Availability, accessibility, and use of green spaces and cognitive development in primary school children

Green spaces may have beneficial impacts on children's cognition. However, few studies explored the exposure to green spaces beyond residential areas, and their availability, accessibility and uses at the same time. The aim of the present study was to describe patterns of availability, accessibility, and uses of green spaces among primary school children and to explore how these exposure dimensions are associated with cognitive development. Exposures to green space near home, school, commuting route, and other daily activity locations were assessed for 1607 children aged 6-11 years from six birth cohorts across Europe, and included variables related to: availability (NDVI buffers: 100, 300, 500 m), potential accessibility (proximity to a major green space: linear distance; within 300 m), and use (play time in green spaces: hours/year), and the number of visits to green spaces (times/previous week). Cognition measured as fluid intelligence, inattention, and working memory was assessed by computerized tests. We performed multiple linear regression analyses on pooled and imputed data adjusted for individual and area-level confounders. Availability, accessibility, and uses of green spaces showed a social gradient that was unfavorable in more vulnerable socioeconomic groups. NDVI was associated with more playing time in green spaces, but proximity to a major green space was not. Associations between green space exposures and cognitive function outcomes were not statistically significant in our overall study population. Stratification by socioeconomic variables showed that living within 300 m of a major green space was associated with improved working memory only in children in less deprived residential areas (β = 0.30, CI: 0.09,0.51), and that more time playing in green spaces was associated with better working memory only in children of highly educated mothers (β per IQR increase in hour/year = 0.10; 95% CI: 0.01, 0.19). However, studying within 300 m of a major green space increased inattention scores in children in more deprived areas (β = 15.45, 95% CI: 3.50, 27.40).

Benzophenone-3: Comprehensive review of the toxicological and human evidence with meta-analysis of human biomonitoring studies

BACKGROUND

Benzophenone-3 (BP-3) and its major metabolite benzophenone-1 (BP-1) are widely used as UV filters in sunscreens and cosmetics to prevent sunburn and skin damage, or as stabilizers to prevent photodegradation in many commercial products. As a result, their presence is ubiquitous in the environment, wildlife and humans. Based on endocrine disruption concerns, international regulatory agencies are performing a closer evaluation.

OBJECTIVE AND METHODS

This work aimed to comprehensively review the available human relevant evidence for safety issues in MEDLINE/PubMed in order to create a structured database of studies, as well as to conduct an integrative analysis as part of the Human Biomonitoring for Europe (HBM4EU) Initiative.

RESULTS

A total of 1,635 titles and abstracts were screened and 254 references were evaluated and tabulated in detail, and classified in different categories: i) exposure sources and predictors; ii) human biomonitoring (HBM) exposure levels to perform a meta-analysis; iii) toxicokinetic data in both experimental animals and humans; iv) in vitro and in vivo rodent toxicity studies; and v) human data on effect biomarkers and health outcomes. Our integrative analysis showed that internal peak BP-3 concentrations achieved after a single whole-body application of a commercially available sunscreen (4% w/w) may overlap with concentrations eliciting endocrine disrupting effects in vitro, and with internal concentrations causing in vivo adverse female reproductive effects in rodents that were supported by still limited human data. The adverse effects in rodents included prolonged estrous cycle, altered uterine estrogen receptor gene expression, endometrium hyperplasia and altered proliferation and histology of the mammary gland, while human data indicated menstrual cycle hormonal alterations and increased risk of uterine fibroids and endometriosis. Among the modes of action reported (estrogenic, anti-androgenic, thyroid, etc.), BP-3 and especially BP-1 showed estrogenic activity at human-relevant concentrations, in agreement with the observed alterations in female reproductive endpoints. The meta-analysis of HBM studies identified a higher concern for North Americans, showing urinary BP-3 concentrations on average 10 and 20 times higher than European and Asian populations, respectively.

DISCUSSION AND CONCLUSIONS

Our work supports that these benzophenones present endocrine disrupting properties, endorsing recent European regulatory efforts to limit human exposure. The reproducible and comprehensive database generated may constitute a point of departure in future risk assessments to support regulatory initiatives. Meanwhile, individuals should not refrain from sunscreen use. Commercially available formulations using inorganic UV filters that are practically not absorbed into systemic circulation may be recommended to susceptible populations.

Mid-childhood fat mass and airflow limitation at 15 years: The mediating role of insulin resistance and C-reactive protein

BACKGROUND

We previously reported an association of high fat mass levels from age 9 to 15 years with lower forced expiratory flow in 1 s (FEV₁ )/forced vital capacity (FVC) ratio (i.e., increased risk of airflow limitation) at 15 years. Here, we aimed to assess whether insulin resistance and C-reactive protein (CRP) at 15 years partially mediate this association.

