Education level inequalities and transportation injury mortality in the middle aged and elderly in European settings

OBJECTIVE

To study the differential distribution of transportation injury mortality by educational level in nine European settings, among people older than 30 years, during the 1990s.

METHODS

Deaths of men and women older than 30 years from transportation injuries were studied. Rate differences and rate ratios (RR) between high and low educational level rates were obtained.

RESULTS

Among men, those of low educational level had higher death rates in all settings, a pattern that was maintained in the different settings; no inequalities were found among women. Among men, in all the settings, the RR was higher in the 30-49 age group (RR 1.46, 95% CI 1.32 to 1.61) than in the age groups 50-69 and > or = 70 years, a pattern that was maintained in the different settings. For women for all the settings together, no differences were found among educational levels in the three age groups. In the different settings, only three had a high RR in the youngest age group, Finland (RR 1.33, 95% CI 1.01 to 1.74), Belgium (RR 1.38; 95% CI 1.13 to 1.67), and Austria (RR 1.49, 95% CI 0.75 to 2.96).

CONCLUSION

This study provides new evidence on the importance of socioeconomic inequalities in transportation injury mortality across Europe. This applies to men, but not to women. Greater attention should be placed on opportunities to select intervention strategies tailored to tackle socioeconomic inequalities in transportation injuries.

Socioeconomic inequalities in mortality among elderly people in 11 European populations

STUDY OBJECTIVE

To describe mortality inequalities related to education and housing tenure in 11 European populations and to describe the age pattern of relative and absolute socioeconomic inequalities in mortality in the elderly European population.

DESIGN AND METHODS

Data from mortality registries linked with population census data of 11 countries and regions of Europe were acquired for the beginning of the 1990s. Indicators of socioeconomic status were educational level and housing tenure. The study determined mortality rate ratios, relative indices of inequality (RII), and mortality rate differences. The age range was 30 to 90+ years. Analyses were performed on the pooled European data, including all populations, and on the data of populations separately. Data were included from Finland, Norway, Denmark, England and Wales, Belgium, France, Austria, Switzerland, Barcelona, Madrid, and Turin.

MAIN RESULTS

In Europe (populations pooled) relative inequalities in mortality decreased with increasing age, but persisted. Absolute educational mortality differences increased until the ages 90+. In some of the populations, relative inequalities among older women were as large as those among middle aged women. The decline of relative educational inequalities was largest in Norway (men and women) and Austria (men). Relative educational inequalities did not decrease, or hardly decreased with age in England and Wales (men), Belgium, Switzerland, Austria, and Turin (women).

CONCLUSIONS

Socioeconomic inequalities in mortality among older men and women were found to persist in each country, sometimes of similar magnitude as those among the middle aged. Mortality inequalities among older populations are an important public health problem in Europe.

Pilot study of urinary iodine concentration and of biochemical thyroid parameters before and after cautious public health intervention on salt iodide content: The Swiss longitudinal 1996–2000 iodine study

OBJECTIVE AND DESIGN

Iodide concentration (IC) in salt was cautiously increased in Switzerland (15 --> 20 ppm iodide). We evaluated the dynamics of the effect of this intervention on urinary iodine concentration (UIC, microg/l) and on thyroid parameters.

SETTING

University Hospital in Bern, Switzerland.

SUBJECTS

A cohort of 36 subjects (12 children, 11 women, 13 men) out of 44 were recruited.

INTERVENTIONS

During the study periods PRE (May 1996-May 1998) and POST (October 1998-December 2000, subdivided into equal subperiods POST1 and POST2), that is, before and after the increase of IC in salt, subjects collected 6248 urine spots for analysis of UIC. Thyroid volumes (n=2/subject) and serum thyroid parameters (n=8/subject) were sequentially evaluated.

METHODS

Average PRE-POST data were compared (multiple regression analysis).

RESULTS

UIC increased overall by 5.1% (P=0.0003). Increase of UIC was highest in children (11.3%, P<0.0001), significant in women (8%, P=0.0016), but not significant in men (P=0.143). Comparison between periods POST1 and POST2 showed that UIC changed more gradually in women than in children. Thyroid volumes were normal, no nonphysiological change occurred. TSH indicated euthyroidism; it decreased in children (1.98 ==> 1.74 mU/l, P=0.04) and increased in men (1.65 ==> 1.91mU/l, P=0.025). FT3 decreased in children (P<0.004) and FT4 decreased in men (P=0.017), both within normal ranges. TSH, FT3 and FT4 were unchanged in women. FT3/FT4 ratios were stable. Anti-TPO-Ab titers were stable (P=0.9). Anti-Tg-Ab titers decreased (P=0.009).

