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This study analyses the impact of improved water supply and sanitation on the level and rate of decline of child diarrhoea mortality in Stockholm 1878-1925. Previous studies have failed to demonstrate an effect of improved water supply on the risk of diarrhoea mortality at the individual level. Using data on access to water and sanitation from a household survey in 1895 and mortality rates and sociodemographic information from individual data 1878-1925 to analyse area differentials in diarrhoea mortality, it was found that the proportion having their own latrine in the household was associated with lower mortality risk in 1895-1900, while the proportion having water in the household was associated with lower diarrhoea mortality risk during the mortality decline until 1925. Population effects of improved water and sanitation on diarrhoea mortality may be better measured at area level than at individual level. [ABSTRACT FROM AUTHOR]

Background: Meta-analyses of randomized trials suggest that health checks and health promotion interventions targeting behavior change in primary care do not prevent cardiovascular morbidity and mortality in the general population. However, whether such interventions are more effective in high-risk populations, such as people living in low socioeconomic settings, remains unclear, as they have been poorly represented in previous trials. Therefore, we aim to evaluate the effectiveness, cost-effectiveness, and implementation of systematic screening followed by an individually oriented, lifestyle-focused, health dialogue intervention for prevention of type 2 diabetes and cardiovascular disease, as compared to opportunistic screening, in primary care in socioeconomically disadvantaged areas., Methods: Using an overall pragmatic approach and a cluster-randomized design with two arms, we aim to enroll 3000 participants aged 50-59 years from 30 primary care centers (PCCs) with an above-average level of Care Need Index in Stockholm Region, Sweden. PCCs will be randomized (1:1) either to a health dialogue intervention, which includes inviting enlisted patients to a systematic screening of risk factors followed by an individually oriented lifestyle-focused health dialogue, or to opportunistic screening, which includes screening patients for a smaller set of risk factors during an appointment at their PCC taking place for other reasons. The main outcome will be change in systolic blood pressure during 6- and 12-month follow-ups. Additional short-term outcomes will be changes in other biological risk factors, health-related quality-of-life, and lifestyle habits, as well as process and implementation outcomes, and unintended side effects. The long-term effect on type 2 diabetes and cardiovascular disease incidence and mortality will be examined using regional and nationwide registers. Changes in systolic blood pressure and other health outcomes will be analyzed using mixed-effect generalized linear modeling and mixed-effect Cox regression to capture variability between and within PCCs. A health economic evaluation will assess resource use and costs in the short- and long-term., Discussion: This trial of lifestyle-focused health dialogues and opportunistic screening in primary care in socioeconomically disadvantaged areas in the largest region of Sweden has the potential to yield valuable insights that could support evidence-based policymaking., Trial Registration: ClinicalTrials.gov (NCT06067178). Prospectively registered September 27, 2023., (© 2024. The Author(s).)

Evidence of inequality in the utilisation of mental health care (MHC) by adolescents in Nordic countries is mixed. This study aims to investigate if there are socioeconomic differences in the utilisation of MHC, while accounting for adolescents' mental health status. We analysed a cohort of 3517 adolescents, followed from 7 to 9th grade (ages 13-16), to examine the association between parental socioeconomic position (SEP: education and disposable income), adolescents' estimated needs, and the utilisation of MHC (defined as visits to secondary psychiatric care or receipt of psychotropic medication). Logistic and negative binomial regression models, with mental health status as moderator, were used to predict utilisation during each grade. Lower SEP predicted higher odds of utilising MHC in adolescents with no/mild symptoms (e.g., odds ratio, OR = 1.33, 95% CI 1.04-1.72, lower vs highest education), but not in those with moderate-to-severe symptoms (estimates close to one and non-significant). This pattern was largely explained by treatment of attention deficit hyperactivity disorder/autism spectrum disorders (ADHD/ASD) in boys. For girls with severe symptoms, lower SEP predicted reduced odds of utilising MHC for other mental disorders (OR = 0.48, 95% CI 0.25-0.92, lower education), and fewer outpatient visits when in contact with such care, although non-significant (incidence rate ratio, IRR = 0.51, 95% CI 0.25-1.05, lowest vs highest income). Our findings suggest a more equitable use of MHC for treating ADHD/ASD, but not other mental disorders such as depression and anxiety, particularly among girls., (© 2023. The Author(s).)

Background: In Norrtälje municipality, within Region Stockholm, there is a joint integrated care organisation providing health and social care, which may have facilitated a more coordinated response to the covid-19 pandemic compared to the otherwise decentralised Swedish system. This study compares the risk of covid-19 mortality among persons 70 years and older, in the municipalities of Stockholm, Södertälje, and Norrtälje, while considering area and individual risk factors., Methods: A population-based study using linked register data to examine covid-19 mortality among those 70 + years (N = 127,575) within the municipalities of interest between the periods March-August 2020 and September 2020-February 2021. The effect of individual and area level variables on covid-19 mortality among inhabitants in 68 catchment areas were examined using multi-level logistic models., Results: Individual factors associated with covid-19 mortality were sex, older age, primary education, country of birth and poorer health as indicated by the Charlson Co-morbidity Index. The area-level variables associated were high deprivation (OR: 1.56, CI: 1.18-2.08), population density (OR: 1.14, CI: 1.08-1.21), and usual care. Together, this explained 85.7% of the variation between catchment areas in period 1 and most variation was due to individual risk factors in period 2. Little of the residual variation was attributed to differences between catchment areas., Conclusion: Integrated care in Norrtälje may have facilitated a more coordinated response during period 1, compared to municipalities with usual care. In the future, integrated care should be considered as an approach to better protect and meet the care needs of older people during emergency situations., (© 2024. The Author(s).)

Background: The coronavirus disease 2019 (COVID-19) disproportionately affects minority populations in the USA. Sweden - like other Nordic countries - have less income and wealth inequality but lacks data on the socioeconomic impact on the risk of adverse outcomes due to COVID-19., Methods: This population-wide study from March 2020 to March 2022 included all adults in Stockholm, except those in nursing homes or receiving in-home care. Data sources include hospitals, primary care (individual diagnoses), the Swedish National Tax Agency (death dates), the Total Population Register "RTB" (sex, age, birth country), the Household Register (size of household), the Integrated Database For Labor Market Research "LISA" (educational level, income, and occupation), and SmiNet (COVID data). Individual exposures include education, income, type of work and ability to work from home, living area and living conditions as well as the individual country of origin and co-morbidities. Additionally, we have data on the risks associated with living areas. We used a Cox proportional hazards model and logistic regression to estimate associations. Area-level covariates were used in a principal component analysis to generate a measurement of neighborhood deprivation. As outcomes, we used hospitalization and death due to COVID-19., Results: Among the 1,782,125 persons, male sex, comorbidities, higher age, and not being born in Sweden increase the risk of hospitalization and death. So does lower education and lower income, the lowest incomes doubled the risk of death from COVID-19. Area estimates, where the model includes individual risks, show that high population density and a high percentage of foreign-born inhabitants increased the risk of hospitalization., Conclusions: Segregation and deprivation are public health issues elucidated by COVID-19. Neighborhood deprivation, prevalent in Stockholm, adds to individual risks and is associated with hospitalization and death. This finding is paramount for governments, agencies, and healthcare institutions interested in targeted interventions., (© 2022. The Author(s).)