METHODS

We included 2263 children from the UK Avon Longitudinal Study of Parents and Children population-based cohort (ALSPAC). Four fat mass index (FMI) trajectories ("low," "medium-low," "medium-high," "high") from 9 to 15 years were previously identified using Group-Based Trajectory Modeling. Data on CRP, glucose, insulin, and post-bronchodilator FEV₁ /FVC were available at 15 years. We defined insulin resistance by the homeostasis model assessment-estimated insulin resistance index (HOMA-IR). We used adjusted linear regression models and a causal mediation analysis to assess the mediating role of HOMA-IR and CRP.

RESULTS

Compared to children in the "low" FMI trajectory, children in the "medium-high" and "high" FMI trajectories had lower FEV₁ /FVC at 15 years. The percentage of the total effect explained by HOMA-IR was 19.8% [-114.1 to 170.0] and 20.4% [1.6 to 69.0] for the "medium-high" and "high" trajectories, respectively. In contrast, there was little evidence for a mediating role of CRP.

CONCLUSION

The association between mid-childhood fat mass and FEV₁ /FVC ratio at 15 years may be partially mediated by insulin resistance.

The evaluation of the 3-30-300 green space rule and mental health

BACKGROUND AND AIMS

Urban green space has many health benefits, but it is still unclear how much actually is needed for better health. Recently a new 3-30-300 rule of thumb for urban forestry and urban greening has been proposed, but this rule has not been evaluated for benefits on health. The rule requires that every citizen should be able to see at least three trees from their home, have 30 percent tree canopy cover in their neighbourhood and not live more than 300 m away from the nearest park or green space. The aim of this study was to evaluate the relationship between the 3-30-300 green space rule and its components in relation to mental health.

METHODS

We conducted a cross-sectional study based on a population-based sample of 3145 individuals aged 15-97 years from in Barcelona, Spain who participated in the Barcelona Health Survey (2016-2017). We created 3-30-300 green space indicators using questionnaire data, GIS, remote sensing and land cover maps. Mental health status was assessed with the 12-item General Health Questionnaire (GHQ-12) and also the use of tranquilizer/sedatives or antidepressants and psychiatrist or psychologist visits. Analyses were conducted using mixed effects logistic regression models with districts as the random effect, adjusted for relevant covariates.

RESULTS

We found that people in Barcelona had relatively little exposure to green space, whether through window view, living in an area with sufficient greenness, or access to a major green space, and only 4.7% met a surrogate 3-30-300 green space rule. Residential surrounding greenness, but not tree window view or access to major green space, was significantly associated with better mental health, less medication use, and fewer psychologist or psychiatrist visits. Meeting the full surrogate 3-30-300 green space rule was associated with better mental health, less medication use, and fewer psychologist or psychiatrist visits, but only for the latter combined the association was statistically significant (Odds ratio = 0.31, 95% CI: 0.11, 0.91).

CONCLUSION

Few people achieved the 3-30-300 green space in Barcelona and we used a surrogate measure. We observed health benefits when the full surrogate rule was met.

Urban environment and health behaviours in children from six European countries

BACKGROUND

Urban environmental design is increasingly considered influential for health and wellbeing, but evidence is mostly based on adults and single exposure studies. We evaluated the association between a wide range of urban environment characteristics and health behaviours in childhood.

METHODS

We estimated exposure to 32 urban environment characteristics (related to the built environment, traffic, and natural spaces) for home and school addresses of 1,581 children aged 6-11 years from six European cohorts. We collected information on health behaviours including total amount of overall moderate-to-vigorous physical activity, physical activity outside school hours, active transport, sedentary behaviours and sleep duration, and developed patterns of behaviours with principal component analysis. We used an exposure-wide association study to screen all exposure-outcome associations, and the deletion-substitution-addition algorithm to build a final multi-exposure model.

RESULTS

In multi-exposure models, green spaces (Normalized Difference Vegetation Index, NDVI) were positively associated with active transport, and inversely associated with sedentary time (22.71 min/day less (95 %CI -39.90, -5.51) per interquartile range increase in NDVI). Residence in densely built areas was associated with more physical activity and less sedentary time, and densely populated areas with less physical activity outside school hours and more sedentary time. Presence of a major road was associated with lower sleep duration (-4.80 min/day (95 %CI -9.11, -0.48); compared with no major road). Results for the behavioural patterns were similar.

CONCLUSIONS

This multicohort study suggests that areas with more vegetation, more building density, less population density and without major roads are associated with improved health behaviours in childhood.

Urban environment and obesity and weight-related behaviours in primary school children

BACKGROUND

Urban environments are characterised by many factors that may influence children's lifestyle and increase the risk of childhood obesity, but multiple urban exposures have scarcely been studied.