CONCLUSION

The significant UIC effects were of uncertain metabolic relevance. No pathological side effects occurred. Differential delays and penetrances of UIC increase in children and adults were hitherto unknown. The unspectacular stepwise policy seems to be safe. Our pilot results in a population with moderate iodine deficiency in women should be confirmed in population-based cluster studies.

SPONSORSHIP

This work was supported by grants from the University Hospital in Bern, the Swiss Federal Office of Public Health (SFOPH), the 'Swiss National Foundation for Scientific Research' (32-49424.96), the 'Fondation Genevoise de Bienfaisance Valerie Rossi di Montelera', the 'Schweizerische Lebensversicherungs- und Rentenanstalt' and the 'Schüpbach Foundation of the University of Bern'.

Quantification of urinary iodine: a need for revised thresholds

OBJECTIVE

To compare different possibilities of reporting the iodine supply in the same urine samples. Indeed, in field studies, urinary iodine concentration (I/L: micro g I/L, micro mol I/L, I/creatinine: micro g I/g creatanine, micro mol I/mol creatinine) is more readily available than excretion (I/24h micro g I/24 h, micro mol I/24h). However, confusion exists regarding the comparability of iodine supply based upon I/L, I/creatinine and I/24h, which for decades have been regarded as biochemically equivalent.

DESIGN

We compared I/24h, I/L and I/creatinine in accurate 24 h collections of urine and I/L and I/creatinine in 47 spot urine samples.

PATIENTS

A total of 13 subjects (Bern n=7, Brussels n=6) collected a total of 110 precise 24 h urine collections (Bern n=63, Brussels n=47). The subjects from Brussels also took a spot sample at the beginning of each 24 h collection.

RESULTS

Iodine supply in both places was mildly deficient according to the criteria of WHO; all but one collection indicated an intake of >0.39 micro mol I/24h (>50 micro g I/24h). The same data presented as I/creatinine (or I/L) indicated an iodine intake of <0.39 (<50 micro g I/24h) in 5% (24%) of the samples in Bern and 23% (57%) in Brussels. Similar findings were observed for 47 spot samples. Whatever the cut-off selected, I/creatinine and I/L were systematically lower than I/24h (P<0.0002). Creatinine showed smaller CV than volume but did not perform better in defining iodine intake.

CONCLUSION

Considering I/24h as a reference, both I/creatinine and I/L clearly underestimate the iodine intake in subjects with adequate proteoenergetic intake. The significant deviations observed illustrate the urgent need for establishing separate ranges for I/24h, I/creatinine and I/L. In population studies, these deviations might even be larger.

Ritonavir plus saquinavir versus single protease inhibitor therapy in protease inhibitor-naive HIV-infected patients: the Swiss HIV Cohort Study

OBJECTIVES

To compare the response to ritonavir (RTV) plus saquinavir (SQV) with single protease inhibitor (PI) therapies among PI-naive HIV-1 infected individuals.

METHODS

Response to treatment was analysed according to the intent-to-treat principle in a prospective observational cohort study of 177 patients who between May 1995 and March 2000 started a double PI therapy with RTV and SQV (nonboosting dosages) plus at least one nucleoside reverse transcriptase inhibitor (NRTI) and 2,214 patients with a single PI therapy plus two NRTIs. We used survival analysis and Cox's proportional hazard regression methods. The primary endpoint was the time to a plasma viral load of < 400 copies/mL. Secondary endpoints were taken as a gain in the CD4 count of >100 cells/microL, and change of initial PI for any reason.

RESULTS

Baseline characteristics in both treatment groups were balanced. Median follow-up in both groups was 10.4 months. Time to an HIV-1 viral load of < 400 copies/mL and an increase in the CD4 count of >100 x 10(6) cells/L was shorter for RTV plus SQV compared with single PI regimens (log rank test for each endpoint P < 0.05). The adjusted hazard ratios of RTV plus SQV compared with single PI regimens were 1.21 (95% confidence interval 0.99-1.47) for achieving an HIV-1 viral load of < 400 copies/mL, 1.12 (0.88-1.42) for an increase in the CD4 count of > 100 cells/microL, and 0.90 (0.73-1.11) for change of first PI regimen.

CONCLUSIONS

Treatment with RTV plus SQV compared with single PI regimens appeared to give similar results for virological or immunological response.

[Does the structure of medical services affect the proportion of death in hospitals? An ecological analysis in the mobility regions of Switzerland?]

OBJECTIVES

With the discussion about measures to reduce over-capacities in the health services in mind, we examined the influence of medical supply structures and services on hospital utilisation directly before death.

METHODS

Based on the specification of the place of dying from the death certificates, we determined the proportions of deaths in hospitals in an ecological study. We analysed deaths of persons above age 65 in each of the 106 mobility regions of Switzerland in the years 1979 to 1980.

