness. Might it be the devil, as purported in Kahlo’s native Mexico? Non-human primates are frequent human playmates in the arts, the circus, and the streets—always amusing, romantic, and mysterious, and sometimes dark. Might the monkey on Kahlo’s back be the harbinger of ill health? Like her contemporaries, Kahlo knew little of her close phylogenetic kinship with her pet or the extreme caution prescribed by this kinship. The threat signaled by the presence of a primate, be it turbulence in Kahlo’s life or herpes B viruses in ours, remains uncharted. The monkey on our back is to decipher the zoonotic puzzle of infection that perpetuates suffering and limits the immense capacity of the human spirit.


Recent years have seen a disheartening string of revelations in which everyday items once considered safe—food packaging, toys, clothes, furniture, electronic components, and many more products—are found to contain carcinogens, endocrine disruptors, and other harmful chemicals.The New York Times: “I can get [toxicity] information on only 20 percent of chemicals we interact with on a daily basis.”The U.S. Environmental Protection Agency (EPA) defines green chemistry as “the design of chemical products and processes that reduce or eliminate the use or generation of hazardous substances. Green chemistry applies across the life cycle of a chemical product, including its design, manufacture, and use.”®. Pfizer developed an alternative green-chemistry process that converted several steps of pregabalin synthesis from use of organic solvents to water. That reduced both health hazards and production heating requirements. With the new synthesis, waste from the process dropped from 86 kg of waste per kg product to 17 kg, and energy use dropped by 82%.5So what does green chemistry look like? Consider the example of pregabalin, the active ingredient in the neuropathic pain drug LyricaProponents say that’s how the field can offer a win–win–win solution: good performance, lower cost, and less environmental impact—what Richard Engler, program manager of the EPA Green Chemistry Program, calls the “triple bottom line.”For many, a standard is a logical next step. “At some point you have to go beyond a definition and principles,” says Engler. “I think that’s something the standard will enable.”® (GCI), is working with federal agencies, nonprofits, end users, and industry to craft a “business-to-business”The American Chemical Society (ACS), a congressionally chartered independent professional organization, through its Green Chemistry Institute® , the professional standard for green construction for which the U.S. Green Building Council offers accreditation. An ANSI standard would motivate whole industries to reconfigure their production processes for lower environmental and health impacts, says Jim Solyst, a principal consultant with ENVIRON International Corporation.Peoples compares the likely impact of an ANSI standard to that of LEEDWorking in partnership with the standards development organization NSF International, ACS GCI established a Joint Committee, which has been guided by two subcommittees and a balance of industry, nongovernmental, public health, academic, and government representatives. The standard-development process and meetings are open to anyone interested, says Peoples. He anticipates ACS GCI will roll out a finalized standard by late fall 2010, adding, “That’s going from a blank sheet of paper to an ANSI standard in just under two years.”Like LEED, the ANSI standard will be voluntary. Companies will be able to confirm their adherence through one of several likely certification levels. The most stringent is independent third-party certification; below that is certification by a trade association or other party separate from the company. A voluntary standard, says Peoples, acknowledges that finding new ways of formulating many items won’t happen overnight. “Voluntary standards allow the marketplace to drive the changes. It will take a long time, and there’s no single path or approach,” he says. By setting a high bar, however, a standard drives everyone to a higher level of performance, Peoples says.The EPA has been a key federal agency partner in developing a standard since green chemistry was “born” there in the early 1990s  “was all about sustainable economic development. That means manufacturing in a different way.” With that emphasis in the global marketplace, she adds, “Having a standard helps an industry or company show they’re not simply talking the talk, but walking the walk.” And other stakeholders acknowledge that since information on environmental health problems is now more accessible, the marketplace itself demands solutions faster than ever before.Department of Defense (DOD) officials expect their own guidelines and policies, along with broader federal ones, will have more impact than an ANSI standard. The DOD wrestles with the particular needs of its national security mission, which can make chemical substitutions difficult, says Carole LeBlanc, special expert on chemical and material risk management in the DOD Office of the Deputy Under Secretary for Installations and Environment. Those needs include long-lived products, critical performance standards with little flexibility, and high-volume production, says LeBlanc, who leads the department’s effort in green chemistry. “The mission of national security always wins in a tie [with other