OBJECTIVE

We evaluated the association between multiple urban exposures and childhood obesity outcomes and weight-related behaviours.

METHODS

We conducted a cross-sectional study including 2213 children aged 9-12 years in Sabadell, Spain. We estimated ambient air pollution, green spaces, built and food environment, road traffic and road traffic noise at residential addresses through a total of 28 exposure variables in various buffers. Childhood obesity outcomes included body mass index (BMI), waist circumference and body fat. Weight-related behaviours included diet (fast food and sugar-sweetened beverage consumption), physical activity, sedentary behaviour, sleep duration and well-being. Associations between exposures (urban environment) and outcomes (obesity and behaviours) were estimated in single and multiple-exposure regression models and in a hierarchical clustering on principal components (HCPC) analysis.

RESULTS

Forty percent of children were overweight or obese. In single exposure models, very few associations were observed between the urban exposures and obesity outcomes or weight-related behaviours after correction for multiple testing. In multiple exposure models, PM_coarse, denser unhealthy food environment and land use mix were statistically significant associated with childhood obesity outcomes (e.g 17.7 facilities/km² increase of unhealthy food environment (OR overweight/obesity status) = 1.20 [95% CI: 1.01; 1.44]). Cluster analysis identified 5 clusters of urban exposures. Compared to the most neutral cluster, the cluster with high air pollution, road traffic, and road noise levels was associated with a higher BMI and higher odds of overweight and obesity (β (zBMI) = 0.17, [95% CI: 0.01, 0.17]; OR (overweight/obesity) = 1.36, [95% CI: 0.99, 1.85]); the clusters were not associated with the weight-related behaviours.

CONCLUSIONS

This systematic study of many exposures in the urban environment suggests that an exposure pattern characterised by higher levels of ambient air pollution, road traffic and road traffic noise is associated with increased childhood obesity risk and that PM_coarse, land use mix and food environment are separately associated with obesity risk. These findings require follow-up in longitudinal studies and different settings.

Physical and mental health effects of repeated short walks in a blue space environment: A randomised crossover study

INTRODUCTION

Blue spaces may benefit mental health and promote physical activity, although the evidence is still scarce. And benefits on physical health are less consistent. The objective of this randomized crossover study was to assess psychological and cardiovascular responses to blue spaces' exposure.

METHODS

A sample of 59 healthy adult office workers was randomly assigned to a different environment (i.e. blue space, urban space, and control site) on 4 days each week, for 3 weeks. For 20 min per day, they either walked along a blue or an urban space or rested at a control site. Before, during and/or after the exposure, we measured self-reported well-being and mood, blood pressure, and heart rate variability parameters. For well-being, we also assessed the duration of these potential effects over time (at least 4 h after exposure).

RESULTS

We found significantly improved well-being and mood responses immediately after walking in the blue space compared with walking in the urban space or when resting in the control site. Cardiovascular responses showed increased activity of the sympathetic nervous system, both during and after walking along the blue and urban spaces. However, cardiovascular responses measured after the walks, showed no statistically significant differences between the blue and the urban space environments.

CONCLUSIONS

Short walks in blue spaces can benefit both well-being and mood. However, we did not observe a positive effect of blue spaces for any of the cardiovascular outcomes assessed in this study.

Early-Life Environmental Exposures and Childhood Obesity: An Exposome-Wide Approach

BACKGROUND

Chemical and nonchemical environmental exposures are increasingly suspected to influence the development of obesity, especially during early life, but studies mostly consider single exposure groups.

OBJECTIVES

Our study aimed to systematically assess the association between a wide array of early-life environmental exposures and childhood obesity, using an exposome-wide approach.

METHODS

The HELIX (Human Early Life Exposome) study measured child body mass index (BMI), waist circumference, skinfold thickness, and body fat mass in 1,301 children from six European birth cohorts age 6-11 y. We estimated 77 prenatal exposures and 96 childhood exposures (cross-sectionally), including indoor and outdoor air pollutants, built environment, green spaces, tobacco smoking, and biomarkers of chemical pollutants (persistent organic pollutants, metals, phthalates, phenols, and pesticides). We used an exposure-wide association study (ExWAS) to screen all exposure-outcome associations independently and used the deletion-substitution-addition (DSA) variable selection algorithm to build a final multiexposure model.