Background: Baricitinib and dexamethasone have randomised trials supporting their use for the treatment of patients with COVID-19. We assessed the combination of baricitinib plus remdesivir versus dexamethasone plus remdesivir in preventing progression to mechanical ventilation or death in hospitalised patients with COVID-19., Methods: In this randomised, double-blind, double placebo-controlled trial, patients were enrolled at 67 trial sites in the USA (60 sites), South Korea (two sites), Mexico (two sites), Singapore (two sites), and Japan (one site). Hospitalised adults (≥18 years) with COVID-19 who required supplemental oxygen administered by low-flow (≤15 L/min), high-flow (>15 L/min), or non-invasive mechanical ventilation modalities who met the study eligibility criteria (male or non-pregnant female adults ≥18 years old with laboratory-confirmed SARS-CoV-2 infection) were enrolled in the study. Patients were randomly assigned (1:1) to receive either baricitinib, remdesivir, and placebo, or dexamethasone, remdesivir, and placebo using a permuted block design. Randomisation was stratified by study site and baseline ordinal score at enrolment. All patients received remdesivir (≤10 days) and either baricitinib (or matching oral placebo) for a maximum of 14 days or dexamethasone (or matching intravenous placebo) for a maximum of 10 days. The primary outcome was the difference in mechanical ventilation-free survival by day 29 between the two treatment groups in the modified intention-to-treat population. Safety analyses were done in the as-treated population, comprising all participants who received one dose of the study drug. The trial is registered with ClinicalTrials.gov, NCT04640168., Findings: Between Dec 1, 2020, and April 13, 2021, 1047 patients were assessed for eligibility. 1010 patients were enrolled and randomly assigned, 516 (51%) to baricitinib plus remdesivir plus placebo and 494 (49%) to dexamethasone plus remdesivir plus placebo. The mean age of the patients was 58·3 years (SD 14·0) and 590 (58%) of 1010 patients were male. 588 (58%) of 1010 patients were White, 188 (19%) were Black, 70 (7%) were Asian, and 18 (2%) were American Indian or Alaska Native. 347 (34%) of 1010 patients were Hispanic or Latino. Mechanical ventilation-free survival by day 29 was similar between the study groups (Kaplan-Meier estimates of 87·0% [95% CI 83·7 to 89·6] in the baricitinib plus remdesivir plus placebo group and 87·6% [84·2 to 90·3] in the dexamethasone plus remdesivir plus placebo group; risk difference 0·6 [95% CI -3·6 to 4·8]; p=0·91). The odds ratio for improved status in the dexamethasone plus remdesivir plus placebo group compared with the baricitinib plus remdesivir plus placebo group was 1·01 (95% CI 0·80 to 1·27). At least one adverse event occurred in 149 (30%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 179 (37%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·5% [1·6 to 13·3]; p=0·014). 21 (4%) of 503 patients in the baricitinib plus remdesivir plus placebo group had at least one treatment-related adverse event versus 49 (10%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 6·0% [2·8 to 9·3]; p=0·00041). Severe or life-threatening grade 3 or 4 adverse events occurred in 143 (28%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 174 (36%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·7% [1·8 to 13·4]; p=0·012)., Interpretation: In hospitalised patients with COVID-19 requiring supplemental oxygen by low-flow, high-flow, or non-invasive ventilation, baricitinib plus remdesivir and dexamethasone plus remdesivir resulted in similar mechanical ventilation-free survival by day 29, but dexamethasone was associated with significantly more adverse events, treatment-related adverse events, and severe or life-threatening adverse events. A more individually tailored choice of immunomodulation now appears possible, where side-effect profile, ease of administration, cost, and patient comorbidities can all be considered., Funding: National Institute of Allergy and Infectious Diseases., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Increased adiposity and visceral obesity have been linked to adverse COVID-19 outcomes. The amount of epicardial adipose tissue (EAT) may have relevant implications given its proximity to the heart and lungs. Here, we explored the role of EAT in increasing the risk for COVID-19 adverse outcomes., Methods: We included 748 patients with COVID-19 attending a reference center in Mexico City. EAT thickness, sub-thoracic and extra-pericardial fat were measured using thoracic CT scans. We explored the association of each thoracic adipose tissue compartment with COVID-19 mortality and severe COVID-19 (defined as mortality and need for invasive mechanical ventilation), according to the presence or absence of obesity. Mediation analyses evaluated the role of EAT in facilitating the effect of age, body mass index and cardiac troponin levels with COVID-19 outcomes., Results: EAT thickness was associated with increased risk of COVID-19 mortality (HR 1.18, 95% CI 1.01-1.39) independent of age, gender, comorbid conditions and BMI. Increased EAT was associated with lower SpO2 and PaFi index and higher levels of cardiac troponins, D-dimer, fibrinogen, C-reactive protein, and 4 C severity score, independent of obesity. EAT mediated 13.1% (95% CI 3.67-28.0%) and 5.1% (95% CI 0.19-14.0%) of the effect of age and 19.4% (95% CI 4.67-63.0%) and 12.8% (95% CI 0.03-46.0%) of the effect of BMI on requirement for intubation and mortality, respectively. EAT also mediated the effect of increased cardiac troponins on myocardial infarction during COVID-19., Conclusion: EAT is an independent risk factor for severe COVID-19 and mortality independent of obesity. EAT partly mediates the effect of age and BMI and increased cardiac troponins on adverse COVID-19 outcomes., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

The horn fly, Haematobia irritans, is a blood-feeding parasitic fly with a global distribution that includes Europe, Africa, Asia, and the Americas. The fly has a major detrimental economic impact upon cattle production, with losses estimated at over $800 million annually in the United States and $2.5 billion in Brazil alone. Insecticide resistance in specific horn fly populations has been a problem for many years and there are several mechanisms whereby resistance develops. Little is known about the complement of metabolic enzymes encoded by the horn fly's genome that might provide the fly with detoxification or sequestration pathways to survive insecticide treatments. The cytochrome P450, glutathione S-transferase, and esterase enzyme families contain members that are capable of sequestering and/or detoxifying xenobiotic molecules such as insecticides. We sought to develop a comprehensive dataset of metabolic enzyme-encoding transcript sequences from the adult horn fly, as this is the life stage whose actions directly impose the economic costs to cattle producers. We used an Illumina paired-end read RNA-Seq approach to determine the adult horn fly transcriptomes from laboratory and field populations of horn flies with varying levels of pesticide resistance, including untreated and pyrethroid-treated newly eclosed adult flies. We followed with bioinformatic analyses to discern sequences putatively encoding cytochrome P450, esterase, and GST enzymes. We utilized read-mapping of RNA-Seq data and quantitative real-time polymerase chain reaction (qRT-PCR) to examine gene expression levels of specific P450 transcripts in several fly populations with varying degrees of pesticide resistance., (Published by Elsevier B.V.)

Background: There is a need for evidence that residency training in family medicine can benefit the care of patients in primary care in low- and middle-income countries. We tested the hypothesis that two years of residency training in family medicine enables doctors to better detect chronic health conditions while requesting fewer laboratory tests and providing more follow-up visits., Methods: We performed a retrospective longitudinal observational analysis of medical consultations from 2013 to 2018 in primary care in Rio de Janeiro, comparing doctors without residency training in family medicine (Generalists) versus family physicians (FPs). Multivariate multilevel binomial regression models estimated the risks of patients being diagnosed for a list of 31 chronic health conditions, having a follow-up visit for these conditions, and having laboratory tests ordered from a list of 30 exams., Results: 569.289 patients had 2.908.864 medical consultations performed by 734 generalists and 231 FPs. Patients seen by FPs were at a higher risk of being detected for most of the chronic health conditions, at a lower risk of having any of the 30 laboratory tests requested, and at a higher risk of having a follow-up visit in primary care., Conclusions: Residency training in family medicine can make physicians more skilled to work in primary care. Policymakers must prioritize investments in capacity building of healthcare workforce to make primary care truly comprehensive., (© 2021. The Author(s).)