RESULTS

The proportion of deaths occurring in hospitals varied between 27% and 81%. Despite missing data regarding stationary and ambulatory care services, more than half of the variance could be explained by means of a multivariate regression analysis. Our results imply an inverse relation between the proportion of deaths in the hospital and the number of consultations provided by primary care physicians, as well as the number of nursing home beds. Further, we observe a direct relation to the number of hospital beds in a region. All indicators are calculated per inhabitant.

CONCLUSIONS

In health care supply planning, such systematic associations should be taken into account. We recommend to analyse regularly interregional differences in supply and outcome of medical performances with the best available data.

Emotional and physical demands on caregivers in home care to the elderly in Switzerland and their relationship to nursing home admission

BACKGROUND

Planning the home care of growing numbers of old, dependent people must include the caregivers' burden.

METHODS

A convenience sample of 129 caregivers of elderly patients with multiple diagnoses was interviewed about the caregiving context, burden, caregivers' tolerance of patients' troublesome behaviours and physical symptoms, mutuality and feelings of closeness between caregiver and patient. Continued maintenance of home care was assessed by a follow-up telephone call.

RESULTS

Caregivers were mainly spouses (67%) and female (73%), and the mean duration of care was 5.5 years. In five activities of daily living (ADL) 50-69% of the patients needed full help. Caregivers reported predominantly negative effects of caregiving on their physical and mental health, rest and sleep, leisure time and social life, problems with patients' symptoms and behaviours and little or no conversing (51%) or exchanging feelings with patients (71%). PREDICTIVE MODELS: Contributors to variance were for burden (35%), impact of care on caregivers' mental health, social relations and leisure time, patients' gender, accumulation of patients' symptoms and behaviours; for caregivers' tolerance toward patients' symptoms and behaviours (17%) caregivers' physical health, patients' level of confusion, feelings of mutuality; for mutuality (22%) and for closeness (19%) caregivers' mental health, patients' accumulation of symptoms and behaviours. Within 23 months 19% of the patients had been institutionalized. Factors giving a higher likelihood of institutionalization were: being male, caregiver was not a partner, and less closeness between caregiver and patient.

CONCLUSION

Caregiving of older persons has bio-psychosocial ramifications for caregivers. Closeness between caregiver and patient seems to be a key factor in determination of the long-term outcome.

Age- and gender-dependent urinary iodine concentrations in an area-covering population sample from the Bernese region in Switzerland

OBJECTIVE

Before a scheduled increase of salt iodide content up to 20 p.p.m. in Switzerland, urinary iodine concentration (UIC, microg/l) of a randomly selected, area-covering, age-stratified population subgroup was sampled in spring 1997. In contrast to former published studies on UIC, we minimized biases by age, gender, rural/urban, socio-economic and cultural influences.

METHODS

We contacted 750 households in the Bernese region using random telephone numbers. Per household, one proband selected by play dice collected a spot urine sample. We defined seven age categories: infants, children, adolescents, adults I-III and seniors, aged 0-5, 6-12, 13-20, 21-35, 36-50, 51-65 and >65 years respectively. Randomized UIC data were compared with WHO criteria of iodine deficiency (ID) and previous non-randomized, age-dependent Swiss UIC data. To recruit a perfect random group of volunteers proved difficult, as study participation of adolescent and male populations was somewhat lower than that of elder and female (P<0.005) populations respectively. Study participation of inhabitants of rural and suburban regions was comparable (P=0.139). Out of 413 obtained urine spots, 412 (55%) were analyzed statistically (58% women, 42% men, P<0.005).

RESULTS

Ninety per cent of all UIC values ranged between 25 and 200 microg/l. Median UIC showed mild ID (94 microg/l). UIC varied significantly between age categories (P=0. 0006). Women had lower UIC than men (P=0.014). Infants had no ID. Women in child-bearing age (13-35 years), adults II, adults III and seniors had mild ID. Compared with recommended supplies of 150 and 200 microg I/day in children and male adolescents respectively, we consider their UIC (110 and 144 microg/l) as at least borderline deficient. Absolute UIC was lowest in seniors. Probands from rural/suburban households had similar UICs. Our UIC data were comparable to published ones.

CONCLUSIONS

Despite long-term national efforts with iodized salt (15 p.p.m. in 1997), mild ID still prevailed in Bern in spring 1997, with rare extreme UIC values. Mild ID with women in child-bearing age (and probably also with children and male adolescents) was a serious concern, as goiter growth with puberty or pregnancy might be the consequence. Mild ID in adults and seniors might be due to restricted NaCl intake. Results of our randomly selected subgroup from a 650 000 population show that age- and gender-dependency are important when comparing our collected data with published UIC data. This fact must be considered with non-randomly selected population subgroups.