RESULTS

The prevalence of overweight and obesity combined was 28.8%. Maternal smoking was the only prenatal exposure variable associated with higher child BMI (z-score increase of 0.28, 95% confidence interval: 0.09, 0.48, for active vs. no smoking). For childhood exposures, the multiexposure model identified particulate and nitrogen dioxide air pollution inside the home, urine cotinine levels indicative of secondhand smoke exposure, and residence in more densely populated areas and in areas with fewer facilities to be associated with increased child BMI. Child blood levels of copper and cesium were associated with higher BMI, and levels of organochlorine pollutants, cobalt, and molybdenum were associated with lower BMI. Similar results were found for the other adiposity outcomes.

DISCUSSION

This first comprehensive and systematic analysis of many suspected environmental obesogens strengthens evidence for an association of smoking, air pollution exposure, and characteristics of the built environment with childhood obesity risk. Cross-sectional biomarker results may suffer from reverse causality bias, whereby obesity status influenced the biomarker concentration. https://doi.org/10.1289/EHP5975.

Changing the urban design of cities for health: The superblock model

BACKGROUND

Car-dependent city planning has resulted in high levels of environmental pollution, sedentary lifestyles and increased vulnerability to the effects of climate change. The Barcelona Superblock model is an innovative urban and transport planning strategy that aims to reclaim public space for people, reduce motorized transport, promote sustainable mobility and active lifestyles, provide urban greening and mitigate effects of climate change. We estimated the health impacts of implementing this urban model across Barcelona.

METHODS

We carried out a quantitative health impact assessment (HIA) study for Barcelona residents ≥20 years (N = 1,301,827) on the projected Superblock area level (N = 503), following the comparative risk assessment methodology. We 1) estimated expected changes in (a) transport-related physical activity (PA), (b) air pollution (NO₂), (c) road traffic noise, (d) green space, and (e) reduction of the urban heat island (UHI) effect through heat reductions; 2) scaled available risk estimates; and 3) calculated attributable health impact fractions. Estimated endpoints were preventable premature mortality, changes in life expectancy and economic impacts.

RESULTS

We estimated that 667 premature deaths (95% CI: 235-1,098) could be prevented annually through implementing the 503 Superblocks. The greatest number of preventable deaths could be attributed to reductions in NO₂ (291, 95% PI: 0-838), followed by noise (163, 95% CI: 83-246), heat (117, 95% CI: 101-137), and green space development (60, 95% CI: 0-119). Increased PA for an estimated 65,000 persons shifting car/motorcycle trips to public and active transport resulted in 36 preventable deaths (95% CI: 26-50). The Superblocks were estimated to result in an average increase in life expectancy for the Barcelona adult population of almost 200 days (95% CI: 99-297), and result in an annual economic impact of 1.7 billion EUR (95% CI: 0.6-2.8).

DISCUSSION

The Barcelona Superblocks were estimated to help reduce harmful environmental exposures (i.e. air pollution, noise, and heat) while simultaneously increase PA levels and access to green space, and thereby provide substantial health benefits. For an equitable distribution of health benefits, the Superblocks should be implemented consistently across the entire city. Similar health benefits are expected for other cities that face similar challenges of environmental pollution, climate change vulnerability and low PA levels, by adopting the Barcelona Superblock model.

Correlates of Walking for Travel in Seven European Cities: The PASTA Project

BACKGROUND

Although walking for travel can help in reaching the daily recommended levels of physical activity, we know relatively little about the correlates of walking for travel in the European context.

OBJECTIVE

Within the framework of the European Physical Activity through Sustainable Transport Approaches (PASTA) project, we aimed to explore the correlates of walking for travel in European cities.

METHODS

The same protocol was applied in seven European cities. Using a web-based questionnaire, we collected information on total minutes of walking per week, individual characteristics, mobility behavior, and attitude (N=7,875). Characteristics of the built environment (the home and the work/study addresses) were determined with geographic information system (GIS)-based techniques. We conducted negative binomial regression analyses, including city as a random effect. Factor and principal component analyses were also conducted to define profiles of the different variables of interest.

RESULTS

Living in high-density residential areas with richness of facilities and density of public transport stations was associated with increased walking for travel, whereas the same characteristics at the work/study area were less strongly associated with the outcome when the residential and work/study environments were entered in the model jointly. A walk-friendly social environment was associated with walking for travel. All three factors describing different opinions about walking (ranging from good to bad) were associated with increased minutes of walking per week, although the importance given to certain criteria to choose a mode of transport provided different results according to the criteria.

DISCUSSION

The present study supports findings from previous research regarding the role of the built environment in the promotion of walking for travel and provides new findings to help in achieving sustainable, healthy, livable, and walkable cities. https://doi.org/10.1289/EHP4603.

Design of a Mobile Application for Transfusion Medicine

One of the most frequent error in transfusion medicine is the failure in verifying the patient's identity prior to transfusion. This paper describes the design and development of a Mobile Application (MA) for transfusion medicine. The app uses barcode and QR reading technology for the verification of the patient's identity and the administration of blood components when making a blood transfusion. Physicians, developers, technicians of transfusion medicine and a User Centered Design team participated in the design. The inclusion of end users was fundamental to get full representativeness of their workflow. The project was based on agile methodologies of project management and software development.

