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in British Columbia who contracted H1N1 in the spring and summer of 2009. People who had received a seasonal flu shot the previous autumn were more likely to contract the new pandemic strain.

Still, the finding is reminiscent of something that was observed in people in Canada during the 2009 H1N1 pandemic.

The authors cautioned against drawing a line between what happened to the pigs in the study and what might happen with people.

Her findings, which were initially dismissed by many in the global influenza research community, were later replicated in studies done in other provinces as well, leading some to dub the phenomenon “the Canadian problem.”

“I think . . . what they’re showing is a biological mechanism that warrants further evaluation in terms of its relevance to the use of seasonal vaccines in humans and what that may mean for the next pandemic threat,” Skowronski said.

It’s a frustrating target for flu vaccine designers. There are 17 known hemagglutinins, which give flu viruses the H in their name. (Most don’t currently infect people.) The hemagglutinins on H1 viruses look different than those on H3 viruses, and antibodies to one don’t protect against another.

Even within a subtype — H1, for instance — there are different strains, and a vaccine against one might offer lots, some or no protection against another. And all these hemagglutinins are constantly changing, which is why flu vaccines have to be updated almost every year.

Instead of being protected, the H1N2-vaccinated pigs developed more severe disease than exposed pigs that hadn’t been pre-vaccinated. When the researchers tested the blood of the vaccinated pigs, they found high levels of antibodies that attached to the stalk of the H1N1 hemagglutinin, but not to the head of the protein.

Skowronski and others suggested the work demonstrates the complexity of influenza immunology — the science of how the viruses interact with immune systems. “The problem is everybody wants influenza to be simple and be like other vaccine-preventable diseases. And it’s not,” Skowronski said.

Infectious diseases expert Dr. Michael Osterholm said with influenza, there is always a complicated interplay between the virus and the person the virus infects, one that is influenced by what viruses and vaccines the person’s immune system has previously encountered.

“It really drives home the need to be very cautious about what are we actually accomplishing.”

House calls are starting to make a comeback amid a rapidly greying population, although they're still rare. The idea: A doctor or nurse-practitioner, sometimes bringing along a social worker, makes regular visits to frail or homebound patients whose needs are too complex for a typical 15-minute office visit - and who have a hard time even getting to a physician's office. "It helps you avoid the emergency situations," said Naomi Rasmussen, whose 83-year-old father in Portland, Oregon, is part of Medicare's Independence at Home study.

Her father, stroke survivor Teodor Mal, is prone to frequent infections and unable to tell his wife or daughter whenever he starts to feel ill. Visits to multiple doctors left him so agitated that a good exam was difficult, and just getting him and his wheelchair there took several hours and a special van. Then Mal began getting his primary care from Portland-based Housecall Providers Inc. When family members see any worrisome changes in his behaviour or appearance, providers can make a quick visit to see if another urinary tract infection or case of pneumonia is beginning, in time to give at-home antibiotics a chance.

It took extra primary care visits, but "he went from bouncing in and out of the hospital to one hospitalization in an entire year," said Housecall Providers nurse Mary Sayre. But this kind of care is hard to find, in part because of reimbursement. Medicare did pay for more than 2.6 million house call visits in 2013. But add in the travel time, and doctors can see - and get paid for - many more patients in a day in the office than they can see on the road. Enter Medicare's Independent at Home demonstration project, now in its third year of testing how well a house call approach really works and how to pay for it. About 8,400 frail seniors with multiple chronic conditions - Medicare's most expensive type of patient - are receiving customized home-based primary care from 17 programs around the country. The incentive for doctors: They could share in any government savings if they also meet enough quality-care goals.

On Thursday, Medicare released its long-awaited analysis of the study's first year and said the project saved an average of $3,070 per participating beneficiary; Conway said all but five practices generated savings. Medicare will divide $11.7 million in incentive payments among the nine practices that met enough of the quality requirements for that financial bonus, including Portland's Housecall Providers. "We need to shift costs to this kind of intervention," said Dr. Pamela Miner of Housecall Providers.