objectives],” says LeBlanc. But green chemistry principles can still come into play.For example, trichloroethylene (TCE), an organic solvent, is still used in many applications although it’s a likely human carcinogen.LeBlanc cites an earlier EPA program, the Significant New Alternatives Policy (SNAP) Program, as a model policy approach that identified best practices for selecting chemicals. SNAP prioritized problems and solutions: it first identified the easiest fixes and mandated their use, then identified harder issues for the medium and long term. “That set a road map for green chemistry,” she says.LeBlanc’s office works through two channels: shaping policy through directives and instructions and through less formal interactions with the branches of the armed services. “The policy piece drives where the road and the rubber meet,” she explains, but there are also “wonderful things you can achieve rather informally” through workshops across the service branches that reveal shared problems and possible solutions.LeBlanc and colleagues identified best management practices for green chemistry that already existed at DOD. From there, they developed training curricula on acquisition systems for online courses at the Defense Acquisition University, which trains 126,000 DOD staff in acquisition, technology, and logistics. Those courses are in the final stages of review. “When you change a chemical, you almost always have to change a process,” explains LeBlanc, and that requires training in the new process.Also, after reviewing its existing programs for assessing chemical composition and safety, the DOD adopted a longer-term approach for tracking chemicals used by military personnel and contractors. A life-cycle assessment approach now examines products and chemicals through three phases of their use: acquisition and procurement, maintenance , and disposal. “This is a whole new way of looking at things for DOD,” says LeBlanc. A June 2009 DOD workshop on reducing hazardous materials also supported the military branches in identifying problem chemicals and planning solutions. Since then, two similar workshops have taken place at the National Aeronautics and Space Administration and the Aerospace Industries of America, a contractors’ group.Among policies that promote green chemistry, the 2006 legislation by the European Union known as REACH  is the most imposing. It addresses the human health and environmental impacts of all chemicals, mandates comprehensive information, and will be phased in over a decade. REACH will require companies to register chemicals they use with a new agency based in Finland. REACH applies to all chemicals produced in or imported into Europe.It’s too early to determine that law’s health impact, but its impact on policy is already formidable. “REACH mandated the provision of information,” explains Solyst, “a vast increase in the amount and availability of information on chemicals. That’s good. And it has made downstream users of chemicals much more aware.” Before, he says, there was not sufficiently detailed information to make the public confident of the origin and composition of many chemicals used in daily life. REACH provides that level of information—but also creates a huge task in managing it.For LeBlanc, REACH is in part an attempt to give Europe a competitive advantage in a global shift toward sustainability. “This is very much a trade issue for the United States,” she says, adding it will have “a huge impact” on the DOD’s supply chain and information in its Material Safety Data Sheets.Stateside, federal governmentwide programs for greening procurement include the EPA’s Environmentally Preferable Purchasing and the Green Procurement Program managed by the General Services Administration. One key incentive program the EPA manages is the Presidential Green Chemistry Challenge Awards, which began in 1996 during the Clinton administration. The awards are typically given annually to outstanding individuals and businesses responsible for innovations in green chemistry in five categories: academic research, small business, designing greener chemicals, greener synthetic pathways, and greener reaction conditions. The awards have raised awareness of green chemistry and fostered the idea that with innovation, you can reduce both environmental impact and cost, Engler says; he explains, “It’s not a tradeoff between the two.”Chasing Molecules: Poisonous Products, Human Health, and the Promise of Green Chemistry,Others are less sure. Elizabeth Gross-man, an investigative journalist and author of Engler and LeBlanc agree there are no drop-in replacements for any toxic chemical used commercially. Green chemistry proceeds application by application, looking for potential substitutes based on desired functions.Meanwhile, congressional reform of the 1976 U.S. Toxic Substances Control Act (TSCA) is on its way,Peoples notes the California initiative “is not about green chemistry per se, but is focused on regulation and information disclosure. Green chemistry as envisioned by the creators, is about reducing or eliminating the use of hazardous materials. It is not about sharing information about hazardous materials. There is a very big difference.”He adds, “Our hope is that at some point in the future all chemistry will simply be green chemistry. That day is generations in the future, but the journey has begun.”Prevention: It is better to