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BACKGROUND: Clinical studies have demonstrated improved gradients after aortic valve replacement with the Trifecta (TR) valve (Abbott Cardiovascular, St Paul, MN) as compared with the Carpentier-Edwards Magna Ease (ME) valve (Edwards Lifesciences, Irvine, CA). Clinical benefits of this strategy have not been demonstrated. METHODS: Patients undergoing aortic valve replacement for severe aortic stenosis with either valve were included. Patients were excluded if they underwent concomitant procedures other than coronary artery bypass grafting. Inverse proportion treatment weighting was used in the analysis. The primary outcome was a composite of cardiac mortality, need for reintervention, and freedom from first congestive heart failure (CHF). Secondary outcomes were all-cause mortality, the composite components, and cumulative CHF admission. Follow-up echocardiograms were assessed in a cohort of patients to assess structural valve degeneration. RESULTS: There were 331 patients in the TR group and 360 patients in the ME group. The TR group had more women (48% vs 32%, P < .001) with smaller roots (left ventricular outflow tract diameter: TR, 2.11 cm; ME, 2.17 cm; P < .001). After weighting there was no significant difference in the composite measure between groups (P > .05). There was no difference in all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.42-1.59; P = .56), and 5-year survival was 91.9% in the ME group and 93.4% in the TR group. There was no difference in cardiac death, reintervention, or first onset of CHF or incidence of structural valve degeneration between groups. There was no difference in the rate of admissions for CHF per 100 patients between the 2 valve types (P = .19). CONCLUSIONS: Early hemodynamic benefits have not translated into differences in medium-term clinical outcomes between these 2 valves. Long-term follow-up is necessary.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Pericardio/cirugía , Anciano , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/diagnóstico , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pericardio/diagnóstico por imagen , Diseño de Prótesis , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
BACKGROUND: Pollution may play a role in population trends of declining semen quality and regional differences in time to pregnancy (TTP) in industrialized societies. Dioxins including 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) have been suspected. In 1976, an explosion near Seveso, Italy resulted in the highest TCDD exposure known in residential populations. Twenty years later, we conducted a retrospective cohort study, the Seveso Women's Health Study. METHODS: Of 981 participants, 472 women attempted pregnancy after the explosion, and 278 delivered a livebirth not associated with contraceptive failure. Individual serum TCDD levels were measured from samples collected soon after the explosion and extrapolated to the conception attempt. We examined the relation of TCDD levels to time to pregnancy (parameterized as the monthly probability of conception within the first 12 months of trying) and to infertility (defined as conception after at least 12 months of trying). We modeled fecundability with discrete-time Cox proportional hazards regression, and we modeled fertility with logistic regression. We tested the sensitivity of the conclusions to differing definitions of eligibility and outcome. RESULTS: Median TCDD level was 50 parts per trillion, median time to pregnancy was 2 months, and 17% reported taking 12 or more months to conceive. For every 10-fold increase in serum TCDD, we observed a 25% increase in time to pregnancy (adjusted-fecundability odds ratio = 0.75 [95% confidence interval (CI) = 0.60-0.95]) and about a doubling in odds of infertility (adjusted odds ratio = 1.9 [95% CI = 1.1-3.2]). Results were similar for extrapolated TCDD and sensitivity analyses. CONCLUSIONS: We found dose-related increases in TTP and infertility associated with individual serum TCDD levels in the women from Seveso, Italy. These findings may have implications for fertility in industrialized areas.