[Changes in the epidemiology of the acute respiratory distress syndrome (ARDS) in children]

OBJECTIVE

Our aim was to analyze, in a retrospective study, changes in acute respiratory distress syndrome (ARDS) within the same pediatric intensive care unit by using the same diagnostic criteria as published in 1982.

PATIENTS AND METHODS

Fifteen patients (mean age 5.1 years, range 16 days-15 years) admitted between 1988 and 1994 fulfilling our former criteria for ARDS were included in the study.

RESULTS

The incidence of ARDS after the age of 7 days was 0.45% of all admissions between the age of 1 week and 16 years vs 1.79% in the former series of patients (p < 0.001). Thus, the yearly rate of ARDS decreased from 5.7 to 2.1 cases per year. Six patients suffered a chronic underlying disease vs none in 1982 (p < 0.01). Triggering of ARDS by infection/inflammation was present in 14/15 patients vs 7/20 in the first series (p < 0.001). Except for the nadir PaO2/FiO2 ratio (54 mmHg vs 97 mmHg, p < 0.01), and duration of FiO2 > or = 0.5 (204 h vs 39 h, p < 0.01) there was no statistically significant difference with regard to respiratory data. Incidence of multiple organ/system failure and numbers of failing organs/systems remained unchanged. Eight of 15 patients died in the actual series vs 8/20 in 1982 (not significant).

CONCLUSIONS

Compared to our former data, the incidence of ARDS has decreased. Although the number of patients with severe chronic disease has increased, mortality remains statistically unchanged. Infection/inflammation is currently the predominant event triggering ARDS. Judging by the PaO2/FiO2 ratio and duration of FiO2 > or = 0.5, pulmonary involvement is more severe. The number of failing organs/systems remains nearly twice as frequent in non-survivors compared to survivors.

Occupational class and ischemic heart disease mortality in the United States and 11 European countries

OBJECTIVES

Twelve countries were compared with respect to occupational class differences in ischemic heart disease mortality in order to identify factors that are associated with smaller or larger mortality differences.

METHODS

Data on mortality by occupational class among men aged 30 to 64 years were obtained from national longitudinal or cross-sectional studies for the 1980s. A common occupational class scheme was applied to most countries. Potential effects of the main data problems were evaluated quantitatively.

RESULTS

A north-south contrast existed within Europe. In England and Wales, Ireland, and Nordic countries, manual classes had higher mortality rates than nonmanual classes. In France, Switzerland, and Mediterranean countries, manual classes had mortality rates as low as, or lower than, those among nonmanual classes. Compared with Northern Europe, mortality differences in the United States were smaller (among men aged 30-44 years) or about as large (among men aged 45-64 years).

CONCLUSIONS

The results underline the highly variable nature of socioeconomic inequalities in ischemic heart disease mortality. These inequalities appear to be highly sensitive to social gradients in behavioral risk factors. These risk factor gradients are determined by cultural as well as socioeconomic developments.

[Severity of respiratory syncytial virus infection influenced by clinical risk factors and subtype A and B in hospitalized children]

BACKGROUND

Since it is possible to identify the subgroups of RSV, A-subtype and B-subtype, there are findings indicating that the subtype may influence severity of RSV infection. Our study was designed to assess the hypothesis that A-subtype infections were more severe than B-subtype infections among hospitalized children.

PATIENTS

All medical records of patients hospitalized with RSV infection between March 1990 and March 1993 were reviewed. A total of 107 children with proven RSV infection were identified.

METHODS

Nasal waste specimens for culture were obtained from infants with suspected RSV infection. Subtype determination was done on frozen virus cultures. The following risk factors were defined: age < or = 3 months, weight < 5 kg, prematurity and underlying cardiac or respiratory disease and immune deficiency. To analyse the relationship between risk factors, subtype and severity a multivariate analysis was performed. Severity was measured by clinical observations as following: pH, PCO2, SaO2, oxygen supplementation, history of apnea and length of hospital stay.

MAIN RESULTS

Of the enrolled patients 11 had underlying disease and 17 were premature. The age range was 1 week to 4.2 years, median 3.5 months. 46 children were younger than 3 months, 33 had a weight of less than 5 kg. The isolates of 84 children were typeable: 63 isolates were subtype A and 21 subtype B. Underlying disease and prematurity were associated with SaO2 < 87% (p = 0.003) and oxygen supplementation (p = 0.017). A weight of less than 5 kg was correlated with a PCO2 > or = 50 mmHg. The RSV subtype was not significantly correlated with severity.

CONCLUSIONS

RSV infection even in very young children is predominantly influenced by underlying disease, prematurity and weight. The RSV subtype was no independent risk factor for an increased morbidity in this retrospective study. Therefore, in our opinion, RSV subtype is less meaningful to predict the severity of RSV infection than known risk factors.