prevent waste than to treat or clean up waste after it has been created.Atom Economy: Synthetic methods should be designed to maximize the incorporation of all materials used in the process into the final product.Less Hazardous Chemical Syntheses: Wherever practicable, synthetic methods should be designed to use and generate substances that possess little or no toxicity to human health and the environment.Designing Safer Chemicals: Chemical products should be designed to effect their desired function while minimizing their toxicity.Safer Solvents and Auxiliaries: The use of auxiliary substances  should be made unnecessary wherever possible and innocuous when used.Design for Energy Efficiency: Energy requirements of chemical processes should be recognized for their environmental and economic impacts and should be minimized. If possible, synthetic methods should be conducted at ambient temperature and pressure.Use of Renewable Feedstocks: A raw material or feedstock should be renewable rather than depleting whenever technically and economically practicable.Reduce Derivatives: Unnecessary derivatization  should be minimized or avoided if possible, because such steps require additional reagents and can generate waste.Catalysis: Catalytic reagents (as selective as possible) are superior to stoichiometric reagents.Design for Degradation: Chemical products should be designed so that at the end of their function they break down into innocuous degradation products and do not persist in the environment.Real-Time Analysis for Pollution Prevention: Analytical methodologies need to be further developed to allow for real-time, in-process monitoring and control prior to the formation of hazardous substances.Inherently Safer Chemistry for Accident Prevention: Substances and the form of a substance used in a chemical process should be chosen to minimize the potential for chemical accidents, including releases, explosions, and fires.


Clinicians are generally advised to consider several risk factors when evaluating patients' cardiovascular disease (CVD) risk. Our aim was to study whether combined assessment of five traditional risk factors might help doctors demarcate a relatively distinct and manageable group of high-risk individuals. We selected five modifiable risk factors and estimated the proportion of a well-defined population with ‘unfavourable’ levels of at least two of them, as defined by four internationally renowned guidelines. The impact of including so-called ‘prehypertension’ among the risk factors was specifically addressed, and the results are discussed in a wider perspective.Guideline implementation was modelled on data from a cross-sectional Norwegian population study comprising 62 104 adults aged 20–79 years . Total, age- and gender-specific point prevalences of individuals with zero, one, two, three or more factors, in addition to established disease, were calculated.One single CVD risk factor was exhibited by 12.4% of the population; two factors by 21.5%; and three or more by 49.7%. Established CVD or diabetes mellitus was reported by 12.5%. In total, 83.7% of the population exhibited a risk or disease profile with at least two factors, if prehypertension was included.If guideline recommendations are literally applied, as many as 84% of adults in Norway could exhibit two or more CVD or risk factors and thus be considered in need of individual, clinical attention. This challenges the widely held presumption that ‘the net will close’ around a manageable group of individuals-at-risk if several risk factors are jointly considered. As the finding of this study arises in one of the world's most long- and healthy-living populations, it raises several practical as well as ethical questions. Mortality from CVD has, however, declined substantially since the 1970s ..28].spss statistical package, version 15.0 , was used for statistical frequency analyses. All surveys in HUNT 2 were approved by the Norwegian Data Inspectorate and the Regional Committee for Ethics in Medical Research.The The prevalence numbers for each separate risk factor is shown in About 98% of the population had at least one of the risk factors (or established disease conditions) in question. If ‘prehypertension’ was excluded, and only hypertension was considered, this number remained almost unchanged, or 95% .More than eight of 10 Norwegians may exhibit two or more CVD risk factors – or established disease – and thus be eligible for targeted clinical attention, if current recommendations are interpreted literally. Rather than aiding practicing clinicians to demarcate a reasonable large and manageable high-risk group with respect to further evaluation and follow-up, combination of risk factors appears to inflate the population at risk.As can be seen from The HUNT 2 study population is well defined, with high participation rates, and considered fairly representative for Norway as a whole. Compared with other European regions, including regions involved in the MONICA project  , it did With respect to family risk for CVD, the HUNT 2 study enabled us to identify individuals who reported first-degree relative(s) with premature myocardial infarction. Stroke in close relatives, however, was in the HUNT 2 study reported without reference to age. As can be seen from In this paper, we have deliberately chosen to outline the potential scenario of complete guideline adherence in the area of individual