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Fertilización/efectos de los fármacos , Dibenzodioxinas Policloradas/sangre , Adolescente , Adulto , Niño , Preescolar , Estudios de Cohortes , Intervalos de Confianza , Femenino , Fertilización/fisiología , Humanos , Lactante , Recién Nacido , Infertilidad Femenina/inducido químicamente , Infertilidad Femenina/epidemiología , Italia/epidemiología , Modelos Logísticos , Oportunidad Relativa , Dibenzodioxinas Policloradas/efectos adversos , Embarazo , Modelos de Riesgos Proporcionales , Liberación Accidental en Seveso/estadística & datos numéricos , Factores de Tiempo , Adulto JovenRESUMEN
The study presents the findings of a population-based survey of the annual incidence of visceral leishmaniasis (VL) in the rural areas of one VL-endemic district in Bihar, India. Stratified multi-stage sampling was applied in the selection of blocks, villages, hamlets, and households. We screened 15 178 households (91 000 individuals) in 80 villages in 7 of 27 administrative blocks of the district, East Champaran. We identified 227 VL cases that occurred in the past 12 months: 149 treated individuals who survived, 14 who died from VL, and 64 active cases. The high-incidence stratum had an estimated incidence of 35.6 cases per 10 000 persons per year (90% CI: 27.7-45.7). The annual incidence rate in the medium stratum areas was 16.8 cases per 10 000 (90% CI: 9.3-30.6). The combined annual incidence rate for the high and medium areas combined was 21.9 cases per 10 000 per year, (90% CI: 14.0-34.2). The Government of India's VL elimination goal is to reduce the VL incidence to one case per 10 000 at the sub-district level; thus, a 35-fold reduction will be required in those areas with the highest VL incidence.
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Enfermedades Endémicas , Leishmaniasis Visceral/epidemiología , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Encuestas Epidemiológicas , Humanos , Incidencia , India/epidemiología , Masculino , Persona de Mediana Edad , Salud Rural/estadística & datos numéricos , Distribución por Sexo , Adulto JovenRESUMEN
INTRODUCTION: Stroke is the third leading cause of death and a leading cause of disability in New York State. A New York study determined that only 19.9% of patients arrived at a designated stroke center within 3 hours of symptom onset. Yet, receiving treatment within 90 minutes of stroke symptom onset is optimal for improved outcomes. Delay in recognition of stroke symptoms and their severity contributes to treatment delay. METHODS: A random-digit-dialed, list-assisted telephone survey about stroke knowledge was administered to 1789 adults aged 30 years or older in upstate New York in 2006. Bivariate and regression analysis were used to examine factors associated with intent to call 9-1-1 for symptoms of stroke. RESULTS: The largest proportion of respondents (72.4%; 95% confidence interval [CI], 69.9%-74.8%) reported they would call 9-1-1 if they noticed they or someone else had difficulty speaking, and the fewest (33.3%; 95% CI, 30.7%-36.0%) respondents reported they would call 9-1-1 for trouble seeing or double vision. Multivariate analysis found that those who had a history of delay in getting medical care in the past 6 months had decreased odds of intending to call 9-1-1 for stroke symptoms (difficulty speaking: adjusted odds ratio [AOR], 0.76; 95% CI, 0.58-1.00; trouble seeing: AOR, 0.69; 95% CI, 0.53-0.91; facial droop: AOR, 0.85; 95% CI, 0.65-1.11; arm weakness: AOR, 0.80; 95% CI, 0.63-1.03). Age, education, and history of a stroke or heart event were not consistently associated with intent to call 9-1-1. CONCLUSION: Survey respondents do not interpret some stroke symptoms as urgent enough to activate the emergency medical system. History of delaying care is a behavioral pattern that influenced intent to call 9-1-1.
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Sistemas de Comunicación entre Servicios de Urgencia , Conocimientos, Actitudes y Práctica en Salud , Accidente Cerebrovascular , Adulto , Distribución por Edad , Anciano , Concienciación , Servicios Médicos de Urgencia , Femenino , Encuestas Epidemiológicas , Humanos , Masculino , Persona de Mediana Edad , New York , Encuestas y CuestionariosRESUMEN
BACKGROUND: Although 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) has been associated with alterations in ovarian function and hormones in animals, it has not been studied in humans. On 10 July 1976, an explosion exposed residents of Seveso, Italy, to the highest levels of TCDD in a population. Twenty years later, we initiated the Seveso Women's Health Study to study reproductive health. OBJECTIVE: We related TCDD levels measured in sera collected near the time of explosion and ovarian function (ovarian cysts, ovarian follicles, ovulation rate, serum hormones) at follow-up. METHODS: We included 363 women who were 20-40 years of age and nonusers of oral contraceptives. We examined the relationship of 1976 serum TCDD levels with ultrasound-detected ovarian follicles among 96 women in the menstrual follicular phase and serum hormone levels (estradiol, progesterone) among 129 women in the menstrual luteal phase at follow-up. Ovulation was defined by serum progesterone levels > 3 ng/mL. RESULTS: The median serum TCDD level was 77.3 ppt, lipid-adjusted. Serum TCDD was not associated with number or size of ovarian follicles. Of women in the luteal phase, 87 (67%) ovulated. Serum log(10)TCDD was not associated with odds of ovulation [adjusted odds ratio = 0.99; 95% confidence interval (CI), 0.5 to 1.9]. Among those who had ovulated, serum log(10)TCDD was not associated with serum progesterone [adjusted beta (adj-beta ) = -0.70; 95% CI, -2.4 to 1.0] or estradiol (adj-beta = -1.81; 95% CI, -10.4 to 6.8). CONCLUSIONS: We found no clear evidence that 1976 TCDD exposure was associated with ovarian function 20 years later in women exposed to relatively high levels in Seveso, Italy.