Biological and psychological monitoring of training status during an entire season in top kayakers

AIM

The aim of this study was to analyze changes in selected biological and psychological variables in a group of top level kayakers along a 42-week training season.

METHODS

Eight top junior sprint kayakers (age=16.8±2.1) (5 men and 3 women) with international competitive experience participated in the research. During the 42-wk season the subjects were tested in three occasions: (T1) in the second week of the general training period, (T2) at the beginning of the specific training period, (T3) at the beginning of the competitive training period. Firstly, subjects were asked to complete the Recovery-Stress Questionnaire for Athletes (RESTQ-Sport) and the Profile of Mood States (POMS) questionnaires, and Borg´s rate of perceived exertion scale (RPE). Immediately after, blood samples were collected and white blood cells, creatine kinase (CK), C-reactive protein (CRP), myeloperoxidase protein levels (MPO) and glutathione status were determined. ANOVA with repeated measures was used to determine the differences between tests.

RESULTS

From the hematological and biochemical measures only total leukocytes changed significantly, increasing at T3 when compared to T1. There were no differences along the entire season in both RESTQ-Sport and POMS scores or indices. Concerning performance, the group improved their maximal strength (+17.4% in bench-press 1RM) and their specific-distance time (+9.8%). The main finding of the present study was that training was well-balanced between stress and recovery because while specific performance increased, signs of overtraining were not found.

CONCLUSION

Training monitoring in athletes should be performed in a multilevel approach using measurements of performance as well as biological or psychological parameters.

Substance abuse and health self-perception in Spanish children and adolescents

OBJECTIVE

The aim of this study was to analyze substance abuse and health self-perception in children and adolescents from the province of Cádiz (Spain).

METHODOLOGY

Participants were 738 students, 50.9 boys and 49.1% girls, from elementary school to high school (1st to 12th grade, mean age 12.2. years), who responded a Spanish adaptation of the Health Behavior in School-aged Children Inventory.

RESULTS

No difference was observed in percentage of boys and girls reporting to smoke or drink alcohol. Smoking and drinking habits increased with age, being higher in 11th and 12th grade students. Significant differences were observed among the percentage of smokers and non smokers recognizing to have parents, older brothers or friends who smoke. Rates of drug abuse were generally low, being cannabis the most frequently consumed illicit drug. Most respondents had a perception of excellent or good health, with no significant gender differences. About half of subjects considered that health exclusively depends on self behavior, but an important percentage also gave a relevant role to luck. Stomach-ache was the most frequent physical complaint, followed by headache. Psychological complaints mainly corresponded to nervousness and bad temper. Only a small percentage of subjects declared the use of medicines or tablets without prescription. No significant difference in the percentage of respondent who perceived an excellent or good health was observed among substance users and non users.

CONCLUSIONS

Substance abuse and health self-perception in children and adolescents are the result of the interaction of a complex series of individual and social factors. Activities aimed to improve health focusing on partial aspects of adolescents' lifestyle most probably will have limited results, and global programs are required.

[Health behaviour of school children at the province of Cádiz]

OBJECTIVE

The aim of this study was to analyze some characteristics of health-related behaviour in school children at the province of Cadiz, centering on engagement in sports and physical activity, and on dietary habits.

METHODOLOGY

Participants were 738 students, mean age 12.2 years, from primary school o high school. 50.9% were boys and 49.1% girls, who responded a Spanish adaptation of the Health Behavior in Schoolchildren Inventory.

RESULTS

Sex differences were observed in the percentage of subjects not engaged in sports, which was higher in girls. Boys practiced sports and physical activity at a higher intensity and more time than girls. A large number of subjects considered good or normal their physical fitness, with only and small percentage describing it as regular. More than half of participants felt a support by parents, and to a smaller extent by brothers and friends. An important part of the subjects did not have breakfast every day, and some even never. A high percentage of the sample ate candies 1 to 3 days per week, being also high the intake of chips, nuts, hamburgers and sausages. Near a quarter of subjects reported not to consume vegetables.

CONCLUSIONS

Results obtained confirm the necessity of an adequate lifestyle habits education and the development of intervention programs in children and youth, counseling on diet and physical activity and targeting on girls, who are less physically active and on risk of serious disorders.