CVD risk assessment. We also chose to include medical surveillance for ‘prehypertension’ in Disease prevention and health promotion are, and should remain, central goals of medicine. It is, however, a major challenge to find a reasonable balance between – on the one hand – biological, specific and risk-oriented approaches to improving health, and – on the other – more general and ‘salutogenetic’ approaches . Definittoo good and at the same time not good enough[We believe the present study serves as a vivid illustration of a piecemeal biomedical empirism that may have become both od enough–35. By ‘od enough.As primary health care doctors and researchers in two of the richest countries in the Western world, we see it as a duty of the medical community not only to care for the health status of the local individuals we serve, but also to consider our chosen aims and means from a global perspective. We are not convinced that the current trend in direction of an authoritative ‘vision zero’ in the area of CVD prevention represents realistic and sound medicine . Peter K


The reliability of patient history and clinical information on Pap test requisitions has been questioned but not previously objectively determined. The effect of incomplete/inaccurate information on quality of patient care has not been previously quantified. Our objectives were (1) to find out how clinicians and their assistants viewed the requisition slip, and whether they understood the reasons for supplying the information requested, (2) to measure the completeness and accuracy of information on the requisition slips, and (3) to determine whether the clinical information and patient history provided on Pap test requisitions could be relied upon to accurately assign a Pap test to the laboratory's “high-risk rescreen” pool.Clinicians and their assistants were surveyed. A total of 899 consecutive Pap test requisition slips were reviewed. Patient history and clinical information from the slips were compared to data from our laboratory information system and/or electronic patient medical records.Most survey respondents felt that proper completion of requisitions was important, but only 17% of clinicians and less staff realized that negative high-risk Pap tests underwent a quality assurance rescreen. Clinicians and/or staff recorded the last menstrual period, specimen source, and clinical information on the requisition slips 96%, 97%, and 88% of the time, respectively. Of 695 Pap tests with applicable computerized records, 172 (25%) qualified for high-risk rescreen based upon information provided on the requisition slip alone. An additional 52 Pap tests (7%), or 23% of the total high-risk Pap tests were discovered to be of high risk only after review of the electronic records.Clinicians and staff were receptive to discussions concerning the completion of requisition slips, but laboratory expectations could be better communicated. Requisition slips were properly completed with a high frequency, but the check boxes did not elicit all the information expected, so revision was necessary. The high accuracy of the completion of requisition slips permitted 77% of high-risk Pap tests to be identified via the requisition slip alone. Our findings challenge the conventional anecdotal impressions of “notoriously unreliable” information on Pap test requisition slips, but our experience may not be applicable to other settings. The Pap test requisition serves as a tool of communication between the laboratory and the submitting physician or authorized paramedical personnel such as nurse practitioners and physician assistants. As such, the Clinical Laboratory Improvement Amendments (CLIA '88) require laboratories to solicit certain patient identification and clinical information as wouldThe objectives of our study were threefold. The first was to find out what clinicians and their staff knew, and what their attitudes were, concerning the significance of providing the laboratory with the patient information requested via the requisition slip. The second objective was to measure the completeness and accuracy of information supplied on the Pap test requisitions. The third was to determine the extent to which incomplete/inaccurate patient history and clinical information provided on Pap test requisition slips might affect the quality of patient care. Specifically, we asked whether the information supplied on the Pap test requisitions could be relied upon to accurately assign the high-risk Pap tests to our laboratory's high-risk rescreen pool.Preliminary results of the surveys and a subset of the case reviews were presented in a poster session at the annual meeting of the College of American Pathologists (CAP '07) in Chicago, IL, on October 1, 2008 and in the subsequently published abstract.