Introduction: Reducing avoidable hospital admissions is often viewed as a possible positive consequence of introducing integrated care (IC). The aim of this study was to investigate the impact of implementing IC in Norrtälje on the rate of admissions for ambulatory care sensitive conditions (ACSC)., Method: Using interrupted time series analyses we investigated the effect of implementing IC in Norrtälje municipality in the northern part of Stockholm county, Sweden. The time period included 48 time points, from year 2000 to year 2011 with measurements before and after introducing IC in Norrtälje in 2006. In order to control for other extraneous events that could affect the outcome measure, but not related to the introduction of IC, we included a control population from Stockholm municipality., Results: After introducing IC in Norrtälje the rate of admissions for ACSC decreased. This decrease was greater in Norrtälje than in the matched control population, however the difference between the two areas was not statistically significant (p = 0.08)., Conclusion: Introducing IC in Norrtälje may have had positive impact on admissions for ACSC for older people living in Norrtälje; however, the interpretation of the impact of IC on admissions for ACSC is complicated by intervening policy changes in health and social care during the study period., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background: During the COVID-19 pandemic, risk stratification has been used to decide patient eligibility for inpatient, critical and domiciliary care. Here, we sought to validate the MSL-COVID-19 score, originally developed to predict COVID-19 mortality in Mexicans. Also, an adaptation of the formula is proposed for the prediction of COVID-19 severity in a triage setting (Nutri-CoV)., Methods: We included patients evaluated from March 16th to August 17th, 2020 at the Instituto Nacional de Ciencias Médicas y Nutrición, defining severe COVID-19 as a composite of death, ICU admission or requirement for intubation (n = 3,007). We validated MSL-COVID-19 for prediction of mortality and severe disease. Using Elastic Net Cox regression, we trained (n = 1,831) and validated (n = 1,176) a model for prediction of severe COVID-19 using MSL-COVID-19 along with clinical assessments obtained at a triage setting., Results: The variables included in MSL-COVID-19 are: pneumonia, early onset type 2 diabetes, age > 65 years, chronic kidney disease, any form of immunosuppression, COPD, obesity, diabetes, and age <40 years. MSL-COVID-19 had good performance to predict COVID-19 mortality (c-statistic = 0.722, 95%CI 0.690-0.753) and severity (c-statistic = 0.777, 95%CI 0.753-0.801). The Nutri-CoV score includes the MSL-COVID-19 plus respiratory rate, and pulse oximetry. This tool had better performance in both training (c-statistic = 0.797, 95%CI 0.765-0.826) and validation cohorts (c-statistic = 0.772, 95%CI 0.0.745-0.800) compared to other severity scores., Conclusions: MSL-COVID-19 predicts inpatient COVID-19 lethality. The Nutri-CoV score is an adaptation of MSL-COVID-19 to be used in a triage environment. Both scores have been deployed as web-based tools for clinical use in a triage setting., Competing Interests: The authors have declared that no competing interests exist.

The objectives of this study were to evaluate the resistance of Amblyomma mixtum and Rhipicephalus microplus ticks from co-infested bovines from the Veracruz region in Mexico to different acaricide families and to demonstrate the viability of the packet test on different A. mixtum instars. The following acaricide families were used: a combination (cypermethrin 15 g + chlorpyrifos 25 g + citronella 1 g + butoxide piperonyl 15 g), amidine (formamidine 12.5 g), pyrethroid (cypermethrin 15 g), and organophosphate (dichlorvos 60 g + chlorpyrifos 20 g). Regarding the packet test in both species, resistance was found for the pyrethroid and amidine families in A. mixtum and R. microplus, as efficacy did not surpass 40 %, including in immature instars; regarding the adult immersion test in R. microplus, the efficacy was 93.3 % for the amidine family and 26.2 % for the pyrethroid family. The proposed methodology is an alternative technique to optimize resistance detection in immature ticks with a heteroxenous life cycle., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The continuous growth of the current dementia epidemic is contingent on the stability of age- and sex-specific trends over time. However, recent evidence suggests declining or stable trends. The aim of this study was to evaluate the real-world changes in the burden of dementia in older adults in Sweden from 1987 to 2016 by estimating age- and sex-specific incidence of dementia diagnosis in hospital inpatient records (dementia incidence). Differences in trends by sex, age, and educational levels were also examined., Methods: The entire Swedish population aged 65 years and older was followed up from 1987 to 2016. Age-, sex-, and education-stratified dementia incidence rates for every follow-up year were estimated using the National Patient Register. Hazard ratio of receiving a dementia diagnosis in the inpatient records per 1 calendar year increase was estimated with discrete time logistic models with a complementary log-log link., Results: After increase, especially in those >85 years of age, dementia incidence started to decrease in the last 5 years of the study period. After 2011, 1 calendar year increase was associated with lower hazard ratio of receiving a hospital diagnosis of dementia. The decrease had the highest magnitude in 70-74-year-olds (-5.5%), followed by 75-79-year-olds (-4.5%) and 80-84-year-olds (-4.0%). The decrease was present in both sexes and at all educational levels up to 90 years of age. Age was associated with the level of dementia incidence, and the trends differed by age group. Educational gradient was observed. University-educated older adults had the lowest rates of dementia. However, the trend over time did not substantially differ by sex or educational level., Conclusion: Our results provide more evidence that dementia incidence may be declining. They also suggest that at least in hospitals, the number of new patients with dementia may decrease in the future., Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Aim: To determine the relationship between parity, glycemic control, cardiovascular risk factors and diabetes-related chronic complications in women with type 1 diabetes., Methods: This was a multicenter cross-sectional study conducted between December 2008 and December 2010 in 28 public clinics in 20 cities from the 4 Brazilian geographic regions. Data were obtained from 1532 female patients, 59.2% Caucasians, and aged 25.2 ± 10.6 years. Diabetes duration was of 11.5 ± 8.2 years. Patient's information was obtained through a questionnaire and a chart review. Parity was stratified in five groups: Group 0 (nulliparous), group 1 (1 pregnancy), group 2 (2 pregnancies), group 3 (3 pregnancies), group 4 (≥ 4 pregnancies). Test for trend and multivariate random intercept logistic and linear regression models were used to evaluate the effect of parity upon glycemic control, cardiovascular risk factors and diabetes-related complications., Results: Parity was not related with glycemic control and nephropathy. Moreover, the effect of parity upon hypertension, retinopathy and macrovascular disease did not persist after adjustments for demographic and clinical variables in multivariate analysis. For retinopathy, the duration of diabetes and hypertension were the most important independent variables and for macrovascular disease, these variables were age and hypertension. Overweight or obesity was noted in a total of 538 patients (35.1%). A linear association was found between the frequency of overweight or obesity and parity (P = 0.004). Using a random intercept multivariate linear regression model with body mass index (BMI) as dependent variable a borderline effect for parity (P = 0.06) was noted after adjustment for clinical and demographic data. The observed variability of BMI was not attributable to differences between centers., Conclusion: Our results suggest that parity has a borderline effect on body mass index but does not have an important effect upon hypertension and micro or macrovascular chronic complications. Future prospective evaluations must be conducted to clarify the relationship between parity, appearance or worsening of diabetes-related chronic complications.

Objective: To analyze the impact of air pollution on respiratory and cardiovascular morbidity of children and adults in the city of Vitoria, state of Espirito Santo., Methods: A study was carried out using time-series models via Poisson regression from hospitalization and pollutant data in Vitoria, ES, Southeastern Brazil, from 2001 to 2006. Fine particulate matter (PM10), sulfur dioxide (SO2), and ozone (O3) were tested as independent variables in simple and cumulative lags of up to five days. Temperature, humidity and variables indicating weekdays and city holidays were added as control variables in the models., Results: For each increment of 10 µg/m3 of the pollutants PM10, SO2, and O3, the percentage of relative risk (%RR) for hospitalizations due to total respiratory diseases increased 9.67 (95%CI 11.84-7.54), 6.98 (95%CI 9.98-4.17) and 1.93 (95%CI 2.95-0.93), respectively. We found %RR = 6.60 (95%CI 9.53-3.75), %RR = 5.19 (95%CI 9.01-1.5), and %RR = 3.68 (95%CI 5.07-2.31) for respiratory diseases in children under the age of five years for PM10, SO2, and O3, respectively. Cardiovascular diseases showed a significant relationship with O3, with %RR = 2.11 (95%CI 3.18-1.06)., Conclusions: Respiratory diseases presented a stronger and more consistent relationship with the pollutants researched in Vitoria. A better dose-response relationship was observed when using cumulative lags in polynomial distributed lag models.