Perceptions of the motivational climate created by parents of young Portuguese swimmers

The purpose of this study was to examine perceptions of parent-initiated motivational climate in young Portuguese swimmers. 244 participants (130 boys, 114 girls; M age = 13 yr., SD = 2), involved in advanced swimming programs (n = 88) or competition (n = 156), responded to the Portuguese version of the Parent-Initiated Motivational Climate Questionnaire. Age did not significantly affect the perceptions the young swimmers had of their parents' initiated motivational climate, but a main effect for sex and an interaction of sex and level of practice interaction were found. Boys in advanced swimming programs perceived a stronger Success-without-effort Climate created by both their father and their mother than did girls at the same level of practice. Boys and girls in both categories had higher perceptions of a Learning/Enjoyment Climate.

Use of nutritional supplements in sports: risks, knowledge, and behavioural-related factors

A large number of recreational and elite athletes use nutritional supplements in hopes of improving performance. These aids can be costly and potentially harmful, and the advertised ergogenic gains are often based on little or no scientific evidence. Due to the lack of regulation of the dietary supplement industry, an abundance of supplement products of dubious value, content, and quality are now available around the world. Many supplement products contain substances that are prohibited in sport or that have been associated with significant morbidity and mortality. For athletes, lack of knowledge or misinformation has been established despite numerous sources of information being available, and the reasons for, and implications of, unsupervised and unrestricted supplement use require further attention. In addition to the necessity of an appropriate regulation of dietary supplements, nutritional education and scientifically sound guidance for athletes is required. Intervention and prevention efforts should be particularly targeted to adolescents.

Smoking as a precipitating factor for migraine: a survey in medical students

Our aim was to analyse the relationship between migraine and smoking in medical students. Medical students who had already received teaching on migraine were asked to answer an ad hoc questionnaire. A total of 361 students filled in the questionnaire: 245 (68%) were women. International Headache Society criteria were fulfilled by 58 (prevalence of migraine 16%) students. A total of 74 (20%) were current smokers: 21 males (18% of men were smokers) and 53 females (22% smokers). Within those 58 students with migraine, 17 (29%) smoke: only 2 were males (14% of males with migraine smoked) while the remaining 15 were females (34% of women with migraine smoked). Within those 17 students who were smokers and migraineurs, 12 (71%) thought that smoking worsens migraine and 10 (59%) that smoking precipitates attacks. The minimum number of cigarettes which subjectively precipitates attacks was 5. Migraine prevalence in the 20s in Spain is 16%. Our data obtained in medical students suggest that smoking can be a precipitating factor for migraine attacks, as the prevalence of active smoking is one-third higher in migraineurs and as there seems to be a relationship between the number of cigarettes and the development of migraine attacks.

[Eating disorders in sports: risk factors, health consequences, treatment and prevention]

Eating disorders appear with relative frequency in sports, such as gymnastics, figure skating or resistance sports, in which weight control is important. Their incidence is greater in women, frequently appearing a low self-esteem, a distorted body image in which the body is perceived with an excess of weight, inefficiency, perfectionism and a sense of control loss, with compensatory attempts exerted through food manipulation and the use of inadequate methods of control weight. Frequently, they are associated in female athletes to irregularities of the menstrual cycle, reduction of the bone mineral density and osteoporosis, giving rise to so-called female athlete triad. Cardiovascular problems, a greater incidence of fractures, and muscular power and resistance losses which impair performance, can also develop. Between the risk for their appearance are attempts to lose weight, often by recommendation of the coach, increases of training loads associated to weight losses, characteristics of the personality that take to excessive preoccupation by body image, or injuries and traumatisms. Treatment requires a multidisciplinary approach, with participation of physicians, psychologists/psychiatrists, nutricionists, coaches and family, being specially important the emphasis on preventive measures.

Identification of dropout reasons in young competitive swimmers

AIM

The purpose of this study was to examine reasons for discontinuing sport participation in Spanish competitive swimmers.

METHODS

Sixty-two swimming dropouts (40 males and 22 females, ranging in age from 14 to 30 years) were administered the Questionnaire of Reasons for Attrition of Gould et al.

RESULTS

The results of the survey indicated that having other things to do was the most important reason for attrition. Other items rated important were related to lack of fun, perception of failure or low skill, while low ratings were given to items related to achievement/status or affiliation. A significant multivariate effect was obtained for gender and for experience at dropout. Analysis of individual items by "t"-test demonstrated that females placed greater emphasis than males on excessive pressure, hard training, dislike of competition, not winning enough and not feeling important enough. Former swimmers with less experience at dropout rated interest in another sport as more important and being too old as less important than swimmers with more experience.

CONCLUSION

The results of this study support the importance of negative factors related with aspects of the athletic environment that lead to discontinuing in competitive swimming.