Association of syncytium-inducing phenotype of HIV-1 with CD4 cell count, viral load and sociodemographic characteristics

OBJECTIVES

To study whether syncytium-inducing (SI)/non-SI (NSI) phenotype of HIV-1 is associated with CD4+ lymphocyte count, plasma HIV RNA level, clinical stage and sociodemographic characteristics in antiretroviral-naive HIV-1-infected patients.

DESIGN

Cross-sectional analysis of single centre cohort study data.

METHODS

SI/NSI phenotype was determined using a cocultivation assay using patients' peripheral blood mononuclear cells and MT2 cells. Standard procedures were used for CD4+ cell counts and viral load measurements in plasma. Univariate and multivariate analyses of association of CD4+ cell counts, viral load, clinical stage, age, sex and mode of HIV transmission were performed.

RESULTS

In univariate analysis, SI phenotype was significantly associated with lower CD4+ cell counts, higher HIV RNA plasma levels, symptomatic HIV disease, male sex and age 32-36 years (middle tercile). In multivariate analysis, only lower CD4+ cell counts were associated with SI phenotype (odds ratio per increase of 100 x 10(6)/l, 0.54; 95% confidence interval, 0.38-0.78).

CONCLUSIONS

HIV-1 SI phenotype was associated with lower CD4+ cell counts but not with higher plasma viral load, clinical stage or sociodemographic variables.

Correlation between maximum bite force and facial morphology in children

The correlation between maximum bite force and facial morphology was studied in 54 boys, 8 to 16 years old, and 66 girls, 7 to 17 years old. Bite force was measured at the first molars with a miniature bite force recorder. Facial morphology was evaluated on profile cephalograms. In addition, the number of teeth in contact in the intercuspal position was recorded with occlusal foils. In the girls, maximum bite force was correlated with the inclination of the mandible, the size of the gonial angle, and the ratio between posterior and anterior face heights. The correlations implied a large bite force with a small mandibular inclination and gonial angle, a large posterior face height in relation to the anterior face height, and a small bite force with the opposite facial characteristics. These correlations were nonexistent or weaker in boys. In both sexes, bite force was correlated with the number of occlusal contacts. Elimination of the influence of age and occlusal contact in the group of girls by the use of partial correlations reduced the correlation between bite force and facial morphology. A significant correlation with the size of the gonial angle remained, however, and the correlation with mandibular inclination was close to significance. In addition to the correlations found with facial morphology, the study clearly demonstrated the need to take gender and occlusal contacts into consideration in future studies of masticatory muscle function and strength in relation to facial morphology.

Bias in meta-analysis detected by a simple, graphical test

OBJECTIVE

Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses.

DESIGN

Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews.

MAIN OUTCOME MEASURE

Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision.

RESULTS

In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias.

CONCLUSIONS

A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution.

Bias in meta-analysis detected by a simple, graphical test

OBJECTIVE

Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses.

DESIGN

Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30% of the trial); analysis of funnel plots from 37 meta-analyses identified from a hand search of four leading general medicine journals 1993-6 and 38 meta-analyses from the second 1996 issue of the Cochrane Database of Systematic Reviews.

MAIN OUTCOME MEASURE

Degree of funnel plot asymmetry as measured by the intercept from regression of standard normal deviates against precision.

RESULTS

In the eight pairs of meta-analysis and large trial that were identified (five from cardiovascular medicine, one from diabetic medicine, one from geriatric medicine, one from perinatal medicine) there were four concordant and four discordant pairs. In all cases discordance was due to meta-analyses showing larger effects. Funnel plot asymmetry was present in three out of four discordant pairs but in none of concordant pairs. In 14 (38%) journal meta-analyses and 5 (13%) Cochrane reviews, funnel plot asymmetry indicated that there was bias.

CONCLUSIONS

A simple analysis of funnel plots provides a useful test for the likely presence of bias in meta-analyses, but as the capacity to detect bias will be limited when meta-analyses are based on a limited number of small trials the results from such analyses should be treated with considerable caution.

How not to miss a somatic needle in the haystack of chronic pain

Interviews with 18 male patients with predominantly psychogenic pain (DSM-III and DSM-III-R) and with 18 male patients with pain of mainly physical origin, consecutively admitted to a medical department, were rated by blinded and independent raters with respect to "symptom description," "manner of speech," "personality characteristics," "interviewer reactions," "interpersonal relationships," and "relationships at work." Patients with predominantly organic pain significantly more often described a clear localization of the pain symptom, used more sensory words for the description of pain quality; more often described discrete changes of pain intensity and periodicity; more often showed pain-intensifying factors dependent on movement and pain-decreasing factors; more often believed pain to be a symptom versus as a disease itself, and tended to have fewer difficulties in their interpersonal relationships than those with predominantly psychogenic pain (p < 0.05 for all factors, two-tailed Fisher's Exact test).