[Our health system is a vertically integrated health care system comprising a network of 3 hospitals and 31 outlying clinics in two states. Our laboratory processed 21,374 Pap tests in 2006.To address the first objective, we designed two surveys: one for clinicians   and a moTo measure the completeness and accuracy of the information supplied on the requisition slips, we retrospectively reviewed 899 consecutive Pap test requisitions accessioned between May 12, 2006 and May 30, 2006. We devised an Excel spreadsheet for data collection. For each requisition, we collected two sets of data. The first set was obtained from the Pap test requisition itself and included specimen source, last menstrual period (LMP), clinical information, and patient history. The source was recorded as “cervical/endocervical,” “vaginal,” or “not given.” The LMP was recorded as “yes” or “no.” If the requisition slip indicted that the patient was pregnant, postpartum, postmenopausal, or had a hysterectomy, we considered that the question of “LMP” was answered. The clinical information that we looked for was pregnant, postpartum, postmenopausal, hormone therapy, abnormal bleeding, discharge, clinically high-risk, “none indicated,” and “none given.” “None given” meant that no boxes were checked and no information was written on the slip. “None indicated” meant that the slip had the null sign or “none” or “none pertinent” written on the slip, indicating that the questions were considered and answered. The patient history items we sought were history of dysplasia, cancer, or high-risk human papillomavirus infection (HPV), previous abnormal Pap test, supracervical hysterectomy, total hysterectomy, “none indicated,” and “none given”. We then determined if the patient fulfilled our laboratory's criteria for “high-risk” quality assurance rescreen  based upThe second set of data was obtained from checking our computerized laboratory information system (LIS) history card file  and also by checking our health system's computerized patient record system, Chartview . The history card file contains all cytology and histology results reported by our laboratory. Chartview contains records of patient visits and procedure notes, either written or audio (dictated). If a particular patient did have LIS or Chartview records available but there were no entries related to the gynecologic (GYN) system or other pertinent records , we counted that as no records.Based upon the computerized data only, we again determined whether or not the patient met our laboratory definition of “high-risk” for the purpose of triggering a second, quality assurance slide screen if the initial one was negative. We compared the determinations of high-risk status from the two sets of data. We especially looked at the number of instances that a patient, not considered “high-risk” by the information on the test requisition, did meet the criteria for “high-risk” rescreen when the additional information from the history card file or Chartview was reviewed. These are patients whose Pap slides would have been denied a rescreen if their initial screen had been negative and if we had not had the additional computerized information.Of the 110 clinician surveys distributed, 46 were returned. Of the 116 staff surveys distributed, 47 were returned. Almost all (95% of clinicians and 96% of staff) respondents agreed with the statement “it is important to convey pertinent information to the lab in order to receive the best care for their patients.” And, almost all respondents reported that the clinical information and history were readily available, although slightly less staff than clinicians thought so. In contrast to 9% of the clinicians, none of the staff viewed the requisition slip questions, as mere busywork.Notably, 63% of clinicians and 53% of their staff answered that they did not know or were not sure if or how the laboratory treated the Pap tests based upon the clinical information and history they supplied. Specifically, only 17% of clinicians and 14% of staff knew that we in the laboratory subjected high-risk Pap tests to a second screen.The vast majority of clinicians (74%) reported that their nurses or assistants completed the clinical information, LMP, and specimen source information while seeing the patient and viewing the chart prior to the arrival of the clinician in the room. The staff surveys corroborated that. The clinical information recorded on the requisition slip was reportedly gathered by asking the patient most of the time, from the chart about half the time, and from information relayed by the clinician for the remainder. Seventy-four percent of all respondents thought that it was important for the lab to know about prior high-grade squamous intraepithelial lesion (HSIL), cone biopsy, or cryotherapy in the past. Most respondents recognized that the lab used “specimen source” to correlate with cytologic findings, determine specimen adequacy, and to correlate with clinical information and history. A variety of protocols were used to determine the “specimen source.” Fifty-four percent of respondents usually automatically checked the “cervical/endocervical” box for patients who were cyclic and for those without a hysterectomy. Thirty percent reported automatically checking the “vaginal” box for women with a history of hysterectomy, and slightly less reported checking the “cervix” and or cervix/endocervical” for a woman with a supracervical hysterectomy.The responses to our check boxes and queries on the requisition slips were tabulated. LMP and specimen source were given in 96% and 97% of cases, respectively. Clinical information was given in 88% of cases. Within this group, there was an indication of “no clinical information,” i.e., the question was considered and answered, in 38 % of the total cases. There was no clinical information given at all in 12% of cases.A flow sheet of our analysis of the requisition slip data is shown in Further study was limited to the 695 or 77% of total cases who did have applicable and