Background: Socioeconomic status (SES) can greatly affect the clinical outcome of medical problems. We sought to assess the in-hospital mortality of patients with the acute coronary syndrome (ACS) according to their SES., Methods: All patients admitted to Tehran Heart Center due to 1(st)-time ACS between March 2004 and August 2011 were assessed. The patients who were illiterate/lowly educated (≤5 years attained education) and were unemployed were considered low-SES patients and those who were employed and had high educational levels (>5 years attained education) were regarded as high-SES patients. Demographic, clinical, paraclinical, and in-hospital medical progress data were recorded. Death during the course of hospitalization was considered the end point, and the impact of SES on in-hospital mortality was evaluated., Results: A total of 6246 hospitalized patients (3290 low SES and 2956 high SES) were included (mean age = 60.3 ± 12.1 years, male = 2772 [44.4%]). Among them, 79 (1.26%) patients died. Univariable analysis showed a significantly higher mortality rate in the low-SES group (1.9% vs. 0.6%; P < 0.001). After adjustment for possible cofounders, SES still showed a significant effect on the in-hospital mortality of the ACS patients in that the high-SES patients had a lower in-hospital mortality rate (odds ratio: 0.304, 95% confidence interval: 0.094-0.980; P = 0.046)., Conclusions: This study found that patients with low SES were at a higher risk of in-hospital mortality due to the ACS. Furthermore, the results suggest the need for increased availability of jobs as well as improved levels of education as preventive measures to curb the unfolding deaths owing to coronary artery syndrome.

Background: School children are confined to and exposed to outdoor environment that happens to be at their disposal during compulsory school time. The health-promoting potential of outdoor environment, and the use of it, is therefore important. We have studied the impact of school outdoor environment in terms of playground features, space, topography and vegetation upon the patterns of moderate to vigorous physical activity (MVPA) across ages and seasons in Swedish pupils at compulsory school., Methods: Four schools in the Middle and Southern parts of Sweden, with outdoor environments differing in playground features, space, topography and vegetation were analyzed during one school year. A sample of 196 children was drawn from eligible pupils in grades 2, 5 and 8, aged 7-14 years. PA was monitored with time-stamped Actigraph accelerometers GT3X+, measuring different intensity levels during outdoor time. Maps were used to mark places where the children stayed and what they did during outdoor time., Results: Mean MVPA during outdoor stay was 39 minutes for the entire school year, time in MVPA correlated positively with outdoor time, as did MVPA with used outdoor play area (p < 0.001). Outdoor MVPA declined with age, boys accumulated more MVPA than girls at all ages (p < 0.001). Ball play areas increased MVPA in 5th graders in September and May (p < 0.001). Overall, ball play areas increased 5th graders' relative MVPA, and helped maintaining it with increasing age in boys but not in girls, whereas woodland stimulated and contributed to maintaining girls' MVPA with increasing age. Outdoor temperature significantly impacted (p < 0.01) MVPA throughout all seasons., Conclusion: We conclude that school outdoor environment design and outdoor play time impact physical activity on a daily basis and may contribute to increasing girls' physical activity and moderate the sharp decline in physical activity by age. The school outdoor environment may thus be a potential health promoter during school time.

Background: Childhood sexual abuse (CSA) is a substantial global health and human rights problem and consequently a growing concern in sub-Saharan Africa. We examined the association between individual and community-level socioeconomic status (SES) and the likelihood of reporting CSA., Methods: We applied multiple multilevel logistic regression analysis on Demographic and Health Survey data for 6,351 female adolescents between the ages of 15 and 18 years from six countries in sub-Saharan Africa, between 2006 and 2008., Results: About 70% of the reported cases of CSA were between 14 and 17 years. Zambia had the highest proportion of reported cases of CSA (5.8%). At the individual and community level, we found that there was no association between CSA and socioeconomic position. This study provides evidence that the likelihood of reporting CSA cut across all individual SES as well as all community socioeconomic strata., Conclusions: We found no evidence of socioeconomic differentials in adolescents' experience of CSA, suggesting that adolescents from the six countries studied experienced CSA regardless of their individual- and community-level socioeconomic position. However, we found some evidence of geographical clustering, adolescents in the same community are subject to common contextual influences. Further studies are needed to explore possible effects of countries' political, social, economic, legal, and cultural impact on childhood sexual abuse., (© 2014 KUMS, All rights reserved.)

Objective: To investigate the effect of five dimensions of social relationships on obesity and potential sex differences in these associations., Design and Methods: This study used longitudinal data from the Swedish Level of Living Surveys (LNU) in 1991 and 2000. The sample included 3,586 individuals. The dimensions of social relationships examined in this study include emotional support, frequency of visiting friends, marital status, marital status changes, and a Social Relationships Index (SRI). Obesity status was based on BMI (kg/m(2)) and calculated with self-reported measurements. The association between social relationships and the incidence of obesity after 9 years of follow-up was evaluated through Poisson regressions., Results: After controlling for confounders, we found that the lack of emotional support (RR = 1.98; 95% CI, 1.1-4.6) influenced the incidence of obesity among men. In addition, men with the lowest levels of SRI (RR = 2.22; 95% CI, 1.1-4.4) had an increased risk of being obese. Among women, SRI was not significantly associated with obesity. Women who changed their marital status from married to unmarried had lower risk of obesity (RR = 0.39; 95% CI, 0.2-0.9)., Conclusions: This study provides evidence for the effect of social relationships on the incidence of obesity, with significant differences by sex., (Copyright © 2013 The Obesity Society.)

Background: Gender differences in mortality vary widely between countries and over time, but few studies have examined predictors of these variations, apart from smoking. The aim of this study is to investigate the link between gender policy and the gender gap in cause-specific mortality, adjusted for economic factors and health behaviours., Methods: 22 OECD countries were followed 1973-2008 and the outcomes were gender gaps in external cause and circulatory disease mortality. A previously found country cluster solution was used, which includes indicators on taxes, parental leave, pensions, social insurances and social services in kind. Male breadwinner countries were made reference group and compared to earner-carer, compensatory breadwinner, and universal citizen countries. Specific policies were also analysed. Mixed effect models were used, where years were the level 1-units, and countries were the level 2-units., Results: Both the earner-carer cluster (ns after adjustment for GDP) and policies characteristic of that cluster are associated with smaller gender differences in external causes, particularly due to an association with increased female mortality. Cluster differences in the gender gap in circulatory disease mortality are the result of a larger relative decrease of male mortality in the compensatory breadwinner cluster and the earner-carer cluster. Policies characteristic of those clusters were however generally related to increased mortality., Conclusion: Results for external cause mortality are in concordance with the hypothesis that women become more exposed to risks of accident and violence when they are economically more active. For circulatory disease mortality, results differ depending on approach--cluster or indicator. Whether cluster differences not explained by specific policies reflect other welfare policies or unrelated societal trends is an open question. Recommendations for further studies are made.