Respiratory health and long-term exposure to air pollutants in Swiss schoolchildren. SCARPOL Team. Swiss Study on Childhood Allergy and Respiratory Symptoms with Respect to Air Pollution, Climate and Pollen

The impact of long-term exposure to air pollution on respiratory and allergic symptoms and illnesses was assessed in a cross-sectional study of schoolchildren (ages 6 to 15 yr, n = 4,470) living in 10 different communities in Switzerland. Air pollution measurements (particulate matter less than 10 microns in diameter [PM10], nitrogen dioxide [NO2], sulfur dioxide [SO2], and ozone) and meteorologic data were collected in each community. Reported symptom rates of chronic cough, nocturnal dry cough, and bronchitis, adjusted for individual risk factors, were positively associated with PM10, NO2, and SO2. The strongest relationship was observed for PM10 (adjusted odds ratios for chronic cough, nocturnal dry cough, and bronchitis between the most and the least polluted community for PM10 were 3.07 [95% CI: 1.62 to 5.81], 2.88 [95% CI: 1.69 to 4.89], and 2.17 [95% CI: 1.21 to 4.89], respectively). The high correlation between the average concentrations of the pollutants makes the assessment of the relative importance of each pollutant difficult. No association between long-term exposure to air pollution and classic asthmatic and allergic symptoms and illnesses was found. There was some indication that frequency of fog is a risk factor of chronic cough and bronchitis, independent of air pollution. In conclusion, this study provides further evidence that rates of respiratory illnesses and symptoms among children augment with increasing levels of air pollution even in countries like Switzerland with moderate average air pollution concentrations.

Clinical speculation: is specificity back? This time thromboangiitis obliterans

Do men with thrombangiitis obliterans (TO) show conspicuous personality features and behavior? Twenty-one men with TO were compared with 20 men with coronary artery disease (CAD). All diagnoses were angiographically confirmed. Mean ages were 40.1 (TO) and 43.4 years (CAD). Semistructured, open-ended interviews were conducted. Interview-behavior: TOs were more hostile, minimizing, evasive, and complicated than CADs (p < .001). The interviewer reacted with more anger, impatience, boredom, astonishment, and less empathy towards TOs (p < .001). Adult behavior: TOs had changed their place of work more often (p < .001), had more absentism from work (p < .001), and had more debts (p = .01) unrelated to the present illness. They smoked more before the illness (p = .01) and continued to smoke more frequently during their illness than CADs (p < .003). They were more often single or divorced (p < .05) and had more conflicts in their relationships (p < .001) than CADs. During conflicts, TOs more often shouted or withdrew and less frequently tried to resolve conflicts with humor and discussions (p < .001) than CADs. TOs were more frequently dissatisfied with their life situation than CADs (p < .001). TOs more often passively submitted to their illness than CADs, who tried to cope by giving up smoking and by exercising (p < .001). Childhood: TOs more often mentioned a bad relationship with their father than CADS (p = .01) and had more disciplinary problems at home and in school (p = .002). TOs show remarkable personality features.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of measures of influence in epidemiology

In epidemiological studies the units of observation often consist of political entities such as countries, each of which has its own specific inner structure. When a multiple regression is performed it is therefore of particular interest to analyse not only the overall behaviour of the dataset, but in addition, to investigate how each individual country contributes to, and deviates from, this overall behaviour. By means of the example 'relation between infant mortality and structural data of countries' several ways are discussed of how each individual country can influence the regression model. Firstly the potential influence which each country might exhibit due to the explanatory variables alone is analysed. Then the actual influence of each country is analysed by taking the explanatory variables and the target variable into account simultaneously. This is done by means of statistical measures not generally familiar to epidemiologists, which have been developed in recent years (leverage values, Cook's distances). These measures also point to deviations of countries from the model, and suggest directions in which to search for explanation. Finally the influence of the 'size' of the countries is investigated.

Excessive motor impairment two hours after triazolam in the elderly

The pharmacokinetics of triazolam 0.25 mg p.o. and psychomotor coordination were compared in nine healthy, elderly volunteers and nine middle aged controls. Motor coordination, as measured by pursuit rotor performance, was impaired in the elderly even before triazolam administration, and in contrast to the controls it deteriorated to a critical level after the drug. Factors associated with the major decrease in psychomotor performance in the elderly volunteers were poor baseline performance, an additional independent-age factor, and the plasma concentration of free triazolam. Although short acting benzodiazepines may have a less detrimental effect on performance on the morning following their intake, there may be serious motor incoordination and falls may occur if the patients have to rise during the night, particularly when the plasma concentration is high, i.e. about 2 h after dosing.