pertinent computerized records. Of these latter, 172/695 or 25% met our laboratory's high-risk criteria based upon the data on the requisition slips alone. Review of the computerized records confirmed the high-risk status in 146 of these 172 patients (85%). In 26 other, high-risk boxes were checked on the requisition (such as HPV+) but upon further review we found that these cases did not actually meet our specific laboratory triggers for a high-risk rescreen. For example, a patient might have had a positive HPV test in the remote past, but the infection had since cleared and that patient had subsequently three consecutive, yearly “no intraepithelial lesion or malignancy” Pap tests and a negative follow-up HPV test. Thus, such a patient's Pap would not have been triaged for a high-risk rescreen. However, we kept these cases in the “high-risk” pool for calculations since if we had only the requisition slips to rely upon, they would have been treated as such. In addition, if the requisition box “clinically high-risk” was checked, we always considered that Pap “high-risk” no matter what the computerized records showed, as the clinician might have had additional information that was not available to us.Of the 695 requisition slips with applicable computerized records, an additional 52 cases or 7% of this group were discovered to meet our laboratory's high-risk criteria only after examination of the computerized records. The requisition slips, when viewed independently, lacked the pertinent information that would have alerted us to the high-risk status of these patients. This group of potentially misclassified patients accounted for 23% (52/224) of the total high-risk group.Further study of the group of 52 high-risk patients identified only by computerized records revealed surprising findings. For 35 of them (67%), the requisition slips had no clinical history given at all. In nine other cases, the person filling out the requisition slip actually wrote the “null” sign or the words “none” in the section for pertinent clinical history.For the 52 patients who we reclassified as “high-risk,” the reasons for the reclassification were HPV+ (5), clinically high-risk (4), abnormal bleeding (9), prior abnormal Pap (15), and dysplasia (24). Some patients had more than one reason for the reclassification.As far as we know, this is the first reported measurement of baseline accuracy of patient history and clinical information supplied on Pap test requisition slips. In the USA, CLIA '88 § 493.1241 spells out that “For Pap smears, the patient's last menstrual period, and indication of whether the patient had a previous abnormal report, treatment, or biopsy”[“The importance of supplying pertinent clinical information in Pap smear requisitions…seems to have gone largely unrecognized, despite the educational efforts of the American College of Obstetrics and Gynecologists, American Academy of Family Practice, and American College of Physicians.” The probIn contrast to the seeming academic and clinical disinterest in the topic of reliability of data on requisition slips, trial lawyers are tuned in. Consider the following two exchanges from depositions of Plaintiff's experts:Counsel: “There was a stipulation that all high-risk patients needed to go through the 10% re-screening process.” Expert: “The cytotechs…were relying upon only the requisitions coming with the slides from the clinicians and those are notoriously unreliable for history.” “Which is why the laboratories, modern laboratories, try to rely on their computer systems, or at least their data files."Counsel: “And so if, hypothetically, the patient had an abnormal biopsy reported out of another institution, unless the physician who's submitting the specimen tells you, is there any way that you are able to learn this information?” Expert witness: “In general, no.”…Counsel: “Do you profess to know what the standard of care is that applied to Dr…as a gynecologist when she filled out the requisition form?” Witness: Yes. She should have filled out the form; the patient had previous abnormal Paps. Counsel: “All right”…what you're telling me—correct me if I am wrong—is that there are standards of care that apply to gynecologists in this situation and that, in your opinion, Dr…deviated from the standard of care, is that correct?” Witness: “Yes, sir.”A prominent expert in the area of error reduction and risk management advised that “one stress the need for pertinent clinical history that is often required to initiate quality control measures for evaluation and reporting of cervical cytology specimens.” Indeed, Under CLIA '88, laboratories are required to include some high-risk cases in their mandatory 10% rescreen of slides initially screened as “negative for intraepithelial lesion or malignancy.” The definition of “high-risk” is left up to the individual laboratory. Some laboratories aim to rescreen all Pap test slides from “high-risk” patients, as defined by the laboratory. But, how does one know if one is accomplishing that goal?The most important clinical finding of our study was that 77% of cases that would truly meet our laboratory's criteria for triage to a high-risk rescreen could in fact be accurately identified via the information provided on the requisition slips. However, there is room for improvement as 23% of Pap test slides from high-risk patients are potentially not being identified and rescreened as