Introduction: The ESCALA* project (Estudio de Salud y Contaminación del Aire en Latinoamérica) is an HEI-funded study that aims to examine the association between exposure to outdoor air pollution and mortality in nine Latin American cities, using a common analytic framework to obtain comparable and updated information on the effects of air pollution on several causes of death in different age groups. This report summarizes the work conducted between 2006 and 2009, describes the methodologic issues addressed during project development, and presents city-specific results of meta-analyses and meta-regression analyses., Methods: The ESCALA project involved three teams of investigators responsible for collection and analysis of city-specific air pollution and mortality data from three different countries. The teams designed five different protocols to standardize the methods of data collection and analysis that would be used to evaluate the effects of air pollution on mortality (see Appendices B-F). By following the same protocols, the investigators could directly compare the results among cities. The analysis was conducted in two stages. The first stage included analyses of all-natural-cause and cause-specific mortality related to particulate matter < or = 10 pm in aerodynamic diameter (PM10) and to ozone (O3) in cities of Brazil, Chile, and México. Analyses for PM10 and O3 were also stratified by age group and O3 analyses were stratified by season. Generalized linear models (GLM) in Poisson regression were used to fit the time-series data. Time trends and seasonality were modeled using natural splines with 3, 6, 9, or 12 degrees of freedom (df) per year. Temperature and humidity were also modeled using natural splines, initially with 3 or 6 df, and then with degrees of freedom chosen on the basis of residual diagnostics (i.e., partial autocorrelation function [PACF], periodograms, and a Q-Q plot) (Appendix H, available on the HEI Web site). Indicator variables for day-of-week and holidays were used to account for short-term cyclic fluctuations. To assess the association between exposure to air pollution and risk of death, the PM10 and O3 data were fit using distributed lag models (DLMs). These models are based on findings indicating that the health effects associated with air pollutant concentrations on a given day may accumulate over several subsequent days. Each DLM measured the cumulative effect of a pollutant concentration on a given day (day 0) and that day's contribution to the effect of that pollutant on multiple subsequent (lagged) days. For this study, exposure lags of up to 3, 5, and 10 days were explored. However, only the results of the DLMs using a 3-day lag (DLM 0-3) are presented in this report because we found a decreasing association with mortality in various age-cause groups for increasing lag effects from 3 to 5 days for both PM10 and O3. The potential modifying effect of socioeconomic status (SES) on the association of PM10 or O3 concentration and mortality was also explored in four cities: Mexico City, Rio de Janeiro, São Paulo, and Santiago. The methodology for developing a common SES index is presented in the report. The second stage included meta-analyses and metaregression. During this stage, the associations between mortality and air pollution were compared among cities to evaluate the presence of heterogeneity and to explore city-level variables that might explain this heterogeneity. Meta-analyses were conducted to combine mortality effect estimates across cities and to evaluate the presence of heterogeneity among city results, whereas meta-regression models were used to explore variables that might explain the heterogeneity among cities in mortality risks associated with exposures to PM10 (but not to O3)., Results: The results of the mortality analyses are presented as risk percent changes (RPC) with a 95% confidence interval (CI). RPC is the increase in mortality risk associated with an increase of 10 microg/m3 in the 24-hour average concentration of PM10 or in the daily maximum 8-hour moving average concentration of O3. Most of the results for PM10 were positive and statistically significant, showing an increased risk of mortality with increased ambient concentrations. Results for O3 also showed a statistically significant increase in mortality in the cities with available data. With the distributed lag model, DLM 0-3, PM10 ambient concentrations were associated with an increased risk of mortality in all cities except Concepci6n and Temuco. In Mexico City and Santiago the RPC and 95% CIs were 1.02% (0.87 to 1.17) and 0.48% (0.35 to 0.61), respectively. PM10 was also significantly associated with increased mortality from cardiopulmonary, respiratory, cardiovascular, cerebrovascular-stroke, and chronic obstructive lung diseases (COPD) in most cities. The few nonsignificant effects generally were observed in the smallest cities (Concepción, Temuco, and Toluca). The percentage increases in mortality associated with ambient O3 concentrations were smaller than for those associated with PM10. All-natural-cause mortality was significantly related to O3 in Mexico City, Monterrey, São Paulo and Rio de Janeiro. Increased mortality risks for some specific causes were also observed in these cities and in Santiago. In the analyses stratified by season, different patterns in mortality and O3 were observed for cold and warm seasons. Risk estimates for the warm season were larger and significant for several causes of death in São Paulo and Rio de Janeiro. Risk estimates for the cold season were larger and significant for some causes of death in Mexico City, Monterrey, and Toluca. In an analysis stratified by SES, the all-natural-cause mortality risk in Mexico City was larger for people with a medium SES; however we observed that the risk of mortality related to respiratory causes was larger among people with a low SES, while the risk of mortality related to cardiovascular and cerebrovascular-stroke causes was larger among people with medium or high SES. In São Paulo, the all-natural-cause mortality risk was larger in people with a high SES, while in Rio de Janeiro the all-natural-cause mortality risk was larger in people with a low SES. In both Brazilian cities, the risks of mortality were larger for respiratory causes, especially for the low- and high-SES groups. In Santiago, all-natural-cause mortality risk did not vary with level of SES; however, people with a low SES had a higher respiratory mortality risk, particularly for COPD. People with a medium SES had larger risks of mortality from cardiovascular and cerebrovascular-stroke disease. The effect of ambient PM10 concentrations on infant and child mortality from respiratory causes and lower respiratory infection (LRI) was studied only for Mexico City, Santiago, and São Paulo. Significant increased mortality risk from these causes was observed in both Santiago (in infants and older children) and Mexico City (only in infants). For O3, an increased mortality risk was observed in Mexico City (in infants and older children) and in São Paulo (only in infants during the warm season). The results of the meta-analyses confirmed the positive and statistically significant association between PM10 and all-natural-cause mortality (RPC = 0.77% [95% CI: 0.60 to 1.00]) using the random-effects model. For mortality from specific causes, the percentage increase in mortality ranged from 0.72% (0.54 to 0.89) for cardiovascular disease to 2.44% (1.36 to 3.59) for COPD, also using the random-effects model. For O3, significant positive associations were observed using the random-effects model for some causes, but not for all natural causes or for respiratory diseases in people 65 years or older (> or = 65 years), and not for COPD and cerebrovascular-stroke in the all-age and the > or = 65 age groups. The percentage increase in all-natural-cause mortality was 0.16% (-0.02 to 0.33). In the meta-regression analyses, variables that best explained heterogeneity in mortality risks among cities were the mean average of temperature in the warm season, population percentage of infants (< 1 year), population percentage of children at least 1 year old but < 5 years (i.e., 1-4 years), population percentage of people > or = 65 years, geographic density of PM10 monitors, annual average concentrations of PM10, and mortality rates for lung cancer., Conclusions: The ESCALA project was undertaken to obtain information for assessing the effects of air pollutants on mortality in Latin America, where large populations are exposed to relatively high levels of ambient air pollution. An important goal was to provide evidence that could inform policies for controlling air pollution in Latin America. This project included the development of standardized protocols for data collection and for statistical analyses as well as statistical analytic programs (routines developed in R by the ESCALA team) to insure comparability of results. The analytic approach and statistical programming developed within this project should be of value for researchers carrying out single-city analyses and should facilitate the inclusion of additional Latin American cities within the ESCALA multicity project. Our analyses confirm what has been observed in other parts of the world regarding the effects of ambient PM10 and 03 concentrations on daily mortality. They also suggest that SES plays a role in the susceptibility of a population to air pollution; people with a lower SES appeared to have an increased risk of death from respiratory causes, particularly COPD. Compared with the general population, infants and young children appeared to be more susceptible to both PM10 and O3, although an increased risk of mortality was not observed in these age groups in all cities. (ABSTRACT TRUNCATED)

Low cardiorespiratory (CRF) is associated with health problems in elderly people, especially cardiovascular and metabolic disease. However, physical limitations in this population frequently preclude the application of aerobic tests. We developed a model to estimate CRF without aerobic testing in older men with chronic cardiovascular and metabolic diseases. Subjects aged from 60 to 91 years were randomly assigned into validation (n = 67) and cross-validation (n = 29) groups. A hierarchical linear regression model included age, self-reported fitness, and handgrip strength normalized to body weight (R(2) = 0.79; SEE = 1.1 METs). The PRESS (predicted residual sum of squares) statistics revealed minimal shrinkage in relation to the original model and that predicted by the model and actual CRF correlated well in the cross-validation group (r = 0.85). The area under curve (AUC) values suggested a good accuracy of the model to detect disability in the validation (0.876, 95% CI: 0.793-0.959) and cross-validation groups (0.826, 95% CI: 0.677-0.975). Our findings suggest that CRF can be reliably estimated without exercise test in unhealthy elderly men.