The Sambungmacan 3 Homo erectus calvaria: a comparative morphometric and morphological analysis

The Sambungmacan (Sm) 3 calvaria, discovered on Java in 1977, was illegally removed from Indonesia in 1998 and appeared in New York City in early 1999 at the Maxilla & Mandible, Ltd. natural history shop. Here we undertake an analysis of its phylogenetic and systematic position using geometric morphometrics and comparative morphology. The coordinates of points in the sagittal plane from glabella to opisthion were resampled to yield "lines" of 50 semi-landmarks. Coordinates of glabella, bregma, lambda, inion, and opisthion were also collected and analyzed separately. Casts of Homo erectus fossils from Indonesia, China, and Kenya and of "archaic H. sapiens" from Kabwe and Petralona, as well as 10 modern human crania, were used as the primary comparative sample. The modern humans were well separated from the fossils in a graphical superimposition of Procrustes-aligned semi-landmarks as well as in principal component and canonical discriminant analyses. In all of these, Sm 3 falls intermediate between the fossil and modern groups. Morphological comparisons of Sm 3 with a selection of Homo erectus fossils revealed its greatest similarity to specimens from Ngandong and the Sm 1 calvaria. Compared to all other H. erectus, Sm 3 was distinctive in its more vertical supratoral plane, less anteriorly projecting glabella and less sharply angled occiput. In these features it was somewhat similar to modern humans. It is not yet possible to determine if this similarity implies an evolutionary relationship or (more likely) individual or local populational variation. Several features of Sm 3 (small size, gracile supraorbital torus and lack of angular torus, and position in principal component analysis) suggest that it was a female. The use of geometric morphometrics provides a means to statistically test the shapes of such fossils in a manner not easily duplicated by other methods. The intermediate position of Sm 3 between fossil and modern samples in several different subanalyses exemplifies the value of this approach.

New fossil hominid calvaria from Indonesia--Sambungmacan 3

A morphologically distinct partial calvaria of Homo cf. erectus from Java, Indonesia is described. The fossil hominid Sambungmacan 3 (Sm 3) was first discovered in 1977 from the banks of the Solo River near the village of Poloyo, Sambungmacan district, in central Java. It was later recovered in a New York City natural history establishment in 1999 and quickly returned to the Indonesian authorities. Examination of Sm 3 shows that the calvaria is well preserved with only portions of the cranial base missing. The most striking characteristics of Sm 3 include: the presence of a vertically rising forehead, more open occipital/nuchal and frontal angles, a more globular vault, and a cranial capacity within the Homo erectus range. Most notably absent in Sm 3 are a number of the classic characters attributed to Homo erectus, such as a strongly expressed angular torus and a continuous supratoral sulcus. The absence of such characters would normally place the calvaria outside the range of Homo erectus (sensu stricto), however, overall quantitative and qualitative morphological assessments of Sm 3 place it within the Homo erectus spectrum. The combination of the morphological characters in Sm 3 may be interpreted in several ways: 1.) the known cranial variation of H. erectus from Indonesia and China is extended; 2.) this calvaria shows evidence of evolutionary change within H. erectus; or 3.) more than one species of Homo existed in the (presumed) Middle Pleistocene of Java.)

Endocast of Sambungmacan 3 (Sm 3): a new Homo erectus from Indonesia

A new fossil calvaria, Sambungmacan 3 (Sm 3), described in New Fossil Hominid Calvaria From Indonesia--Sambungmacan 3 by Márquez et al., this volume, yields one of the most advanced and complete endocasts yet recovered from Java. This communication provides a thorough interpretation of the external anatomical landmarks observable on Sm 3. Using computer tomography (CT) and traditional morphological measurements, our comparative paleoneurological analyses show that while Sm 3 has a mosaic of features that are similar to both Indonesian and Chinese H. erectus, it also possesses significant characters reminiscent of later hominins. These include a greater degree of asymmetry characterized by a possible left-occipital, right-frontal petalial pattern, left-right volumetric cerebral asymmetry, and marked asymmetry in Broca's cap. Moreover, the frontal lobe offers a more rounded, shortened appearance in contrast to the flat, elongated appearance of other Indonesian fossils (e.g., Sangiran 17). Another unique trait is exhibited in the transverse plane where the widest breadth of Sm 3 occurs more superiorly than in other Indonesian H. erectus. Thus, the endocast of Sm 3 presents a unique morphology not seen previously in the hominin fossil record. While the strong modern human characteristics in this endocast may not represent a particular ancestry, they do allow us to recognize a new dimension of the remarkable variation in Indonesian Homo erectus.

Field dependence-independence of basketball referees

This study examined the field dependence-independence of basketball referees. A total of 205 subjects (nonathletes, athletes active in individual or team sports, and referees) completed the Group Embedded Figures Test. Analysis indicated no significant differences among referees due to age, group, or number of years officiating. Statistically significant lower scores were obtained by team-sport players and referees than by nonathletes. Mean scores of team-sport players and referees did not differ significantly.