The Affordable Care Act created the Medicare study, and legislation is pending in Congress to extend the project another two years. The program is "bringing the house calls of yesteryear into the 21st century," said Sen. Edward J. Markey, D-Mass. He said Thursday's pilot results are promising enough to make the project permanent so that many more Medicare patients eventually could seek this kind of care.

"Whether you're in a healthcare facility, a manufacturing facility, driving a vehicle - if you're tired, the risks of mistakes are going to go up." Two studies comparing eightand 12-hour schedules during day and night shifts found that 12hour night shifts were associated with more physical fatigue, smoking or alcohol use, according to a 2004 report from the U.S. Centers for Disease Control and Prevention. "It's the law of diminishing returns," said Liane Davey, vicepresident of team solutions with Lee Hecht Harrison Knightsbridge, which specializes in talent recruitment and development.

"We think that we're staying and doing more and being more productive; but the negative outcome of doing that actually means our core quality suffers." Irregular schedules - such as switching from a block of night shifts to day shifts - can result in sleep disturbance which can become chronic, Mustard noted. "If you build up a period of disturbed sleep ... this is somewhat different from fatigue, although in a sense the consequence is kind of the same. "If we can't rest, we're not renewing our cognitive and physical capacities."

German-born Moritz Erhardt was a week from completing a work placement at Bank of America Merrill Lynch in London when he died in 2013. A British coroner said the 21-year-old intern died of an epileptic seizure that may have been triggered by fatigue. Erhardt's case sparked widespread speculation that the notorious long working hours and competitive environment at top investment banks were to blame for his death. Matt Ferguson said his 22-yearold brother, Andy, died in a headon collision in 2011 after logging excessive hours as an unpaid intern at an Edmonton radio station.

When Jeff and Andrea Archibald launched their design agency, the couple initially worked from home and logged significant extra time to establish their business. "We definitely hit 60-hour work weeks mainly because when there's two of you, you have to do all the billable work," recalled Jeff Archibald. "When you're starting out, your rate's a little lower, and then you have to balance out with all the business side of things, like invoicing. You don't have anybody on staff that can do those kinds of things, so you're basically wearing all of the hats," he said. "What ends up happening is you have all your meetings and your phone calls ... during the day and you do your production work at night - and that's not just us. A lot of our friends are in similar situations."

The Archibalds are now part of a team of seven at their Edmonton custom Web and branding firm, Paper Leaf. Weekly meetings help assess key tasks to accomplish within a given day and week - and avoid overbooking. "One of the singularly biggest concerns I think we all have is balancing the amount of workload so that we can have a profitable company - but also not overwork people," Jeff Archibald said.

"When you overwork, you're staring down the barrel of burnout. It's a real short-term gain." Mustard said employees logging overtime should be aware of the pace of their work and ensure they are taking breaks. "Being thoughtful about nutrition, making sure that you're not missing meals is very important. And then rest. Not shortening your chance to have sleep."

Except that if the plan for medicare designed by Stephen Harper is actually carried out (and the numerous other threats materialize), there is one very large assumption that will be patently false. Medicare allows everyone (including the 1%) to lop off a big chunk from their retirement needs -- in the U.S., private health insurance costs the average American family $15,000 a year -- and even that covers only a portion of costs.

A U.S. study, "Get Sick, Get Out: The Medical Causes of Home Mortgage Foreclosures," shows just how devastating sickness can be without public health care: "Half of all respondents (49%) indicated that their foreclosure was caused in part by a medical problem…" The study also examined the impact of medical disruptions -- large out-of-pocket health payments, loss of work due to medical issues, and those tapping into home equity to pay medical bills. Sixty-nine per cent of respondents reported at least one of these factors.

Medicare isn't dead yet, you say. But for Canadians looking to retire in 25 to 40 years, given the trends, it well could be. Medicare is under attack on so many fronts it will take incredible determination on the part of those who will need it to ensure it's there when they retire. Yet younger generations -- who face the greatest threat of losing public health care -- don't seem to think about it that much. They should -- and before the fall election.