Background: Given gender differences in the risk of coronary artery disease (CAD), the present study sought to investigate these dissimilarities amongst patients who underwent angiography at a major, tertiary heart hospital in Iran., Methods: Between 2005 and 2010, 44,820 patients who underwent coronary angiography were enrolled in a registry. Pre-procedural data such as demographics, CAD risk factors, presenting symptoms, and laboratory tests, as well as post-procedural data were collected. The data were, subsequently, compared between the men and women., Results: Out of the 44,820 patients (16,378 women), who underwent coronary angiography, 37,358 patients (11,995 women) had CAD. Amongst the CAD patients, the females were not only significantly older, less educated, and more overweight than were the males but also had higher levels of triglyceride, cholesterol, low-density lipoprotein, high-density lipoprotein, and fasting blood sugar (P< 0.001). Of all the risk factors, hypertension and diabetes mellitus showed the strongest association in our female CAD patients (OR=3.45, 95%CI: 3.28-3.61 and OR=2.37, 95%CI: 2.26-2.48, respectively). Acute coronary syndrome was more prevalent in the men (76.1% vs. 68.6%, P< 0.001), and chronic stable angina was more frequent in the females (31.4% vs. 23.9%, P< 0.001). With respect to post-procedural recommendations, the frequency of recommendations for non-invasive modalities was higher in the females (20.1% vs. 18.6%, P< 0.001)., Conclusion: Hypertension and diabetes mellitus had the strongest association with CAD in our female patients. In the extensive CAD patients, medical treatment was recommended to the women more often.

Background: Childhood sexual abuse (CSA) is a problem of considerable proportion in Africa where up to one-third of adolescent girls report their first sexual experience as being forced. The impact of child hood sexual abuse resonates in all areas of health. The aim of this study was to describe the prevalence of childhood sexual abuse and variations across socioeconomic status in six sub-Saharan countries., Methods: Datasets from Demographic and Health Surveys (DHS) in six sub-Saharan African countries conducted between 2003 and 2007 were used to access the relationship between CSA and socio economic status using multiple logistic regression models., Results: There was no association between CSA and education, wealth and area of settlement. However, there was contrasting association between CSA and working status of women., Conclusion: This study concurs with other western studies which indicate that CSA transcends across all socio economic group. It is therefore important that effective preventive strategies are developed and implemented that will cross across all socio-economic groups.

Background: The gap between evidence-based guidelines for clinical care and their use in medical settings is well recognized and widespread. Only a few implementation studies of psychiatric guidelines have been carried out, and there is a lack of studies on their long-term effects.The aim of this study was to measure compliance to clinical guidelines for treatment of patients with depression and patients with suicidal behaviours, two years after an actively supported implementation., Methods: Six psychiatric clinics in Stockholm, Sweden, participated in an implementation of the guidelines. The guidelines were actively implemented at four of them, and the other two only received the guidelines and served as controls. The implementation activities included local implementation teams, seminars, regular feedback, and academic outreach visits. Compliance to guidelines was measured using quality indicators derived from the guidelines. At baseline, measurements of quality indicators, part of the guidelines, were abstracted from medical records in order to analyze the gap between clinical guidelines and current practice. On the basis of this, a series of seminars was conducted to introduce the guidelines according to local needs. Local multidisciplinary teams were established to monitor the process. Data collection took place after 6, 12, and 24 months and a total of 2,165 patient records were included in the study., Results: The documentation of the quality indicators improved from baseline in the four clinics with an active implementation, whereas there were no changes, or a decline, in the two control clinics. The increase was recorded at six months, and persisted over 12 and 24 months., Conclusions: Compliance to the guidelines increased after active implementation and was sustained over the two-year follow-up. These results indicate that active local implementation of clinical guidelines involving clinicians can change behaviour and maintain compliance.

Objective: Whether a high-protein (HP) diet promotes body weight loss (BWL) when compared with a low-protein (LP) diet is still unclear. Therefore, we evaluated the effects of an HP diet on BWL during postpartum., Methods: A food-frequency questionnaire with 81 items was applied at 6 mo after delivery to evaluate the diet of 430 postpartum women aged 18-45 y. Body weight was measured approximately at 0.5, 2, 6, and 9 mo after delivery. Body weight loss was modeled by comparing an HP diet (> or =1.2g . kg(-1) . d(-1)) with an LP diet (<1.2g . kg(-1) . d(-1)) using mixed-effects linear regression models adjusted for energy intake, percentage of body fat at baseline, stature, age, race, smoking, and schooling., Results: Usual energy intake was higher in the HP than in the LP diet group (2623 versus 1791kcal, P<0.0001). Daily mean protein intakes were 1.54+/-0.32g . kg(-1) . d(-1) for the HP group and 0.83+/-0.20g . kg(-1) . d(-1) for the LP group. A multivariate model showed that women in the HP group lost 316+/-0.062g of body weight more per month (P<0.01) when compared with the LP group., Conclusion: A reported higher protein intake may improve moderate postpartum body weight loss. Further studies should evaluate the long-term consequences of an HP diet postpartum.

Background: Multiple control areas and time-series analyses have been recommended for effect evaluations of community-based health promotion. Large fluctuations, maybe due to chance, among the areas and over the years might obscure the intervention effect., Methods: A quasi-experimental time-series analysis with several control areas was performed as an effect evaluation of a community-based elderly safety promotion program. The program was implemented during 1995-99 in a community in the Stockholm Metropolitan area (population +65 years: 5500; number of first hip fractures in 1995: 60). Four control areas were selected based on similar hip fracture-related characteristics as the intervention community, complemented with two larger control areas. The time series covered 6 years pre-intervention (1990-95) and 6 years post-intervention (1996-2001). The study population was divided into two age groups and gender, resulting in 28 panels. The first hip fracture incidence was obtained from the Swedish national in-patient register., Results: The time series revealed no discernible pattern, and conventional analyses showed no conclusive results. A multivariate analysis, examining the time trends by employing the intra-annual and intra-panel variance, revealed the underlying trends in hip fracture rates. Comparisons between predicted numbers of hip fractures in the intervention and control areas was enabled, which resulted in 14 less hip fractures in the intervention community than expected from the control communities. If one extreme value was altered, the result changed considerably., Conclusion: Effect evaluations of community-based health promotion programs using time-series from small communities might give faulty results, if statistical modelling is not employed.

Objective: To assess the relationship between air pollution and acute respiratory disorders in children., Methods: A time series ecological study was carried out in three public health posts in a region of the city of Rio de Janeiro (Southeastern Brazil), between April 2002 and March 2003. Data for PM10, SO2, NO2, CO and O3 were analyzed daily and as closure variables, a total of 45,595 emergency pediatric consultations for respiratory symptoms or specifically for disorders in the upper and lower airways. To control for confounders, other variables were included in the model including those relating to weather, seasonality, temperature, relative air humidity, rain volume, respiratory infections and the calendar effects (such as holidays and weekends). A Poisson regression was applied using generalized counting models to estimate the effects of pollutants and confusing factors., Results: Only O3 had a positive and statistically significant effect, both among emergency consultations for respiratory problems and consultations for symptoms relating to the lower airways. Effect and exposure occurred on the same day (lag 0). A significant negative association was found with CO and pediatric consultations for respiratory complaints. Other air pollutants were not found to have a significant effect., Conclusions: There were found associations between outdoor air pollution and the number of emergency pediatric consultations for respiratory problems in the studied area, in spite of the fact that the levels of all pollutants monitored during the study period were below recommended levels.