[Content analysis in the assessment of the new model of primary health care in the Valencian community]

The objective of this research is to find out how the process of implementation and development of the new model of primary health care is taking place in the Valencian Community, according to the press and the opposition political parties. An analysis of two types of texts was conducted: daily journal articles parliamentary questions. The press referred to implementation more often than to development, assessing the implementation in a positive way and the development in a negative one. The opposition political parties in the regional parliament also questioned on the model implementation more often on its development, and negatively assess the process as a whole.

[Professional perspective in primary health care reform: a qualitative approximation]

The objective of this study was to find out opinions and experiences of primary health centre professionals on the process of implementation and development of the New Model of Primary Health Care in the Valencian Community. Nin semi-structured group interviews with professionals were carried out, directed by two researchers who proposed the topics for discussion by means of open questions and took notes on the interventions. Some others aspects of health centres' situation were also assessed by observation. The majority of the professionals thought high prevalence disease programmes should be elaborated by the Health Administration that community participation was an important dimension but difficult to develop, that the population perceived an improvement in health care with the new model, and that relationships with Health Area Managers were good, even though they were not thought to have a real management role. The greatest differences in opinions and experiences among primary health care teams concerned the development of some dimensions of the new model, especially comprehensive care, continuous care and team work.

Field dependence-independence of male and female Spanish athletes

We examined the field dependence-independence of Spanish athletes, 293 men and women (aged 18 to 23 years) active in individual and team sports, and nonathletes. Subjects were tested on the Group Embedded Figures Test. Analysis indicated that men active in team sports were more field-dependent than those non-involved in sports, and that team-sport women exhibited a higher field-dependence than individual-sport athletes or nonathletes of both sexes. Our data reflect a significant interaction between type of sport and sex.

[Evaluation of a program for reducing the surgical waiting list on the basis of on the spot payment]

BACKGROUND

The aim of this study was to evaluate a program to shorten the surgical waiting list on the basis of on the spot payment for each intervention performed outside the ordinary time schedule. The evaluation was based on preestablished hypothesis concerning the possible beneficial and adverse effects of on the spot payment.

METHODS

Eighty-four units corresponding to 6 surgical specialties in 14 hospitals of the Valencian Public Health Care Department were included in the study. The effects of this program were compared between the units which carried out the program from March to June 1992 (experimental group: EG) and the units which did not undertake the program (control group: CG).

RESULTS

The interventions performed in the program constituted 31% of the initial waiting list of the EG units. Bed profitability increased in the EG with surgeon productivity decreasing within the ordinary time schedule in the units of general surgery in the EG (16%) and the selection of diagnoses did not coincide with clinical priorities (positive selection of fimosis, fallopian tube tieing and negative selection of goiter and prostatic hyperplasia).

CONCLUSIONS

The design of programs based on the spot payment should take the possible adverse effects into account establishing mechanisms to avoid the decrease in ordinary activity and the selection of patients on the basis of criteria different to clinical priorities.

[Community participation in health at the Instituto Mexicano del Seguro Social in Jalisco]

This paper describes the achievements and problems of a community participation model in health care, developed by the Mexican Social Security Institute since 1985. The health team involved between 10 and 20 percent of the personnel due to the slow adoption this program requires in new of the cultural change it implies. The community's answer has been satisfactory, as it can be seen by the ware of 100 neighbours and school committees, and around the 2,000 housewives and school students who are been working as promoters. This figures stand monthly. The self-care groups on chronic diseases constitute another form of participation. The community activities are progressively focused on causes of health and disease, embracing our 70 per cent of health promotion and disease prevention actions. The work realized by the community over cause one third of that realized by the preventive medicine personnel. This health community participation model represents a valuable and viable alternative.

[Healthy carriers of enteropathogenic micro-organisms among the child population of Seville]

We have studied for 1-year period a group of 144 children (31 newborn infants, 62 aged 1 year and 51 aged 2 years) who were randomly selected from the registrar's office of Sevilla with the purpose of determining the incidence of diarrhoea and the prevalence of enteropathogenic microorganisms. Two samples of faeces (one at the beginning and the second by the second semester of the 1-year period) were obtained from all children which were processed for culture and parasite and rotavirus examination. We found a prevalence rate of enteropathogenic Escherichia coli carriers (EPEC) of 7%, of Giardia lamblia of 4% and of rotavirus of 14%. The state of EPEC was more frequent among children from high social-economic status. The state of G. lamblia carrier was six-fold higher in children with body weight alterations and in non-vaccinated or incompletely vaccinated children.