A cross-cultural comparison of attitudes toward alcohol among French and United States college students

The purpose of the present study was to compare attitudes toward alcohol in two Western cultures with traditionally distinct drinking patterns, the United States and France. France is generally considered as the greatest world consumer of alcoholic beverages whereas the United States is ranked lower with a different drinking typology. A 14-scale semantic differential was administered to 295 first-year college students at the University of Lille in France and to 242 freshman and sophomore college students in the United States. Data were analyzed by means of a discriminant analysis. After the final step of a stepwise entry of variables, 11 of the 14 adjective pairs remained in the analysis, producing a highly significant function. This function yielded an overall accuracy of classification of 79%. Results were congruent with previous findings suggesting overpermissive attitudes toward alcohol among the French respondents and more ambivalent attitudes toward alcohol among American subjects.

[Engel's "psychogenic pain and the patient susceptible to pain": a retrospective, controlled clinical study]

Engel's hypothesis of pain-prone patients having a distinct pattern of developmental psychosocial experiences was tested in a controlled design including four groups of 20 patients each: a) psychogenic pain, b) organic pain, c) psychogenic bodily symptoms, d) organic disease. On admission an open-ended interview, including childhood experiences was tape-recorded. Measures were taken to minimize observer-bias. Patients in group a) had, compared to the other groups, significantly increased prevalence of: "Parents, verbally and/or physically abusive of each other", "parents, abusive of the child", "child, deflecting aggression from one parent to the other onto himself", "parents, who suffered from illnesses/-pain", "parent of the same gender as the patient suffering from pain", "pain of patient and parent in the same location", "number of operations in adulthood", "disturbance of interpersonal relationships", and "disturbance of work life". Factor analysis produced two factors explaining 73% of the variance in group a): F1 ("Brutality-Overcompensation") was related to "duration of pain", F2 ("Submission-Inhibition") to "number of operations, accidents" in adulthood.

Engel's "Psychogenic Pain and the Pain-Prone Patient:" a retrospective, controlled clinical study

Engel's hypothesis of pain-prone patients having a distinct pattern of developmental psychosocial experiences was tested in a controlled design including four groups of 20 patients each: A) psychogenic pain, B) organic pain, C) psychogenic bodily symptoms, and D) organic disease. On admission an open-ended interview, including childhood experiences, was tape-recorded. Measures were taken to minimize observer bias. Patients in group A had, compared to the other groups, significantly increased prevalence of: "Parents, verbally and/or physically abusive of each other," "parents, abusive of the child," "child, deflecting aggression from one parent to the other onto himself," "parents, who suffered from illnesses/pain," "parent of the same gender as the patient suffering from pain," "pain of patient and parent in the same location," "number of operations in adulthood," "disturbance of interpersonal relationships," and "disturbance of work life." Factor analysis produced two factors explaining 73% of the variance in group A: F1 ("Brutality-Overcompensation") was related to "duration of pain," and F2 ("Submission-Inhibition") was related to "number of operations, accidents" in adulthood.

Pressure-volume curves, static compliances and gas exchange in hyaline membrane disease during conventional mechanical and high-frequency ventilation

Eight premature infants with hyaline membrane disease needing artificial ventilation were studied at a mean age of 26.5 h. After a preparative phase they were randomly assigned either first to conventional mechanical ventilation (CMV; delivered by a Siemens Servo 900 C), followed by high-frequency ventilation (HFV; delivered by Percussionaire VDR 1 at 10 Hz) or vice versa, each period lasting 4 h. At the end of each period, arterial blood gases, lung volumes and alveolar pressures (Palv) during CMV or HFV and pressure-volume (P-V) curves of the total respiratory system were determined. Expiratory volumes were measured spirometrically, Palv by the clamping method, and the P-V curve was constructed by the syringe method. Single point static compliance at end-inspiration was higher during HFV (0.40 +/- 0.10 vs. 0.32 +/- 0.08 ml/cmH2O.kg-1; p = 0.02), whereas at end-expiration no difference was noted. Two points static compliances were also better during HFV than during CMV (0.32 +/- 0.08 vs. 0.24 +/- 0.06 ml/cmH2O.kg-1; p = 0.01). Static compliances derived from the steepest part of the inflation limb of the P-V curve were 0.55 +/- 0.12 after CMV and 0.50 +/- 0.12 ml/cmH2O.kg-1 after HFV (n.s.). Compared to CMV, HFV resulted in similar oxygenation and CO2-elimination at equal mean lung volumes, but at significantly lower mean Palv. It is concluded that recruitment of lung volume is achieved with less static recoil pressure by HFV. These findings are explained by differences in inspiration allowing more time for volume recruitment during HFV.