Background: Area-based studies of childhood injuries strongly suggest that neighborhood socio-demographic and economic circumstances impact on various - though not all - types of injuries. The primary aim of this study was to investigate the stability over time of the association between area characteristics and childhood injuries of various causes., Methods: Register-based and ecological, the study encompassed Stockholm County's 138 parishes, and considered two time periods (1993-95; 2003-05). Two indices were measured: economic deprivation and social fragmentation, and parishes were allocated to their respective quintile on each index. Data on both unintentional and intentional injuries for children (boys and girls) aged 10-14 and 15-19 respectively were gathered from the County Council's hospital inpatient register. For each period and index, gender, age and cause-specific comparisons were made to assess the rate ratios (with 95% confidence intervals) of being injured using parishes belonging to the best index level as a comparison group. A series of simple and partial Pearson correlations were also calculated to assess the independent contribution of each index., Results: Regardless of time period, there were rather few significant rate ratios and, when they occurred, there were both under and excess risks. For instance, in each period, boys from both age groups living in parishes with the highest levels of economic deprivation had lower rate of injury as a motor vehicle rider. Most strikingly, intentional injuries were more frequent during the second time period and in considerable excess among girls aged 15-19 from more economically deprived areas. Also, during that last period, none of the injury causes correlated significantly with the index of social fragmentation after adjustment for economic deprivation (partial correlation)., Conclusion: Over a ten-year period, differential economic deprivation among parishes has widened more than social fragmentation in Stockholm County. The correlation between those indices is high in both periods of time whilst the association between the levels of each index and injury rates varies depending on group of injuries or time period considered. It is of concern that intentional injuries have increased numerically and are significantly and positively correlated with economic deprivation (net of social fragmentation), in particular among girls.

Objective: To assess the association between preventive care provided in public dental services and young people's oral health., Methods: Oral health data on 4,033 young people aged 15 to 19 years living in 85 municipalities of the state of Rio Grande do Sul, Southern Brazil, were obtained from the national oral health survey "Saúde Bucal Brasil 2003" for the period 2002-2003. The following variables were studied: age, gender, income, education, time elapsed since last dental visit, reason for dental visit, and water fluoridation. Data on dental care services were obtained from the national database of public health services. Statistical analysis was performed using multilevel logistic regression., Results: Youngsters from the 21 municipalities with the lowest preventive care (scaling + fluoride + sealants) rates per 100 inhabitants were 2.27 (95% CI: 1.45;3.56) more likely to have non-filled dental cavities than those from the 21 municipalities with the highest care rates. After adjustment for a number of individual and contextual factors this likelihood decreased to 1.76 (95% CI: 1.13;2.72). The variance attributable to variables at municipal level was 14.1% for the empty model and decreased to 10.5% for the fully adjusted model., Conclusions: Rio Grande do Sul public dental services may have contributed for the reduction in the number of non-filled cavities in young people. However, it was not possible to detect the impact of this service on total dental caries experience.

Aim: Sweden's child injury fatality rates are among the lowest in the world. The country has engaged in a number of community injury-prevention programmes. The purpose of this study was to compare child injury hospitalization rates from the Skaraborg District with the rest of Sweden. Our study hypothesis was that municipalities that offered comprehensive child injury-prevention programmes would see significant decreases in their child injury hospitalization rates, compared with other areas., Methods: The study areas comprised three groups, consisting of municipalities in Skaraborg that had adapted the Safe Communities approach to injury prevention programmes, other municipalities in the District, and the rest of Sweden. The aim of the analysis was twofold: (1) to fit time trends for children's injuries in various areas in an integrated manner; and (2) to compare time trends across locations between community safety-promotion programmes as well as with the control areas. Panel data models and parametric splines were used., Results: There were differences between incidence rates in the study areas and with regard to gender. There was a steep decrease in injury rates in one of the Safe Communities study areas for both genders., Conclusions: The methods applied in this analysis reveal more detailed and sophisticated time trends than the usual simple linear regression approach. The model provided a clearer view of the interactions of gender, area, and time as they impacted on children's injuries, and allowed for better insight into the impact of safety programmes.

Sugarcane workers in Brazil are exposed to various genotoxic compounds, including polycyclic aromatic hydrocarbons (PAHs), derived from an incomplete combustion process of burnt sugarcane fields. The effects of the occupational exposure to sugarcane fields burning were measured in urine samples of sugarcane workers from the northwest of the State of São Paulo when exposed (harvesting) and when non-exposed (non-harvesting). The urinary levels of 1-hydroxypyrene (1-OHP) and the influence of the genetic polymorphisms CYP1A1, GSTM1, GSTT1 and GSTP1 were evaluated. Our results showed that the 1-OHP levels were significantly higher (P<0.0000) in the exposed sugarcane workers (0.318 mumol mol(-1) creatinine) than in the non-exposed workers (0.035 mumol mol(-1) creatinine). In an unvaried analysis, no influence regarding the polymorphisms was observed. However, multivariate regression analysis showed that the CYP1A1()4 polymorphism in the exposed group, and age and the GSTP1 polymorphism in the non-exposed group significantly influenced urinary 1-OHP excretion levels (P<0.10). The same group of sugarcane workers was significantly more exposed to PAHs during the harvesting period than during the non-harvesting period.

Of interest is how some countries have achieved a profound reduction of child injury mortality. Still little is reported on the impact of a combination of urban planning, social welfare development and safety measures. We therefore present trends in childhood (0-14 years) injury mortality in Sweden 1966-2001 and discuss the factors behind any reductions observed. Annual total and cause-specific injury mortality rates were computed by age subgroups and gender. Trend analyses were performed with year as independent and mortality rate as dependent variable. A piecewise linear function was fitted to the annual mortality rates. Data were categorized into five 7-year intervals. In total, there were 5264 deaths due to injury in the study population during the period 1966-2001, of which 3368 (64%) were of boys and 1896 (36%) girls. The most frequent external cause of death was transport injury (48%), drowning (14%), homicide (5.8%), fire (5%), and fall (2.7%). About 66% (n=3474) of deaths occurred during the first half of the study period (1966-1981) with an average incidence rate of mortality 13.0 compared to 5.6 per 100,000 inhabitants during the second half of the period (1982-2001). For total injuries, there was a statistically significant decrease in mortality among all subgroups of children in both sexes. The slopes are greater among the younger children (0-4, 5-9 years) than the older ones (10-14 years). Several factors behind this strong decline of childhood injury mortality of interest to evaluate are (i) the implementation of the functionalist architectural style including transport separation, legislation and safety in cars; (ii) the expansion of public child day-care centers including more organized leisure activities; (iii) the establishment of long-term nationwide mandatory program for swim training among school children and (iv) local child-safety programs considering differences in exposure to risk between urban and rural areas.

Background: The incidence of myocardial infarction (MI) varies among socioeconomic groups, and geographic differences in incidence rates are observed within most urban regions. Whether spatial social differentiation gives rise to social contexts detrimental to health is still an open question. In this study, we evaluate 2 aspects of the neighborhood context as contributory factors in MI: level of economic resources and degree of socioeconomic homogeneity. We adopt a multilevel approach to analyze potential mechanisms, which involve individual social characteristics., Methods: We analyzed data from the SHEEP study, a population-based case-control study of first events of acute MI in Stockholm County in 1992-1994. Data on socioeconomic characteristics in neighborhoods came from total population registers of income and social circumstances., Results: The level of neighborhood socioeconomic resources had a contextual effect on the relative risk of MI after adjustment for individual social characteristics. The incidence rate ratio (IRR) in low-income, compared with high-income, neighborhoods was 1.88 for women and 1.52 for men. Although the degree of socioeconomic homogeneity in neighborhoods has less impact on MI, the IRR for men in homogenous low-income areas compared with men living in heterogeneous high-income areas was 2.65. For men, the combined exposure to low-personal disposable income and low-income level in the neighborhood seemed to have an additive effect but for women, a synergistic (supra-additive) effect was found., Conclusion: The socioeconomic context of neighborhoods has an effect on cardiovascular outcomes.