The big five vultures anticipating the joys of feeding off medicare's carcass include: B.C. medical privateer Brian Day's legal challenge to medicare; the still unsigned Canada-U.S. "trade" deal (Comprehensive Economic and Trade Agreement); the continuing scam of public-private partnerships fleecing health budgets of hundreds of millions of dollars in excess costs in virtually every province; a new domestic services treaty (Trade In Services Agreement); and lastly, Stephen Harper's new, imposed, health "accord" that will decrease federal contributions to the provinces by $36 billion over 10 years.

The authors tout their survey of 1,381 aides in three western provinces, just published in the Canadian Journal on Aging, as the first scientific study of a group who has been called health care’s “hidden” army.

But Govind Rao, a researcher with the Canadian Union of Public Employees, which represents care aides in some provinces, argued that the workers are, in fact, “very skilled” and well-qualified to do the work.

The problem, said Mr. Rao, is that there are not enough of them. “We have care aides who are overworked, and they’re not able to get their work done and answer patients when patients need them.” He also said it was “offensive” to even raise the issue of the workers’ ethnic make-up, saying there is no evidence that having English as a second language would affect their skill as care-givers.

It is estimated — no one knows the true number — that as many as 250,000 care aides, also known as personal support workers, are employed in Canada, providing 70-80% of the direct care to nursing-home residents. Most provinces require some kind of education and certification to work in the field, but the standards differ widely, said Prof. Estabrooks. Unlike nurses, physiotherapists and other professionals in the sector, they are not subject to regulation. Meanwhile, the number of registered nurses has been dwindling, partly due to cost cutting, experts say.

Figuring out precisely what people perceive as "just pay" is complicated, but there are social standards and patterns. People who feel paid appropriately experience a balance of investments and rewards. Investments such as education, skill, effort and seniority are on one end of the scale - that is, how much have you put in? Rewards are on the other. When the scale tips toward investments, you feel underpaid; when it tips toward rewards, you feel overpaid. We all have internal standards, but we also rely on social comparisons: "Why does so-and-so earn more than me? I have better credentials, work harder and have more seniority!" Getting less than you deserve It hurts to feel under-rewarded - to get less than what (you think) is just - on a cognitive, emotional and even physical level. Perceived underpayment and job dissatisfaction go hand in hand. A recent Accenture study of 3,600 entry- to managementlevel business professionals across 30 countries found that feeling underpaid is the top reason for worker dissatisfaction.

Likewise, in the CANWSH and GSS studies, roughly one-quarter of those who feel severely underpaid are "very dissatisfied" with their job, while about 6 per cent of those who feel appropriately paid are "very dissatisfied." Feeling underpaid doubles the probability that a worker will report experiencing "stress, depression and problems with emotions" on a majority of days in any given month. Physiological reactions are common, too. Perceived underpayment raises the risks of rating oneself as having poor health, headaches, and stomach, back and chest pain. All this affects sleep quality: Those who feel severely underpaid have more difficulty falling or staying asleep. Perceived underpayment also hurts because it amplifies other stresses, such as interpersonal conflict, work interfering with non-work life, and having too much work and not enough time. That's a lot of suffering - and it isn't equally distributed in the population. In collaboration with Atsushi Narisada and Sarah Reid, our research shows that the pain of feeling under-rewarded hurts more among those who earn less, mostly because of the link with greater financial insecurity.

Everyone has a stake in understanding the social causes and consequences of perceived underpayment. We need to talk about it and address it collectively as departments, organizations and institutions. The conditions that surround unjust earnings are ripe with chronic stress. Ultimately, that makes this a public health concern. If monkeys aren't cool with getting less than they deserve, why should we be? Health Advisor contributors share their knowledge in fields ranging from fitness to psychology, pediatrics to aging. Dr. Scott Schieman is a Canada Research Chair (Social Contexts of Health) and professor of sociology at the University of Toronto. His research focuses on the causes and health consequences of social stress. You can follow him on Twitter @ScottSchiemanUT.

the best option is a public insurance scheme with a single payer that provides benefits based on a standardized evaluation of care needs

This would ensure that all Canadians have better care and that access to long-term care services is more equitable. With a universal public insurance plan transaction costs and loading fees would be lower, so it would also be less expensive than private insurance.