Mechanism of the excessive sedative response of cirrhotics to benzodiazepines: model experiments with triazolam

Mechanisms responsible for disproportional sedation resulting from triazolam administration to patients with cirrhosis were investigated. Ordinary sedative doses (0.25 mg) were given p.o. to 8 cirrhotics and 18 controls. Plasma concentrations of unbound drug were assessed by capillary gas chromatography and equilibrium dialysis. Median apparent oral clearances of unbound triazolam were 14.8 ml per min per kg in cirrhotics and 23.9 ml per min per kg in controls (p less than 0.01). Clearances were significantly correlated with severity of liver disease as assessed by the aminopyrine breath test (Rs = 0.77, n = 17, p less than 0.001). At a time when plasma concentrations of unbound triazolam were the same in both groups, i.e., 2.25 hr after dosing, flicker sensitivity at 5 Hz which was used as an index of CNS performance was impaired by a factor of 3.2 in cirrhotics and 1.4 in controls (p less than 0.01 for group difference). Performance was also significantly lower in cirrhotics with the digit symbol substitution test (p less than 0.05). It is concluded that, in patients with cirrhosis, disproportional sedation after benzodiazepine administration may be due not only to impaired drug elimination, but also to hypersensitivity of the brain.

[The proposed law on safeguarding of data--a threat to medical-epidemiologic research in Switzerland?]

The draft of the new law on the confidentiality of personal data severely curtails medical and epidemiological research. This might be detrimental and dangerous to public health. The project therefore has to be amended.

Bufuralol metabolism in human liver: a sensitive probe for the debrisoquine-type polymorphism of drug oxidation

The genetically controlled polymorphism causing decreased metabolism of debrisoquine is closely related to that of the metabolism of bufuralol and numerous other drugs and has important clinical consequences. A sensitive in vitro assay was developed which quantifies the production of 1'-hydroxy-bufuralol (carbinol) from bufuralol in human liver microsomes. Initial formation rates of carbinol suggested Michaelis-Menten kinetics with an apparent KM of 61 and 171 mumol l-1 and Vmax of 3.2 and 5.8 nmol mg-1 microsomal protein h-1 in two human liver samples. The Vmax in microsomes of thirty-two liver samples was 4.2 +/- 1.0 (SD) nmol carbinol mg-1 protein h-1. Metabolism of debrisoquine in vivo, as expressed by the 'metabolic ratio' of debrisoquine over 4-OH debrisoquine correlated (r = -0.65, P less than 0.01; n = 18) with carbinol production rate in microsomes in vitro. Microsomes of one individual identified as poor metabolizer of debrisoquine in vivo showed reduction of carbinol formation to 1.97 nmol mg-1 h-1. Mixing his microsomes with those of an extensive metabolizer resulted in additive formation of carbinol excluding mediation of the defect by a soluble inhibitor. These data support the concept of a primary defect in microsomal oxidation of bufuralol. The described assay offers a sensitive tool to investigate the molecular mechanism of the 'debrisoquine polymorphism'.

[Evaluation of the Swiss Hospital Association diagnostic and surgical statistics]

Number of admissions, days of care and the average length of stay are presented by age, sex and other criteria for Swiss short stay hospital. Persons 60 and over consumed more than 50 percent of all days of care. On the average, females of all age groups, except from 5 to 54 years of age, were hospitalized longer than males. Principal factors influencing the length of stay are: age, diagnosis and mode of discharge. The increase in the number of persons 65 and over admitted to medical departments corresponds to the demographic development, while it exceeds the demographic increase for surgical departments.

Changes in the cyclic AMP content during growth and development of Acetabularia

The 3',5'-adenosine monophosphate (cyclic-AMP) content of the unicellular alga Acetabularia has been examined at various developmental stages. It has been found that very young algae, less than 10mm in length, have a high cAMP content [more than 7 pmoles per 100 mg wet weight (WW)], but that with the growth of the algae, the cAMP content decreases rapidly, reaching the low level of 0.5--1.0 pmoles per 100mg WW. The cAMP content remains at this level until cap differentiation, after which an increase in cAMP content accompanies cap enlargement. It has been shown that these results are unlikely to be affected by changes in the cAMP content induced by variations in circadian rhythm. Treatment with theophylline (2.10(-3) M), a phosphodieterase inhibitor, results in an increase in the cAMP content and delays growth and cap formation. Experiments on the effects of theophylline upon the circadian rhythm of oxygen evolution have shown that the continuous presence of theophylline in the culture medium does not induce a phase shift in the rhythm. The cAMP content of anucleate Acetabularia shows development stage variations parallel to that of the whole algae.