To determine the diagnostic significance of the kappa/lambda ratio in germinal center (GC) B cells in Hashimoto thyroiditis (HT), we used 4-color flow cytometry to immunophenotype 27 samples (21 patients) of well-characterized HT B-cell clonality was analyzed further by polymerase chain reaction (PCR) of the immunoglobulin heavy chain (IgH) and bcl-2/IgH fusion genes using DNA extracted from aspirate smears and/or paraffin-embedded tissues. By flow cytometric analysis, the CD10+ GC B cells had a higher mean +/- SD kappa/lambda ratio than the CD10- B cells (5.1 +/- 3.3 vs 2.0 +/- 0.8; P < .0001, Student t test). In 18 samples (67%), CD10+ GC B cells had a kappa/lambda ratio greater than 3.07 (the upper limit of kappa/lambda ratio reported in reactive nodes; range, 3.2-14.4 in the 18 cases). Cases tested by PCR showed no evidence of a clonal proliferation. None of 21 cases developed lymphoma during clinical follow-up of up to 3 years. The kappa/lambda ratio of CD10+ GC B cells in HT can be skewed markedly beyond that reported in reactive lymph nodes. This finding frequently is present in HT. Pathologists should be familiar with this phenomenon to prevent misdiagnosis of follicular lymphoma in patients with HT.

A consensus linkage map has been developed in the chicken that combines all of the genotyping data from the three available chicken mapping populations. Genotyping data were contributed by the laboratories that have been using the East Lansing and Compton reference populations and from the Animal Breeding and Genetics Group of the Wageningen University using the Wageningen/Euribrid population. The resulting linkage map of the chicken genome contains 1889 loci. A framework map is presented that contains 480 loci ordered on 50 linkage groups. Framework loci are defined as loci whose order relative to one another is supported by odds greater then 3. The possible positions of the remaining 1409 loci are indicated relative to these framework loci. The total map spans 3800 cM, which is considerably larger than previous estimates for the chicken genome. Furthermore, although the physical size of the chicken genome is threefold smaller then that of mammals, its genetic map is comparable in size to that of most mammals. The map contains 350 markers within expressed sequences, 235 of which represent identified genes or sequences that have significant sequence identity to known genes. This improves the contribution of the chicken linkage map to comparative gene mapping considerably and clearly shows the conservation of large syntenic regions between the human and chicken genomes. The compact physical size of the chicken genome, combined with the large size of its genetic map and the observed degree of conserved synteny, makes the chicken a valuable model organism in the genomics as well as the postgenomics era. The linkage maps, the two-point lod scores, and additional information about the loci are available at web sites in Wageningen (http://www.zod.wau.nl/vf/ research/chicken/frame&#95;chicken.html) and East Lansing (http://poultry.mph.msu.edu/).

There are concerns about the possible short-term effects of outdoor air pollution on health in the United Kingdom. In a study conducted during the time period between 1987 and 1992, investigators determined that ozone had small, but significant effects on emergency respiratory admissions. In the current study, the authors investigated associations between emergency admissions and outdoor air pollution for the time period from 1992 to 1994, inclusive, and compared the results with those obtained in the earlier study. The authors also examined particulate matter less than 10 microm in diameter (PM10) and carbon monoxide in the current study. Appropriate confounding factors, such as seasonal patterns, temperature, and humidity, were controlled for, and the authors used Poisson regression to estimate the association between daily emergency admissions for respiratory and cardiovascular diseases and ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, particles measured as Black Smoke, and PM10. Significant positive associations were found between emergency hospital admissions for respiratory disease and PM10 and sulfur dioxide, but such an association did not exist for ozone. The results were not significantly different from earlier results from London and were comparable with those determined in North America and Europe. Cardiovascular disease was associated with carbon monoxide and Black Smoke, but weaker associations existed with the other pollutants studied.

To determine the factors contributing to tuberculosis incidence in the U.S.-born and foreign-born populations in San Francisco, California, and to assess the effectiveness of tuberculosis control efforts in these populations, we performed a population-based molecular epidemiologic study using 367 patients with strains of Mycobacterium tuberculosis recently introduced into the city. IS6110-based and PGRS-based restriction fragment length polymorphism (RFLP) analyses were performed on M. tuberculosis isolates. Patients whose isolates had identical RFLP patterns were considered a cluster. Review of public health and medical records, plus patient interviews, were used to determine the likelihood of transmission between clustered patients. None of the 252 foreign-born cases was recently infected (within 2 yr) in the city. Nineteen (17%) of 115 U. S.-born cases occurred after recent infection in the city; only two were infected by a foreign-born patient. Disease from recent infection in the city involved either a source or a secondary case with human immunodeficiency virus (HIV) infection, homelessness, or drug abuse. Failure to identify contacts accounted for the majority of secondary cases. In San Francisco, disease from recent transmission of M. tuberculosis has been virtually eliminated from the foreign-born but not from the U.S.-born population. An intensification of contact tracing and screening activities among HIV-infected, homeless, and drug-abusing persons is needed to further control tuberculosis in the U.S.-born population. Elimination of tuberculosis in both the foreign-born and the U.S. -born populations will require widespread use of preventive therapy.

Objective: To test for a significant association between air pollution and emergency hospital admissions for circulatory diseases (international classification of diseases-9 390-459) in London, England, that would be consistent with a causal effect of pollution on the previous day., Methods: Long term concurrent trends, temperature, humidity, day of the week, influenza epidemic of 1989, and cyclical covariations with periodicity > 20 days in daily measures of pollution and admissions for 1987-94 were allowed for., Results: There were 373556 admissions. No association was found between O3 and circulatory diseases. Four other pollutants were associated with acute myocardial infarction and circulatory diseases combined. P values and attributable cases (95% confidence intervals) for acute myocardial infarction were: black smoke P = 0.003, 2.5% (0.8% to 4.3%); NO2 P = 0.002, 2.7% (0.8% to 4.6%); CO P = 0.001, 2.1% (0.7% to 3.5%); and SO2 P = 0.0006, 1.7% (0.7% to 2.6%). There were also associations between black smoke and angina (P = 0.02), NO2 and arrhythmia (P = 0.04), and CO and other circulatory diseases (P = 0.004), but none with heart failure. Acute myocardial infarction was the only diagnosis for which there were significant associations with and without adjustment for cyclical terms. The associations with acute myocardial infarction were significant only in the cool season., Conclusion: Population data were consistent with 1 in 50 heart attacks currently presenting at London hospitals being triggered by outdoor air pollution. Further research is now needed to investigate whether background concentrations of black smoke, NO2, CO, and SO2 are a preventable cause of myocardial infarction. These results, if applied to all myocardial infarctions in the United Kingdom, indicate a potential saving of 6000 heart attacks a year.

The Air Pollution and Health: a European Approach (APHEA) project is a coordinated study of the short-term effects of air pollution on mortality and hospital admissions using data from 15 European cities, with a wide range of geographic, sociodemographic, climatic, and air quality patterns. The objective of this paper is to summarize the results of the short-term effects of ambient oxidants on daily deaths from all causes (excluding accidents). Within the APHEA project, six cities spanning Central and Western Europe provided data on daily deaths and NO2 and/or O3 levels. The data were analyzed by each center separately following a standardized methodology to ensure comparability of results. Poisson autoregressive models allowing for overdispersion were fitted. Fixed effects models were used to pool the individual regression coefficients when there was no evidence of heterogeneity among the cities and random effects models otherwise. Factors possibly correlated with heterogeneity were also investigated. Significant positive associations were found between daily deaths and both NO2 and O3. Increases of 50 micrograms/m3 in NO2 (1-hour maximum) or O3 (1-hour maximum) were associated with a 1.3% (95% confidence interval 0.9-1.8) and 2.9% (95% confidence interval 1.0-4.9) increase in the daily number of deaths, respectively. Stratified analysis of NO2 effects by low and high levels of black smoke or O3 showed no significant evidence for an interaction within each city. However, there was a tendency for larger effects of NO2 in cities with higher levels of black smoke. The pooled estimate for the O3 effect was only slightly reduced, whereas the one for NO2 was almost halved (although it remained significant) when two pollutant models including black smoke were applied. The internal validity (consistency across cities) as well as the external validity (similarities with other published studies) of our results on the O3 effect support the hypothesis of a causal relation between O3 and all cause daily mortality. However, the short-term effects of NO2 on mortality may be confounded by other vehicle-derived pollutants. Thus, the issue of independent NO2 effects requires additional investigation.