intended. For the purposes of this study, we reviewed all the LIS and Chartview data available to us. However, in the day-to-day practice, we routinely look only at the LIS records. The pathologists and, less often, the cytotechnologists only look up the Chartview medical records if there is a question at the time of reviewing the Pap. Resources do not permit us to perform intensive chart reviews on every routine Pap test that comes to the laboratory. Thus in real life, some of those patients in fact would be inadvertently denied an intended quality assurance rescreen, based upon our laboratory's quality assurance program.We are a single laboratory. As this pre-analytical variable has not been previously measured, there are no benchmarks for it. We recognize that such a study would not even be feasible in many laboratories, which do not have access to corroborating data, as we do.The completeness of Pap test requisition slips is one indicator of the effectiveness of laboratory to clinician communication. In the course of doing this study, we realized that we had not effectively communicated to the clinicians and their staff our expectations for the requisitions slips, and how we use them. A number of survey participants wrote us notes requesting the results and clarification concerning issues we raised. Anecdotally, we hear about laboratorians bemoaning the inaccuracy and incompleteness of requisition slips. And, here we see that our colleagues on the other end of the communication really do have an interest in doing what is necessary to provide the best outcome for their patients. So, it appears to us that this perceived universal problem is due to a breakdown in effective communication. Threats from regulators, government, and compliance officers or complaints from laboratorians can be expected to be nonproductive. However, here is an opportunity for interdepartmental cooperation and mutual education that can benefit all involved.In practice, there are factors that limit optimal communications via Pap test requisition slips. One variable is how the information is obtained. For example, a patient may not remember the medically pertinent details of her past Pap test results or treatment. Improvement of laboratory-clinical communications, including design of requisition slips, optimization of clinical workflows, additional training and education of staff, and improved management of time constraints are possible areas of exploration for a future impact.Clinicians and their staff were very receptive to discussions of expectations of communications between them and the lab, and specifics on how those communications might impact and improve care for their patients. However, significantly, about half of them were unaware that the laboratory performed additional quality assurance rescreening of high-risk Pap test slides. Thus was identified a potential area for further education. Our initial version of the requisition slip did not elicit all the information sought by the laboratory, prompting revision. Clinical information and patient history were provided on the requisition slips in the vast majority of cases. The high accuracy of completion of requisition slips in this study permitted 77% of high-risk Pap tests to be identified via the requisition slip alone. Thus the common anecdotal impression of “notoriously unreliable” informatNo competing interest to declare by any of the authors.http://www.icmje.org/#author.All authors of this article declare that we qualify for authorship as defined by ICMJE Each author has participated sufficiently in the work and take public responsibility for appropriate portions of the content of this article.Each author acknowledges that this final version was read and approved.This study was conducted with approval from Institutional Review Board (IRB)  of all the institutions associated with this study. Authors take responsibility to maintain relevant documentation in this respect.


Robert Huber and his colleagues, Johann Deisenhofer and Hartmut Michel, elucidated the three-dimensional structure of the Rhodopseudomonas viridis photosynthetic reaction center. This membrane protein complex is a basic component of photosynthesis – a process fundamental to life on Earth – and for their work, Huber and his colleagues received the 1988 Nobel Prize in Chemistry. Because structural information is central to understanding virtually any biological process, Huber likens their discovery to “switching on the light” for scientists trying to understand photosynthesis. Huber marvels at the growth of structural biology since the time he entered the field, when crystallographers worked with hand-made instruments and primitive computers, and only “a handful” of crystallographers would meet annually in the Bavarian Alps. In the “explosion” of structural biology since his early days of research, Huber looks to the rising generation of scientists to solve the remaining mysteries in the field – such as the mechanisms that underlie protein folding. A strong proponent of science mentorship, Huber delights in meeting young researchers at the annual Nobel Laureate Meetings in Lindau, Germany. He hopes that among these young scientists is an “Einstein of biology” who, he says with a twinkle in his eye, “doesn’t know it yet.” The interview was conducted by JoVE co-founder Klaus J. Korak at the Lindau Nobel Laureate Meeting 2008 in Lindau, Germany.