The overall trend, she said, is a home care budget that doesn't live up to expectations.

"Verbally we see a commitment to shifting more care towards the home," Henningsen said in a telephone interview. "What we noticed from putting this report together is that the percentage of the public funding certainly didn't reflect those messages or that direction."

The report said demand for home care is soaring as Canada's baby boomers enter their twilight years. About 1.4 million people accessed home care services in 2011, up 55 per cent from 2008.

Henningsen said the association would like to see all orders of government redistribute their health care budgets to make home care a higher priority

She said new cash would not be necessary, adding reallocating funds currently devoted to other areas would go a long way towards addressing the shortfall.

CivicAction also lists income inequality and job insecurity as contributing factors for mental health issues. Wayne Lewchuk, a professor at McMaster University who has studied precarious labour extensively, said its strain goes beyond a worker’s schedule and employment status. “You’re less likely to have friends at work because you’re moving from workplace to workplace,” Lewchuk said. “Your support system is weaker.”

Ontario seniors homes have the worst fire fatality record in North America with 45 deaths since 1980.

Four private members’ bills and three inquests have all recommended sprinklers.

Residences built after 1998 must have sprinklers but the devices are still not required in 4,000 older “care occupancies,” which house more than 200,000 seniors and other vulnerable people across Ontario including the intellectually challenged. The frail, elderly are more likely to die in fires than any other age group, experts say.

Madeleine Meilleur, Minister of Community Safety and Correctional Services

“Sprinklers are not the only answer. They are important, but nothing will replace the staffing levels and how they are trained in case of fire,”

There are never fire deaths in homes with sprinklers except in the rare case where a person who caused the fire is overcome by injuries, said Sean Tracey, of the U.S.-based National Fire Protection Association.

Toronto Fire Services is first conducting a survey of each care home in the city to learn the cognitive abilities of residents before conducting the mock tests.

Here is how the chiefs did the study: Firefighters visited a retirement or nursing home — sometimes without advance notice — and performed a mock evacuation based on the number of overnight staff when few employees are on shift. Firefighters ordered staff to conduct a fire drill. Using a stopwatch, they tested staff’s ability to move residents out of the building or behind a firewall

Oak Terrace long-term care home, a government-licensed nursing home operated by the Revera chain, failed a test in October 2010.

After fire officials sent a letter to each member of Revera’s board of directors, the home decided to install sprinklers

Revera has installed sprinklers in 85 per cent of its 200 retirement and nursing homes across Canada

Homes that fail mock evacuation tests are hit with legal orders under the Fire Prevention and Protection Act, telling them to hire enough staff to be able to safely evacuate 24 hours a day — or install sprinklers.

Sprinkler installation costs roughly $3 a square foot. That translates to $40,000 for a 30-person home or about $110,000 for a 155-person home.

Fragile residents, combined with inadequate staffing and the fiery nature of materials in modern furniture, like the foam padding in couches, are a recipe for disaster.

In 2010, a year after the Orillia fire killed four residents (and left two brain dead), the government began a consultation on fire safety. Meilleur said she expects the report will be released in June.

an early draft said most respondents (more than 230 comments came from firefighters, retirement homes, municipalities and advocates) agreed that sprinklers should be mandatory in all care homes.

“If 45 children had died in fires would we still be waiting for the government to take action?”

residents, some drugged for a night’s sleep

With older patients making up 12 to 21 percent of all emergency visits, ED providers might miss important conditions because many older patients have multiple, complicated histories of communication problems, depression or an altered mental status, or a combination of social and medical problems that make triaging acute illness even more difficult.

study published in the journal PLoS One

health care expenditures in Canada are on a steep upward climb

hospitals and governments should look at ways to break down the silos around prescription drug purchasing and dispensing

Substituting the least expensive version of each drug could have saved $1.6 million, or 47 per cent, for PPIs

Medications represent an increasing share of those costs, currently around 16 per cent.

if U.S. doctors were able to reel in the administrative costs to a level on par with those polled in Ontario, it would result in an annual savings of more than $27 billion for the American health-care system.