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Exposición a Riesgos Ambientales , Contaminantes Ambientales/sangre , Ovario/efectos de los fármacos , Dibenzodioxinas Policloradas/sangre , Adulto , Contaminantes Ambientales/toxicidad , Estradiol/sangre , Explosiones , Femenino , Humanos , Italia/epidemiología , Quistes Ováricos/diagnóstico por imagen , Quistes Ováricos/epidemiología , Folículo Ovárico/diagnóstico por imagen , Folículo Ovárico/efectos de los fármacos , Ovario/diagnóstico por imagen , Ovario/fisiología , Ovulación/efectos de los fármacos , Dibenzodioxinas Policloradas/toxicidad , Progesterona/sangre , UltrasonografíaRESUMEN
Despite advancements in our understanding of HIV-1 pathogenesis, critical virus components for immunity, vaccines trials, and drugs development, challenges remain in the fight against HIV-1. Of great importance is the inhibitory function of microbicidal cell penetrating peptides and bacterial toxins that interfere with production and neutralize infection of HIV-1 particles. We demonstrate that the neutralizing activity of a cationic 18 amino acids peptide, is similar to a broadly neutralizing human antibody, and inhibits production of two HIV-1 strains in human cell lines. Pretreatment of cells with bacterial toxins or toxoids derived from enterotoxigenic E. coli, boost subsequent activity of the peptide against HIV-1, to inhibit simultaneously production and infection. The synthetic peptide crosses the cell membrane into the cytoplasm and nucleus. In vitro analysis of a possible target for this peptide revealed specific binding to recombinant HIV-1 gag p24. This is the first demonstration of a synergy between bacterial toxins and a cell-penetrating peptide against HIV-1.
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CONTEXT: Chronic obstructive pulmonary disease (COPD) is recognized as a major healthcare problem in the United States and around the world. OBJECTIVE: This survey regarding initial experience in patients with COPD collected feedback about newly initiated therapy with fluticasone propionate/salmeterol (FSC; ADVAIR DISKUS). DESIGN: Three telephone surveys were conducted; Survey 1 prior to initiating therapy with FSC 250/50, and Surveys 2 and 3 at 2 weeks and 30 days after initiating therapy with FSC 250/50, respectively. SETTING: One thousand primary care physicians recruited outpatients into the trial. PATIENTS: Patients were either newly diagnosed with COPD associated with chronic bronchitis or were still experiencing breathing difficulties on an anticholinergic medication. INTERVENTIONS: Patients initiated FSC 250/50 and received a 1-month supply of FSC 250/50 with an albuterol inhaler for rescue use. MAIN OUTCOME MEASURES: Outcome measures were patient perceptions of satisfaction, compliance, and convenience and changes in breathing on 1 (negative) to 9 (positive) point scales. RESULTS: Five hundred sixteen patients completed all 3 surveys. The mean age was 61 years, 63% were female, and 62% had been diagnosed with COPD associated with chronic bronchitis for 3 years or less (Table 1). CONCLUSION: Patients reported high satisfaction, compliance, and convenience with FSC 250/50 within 2 weeks of initiating therapy, all maintained over the trial period. Additionally, patients had positive changes in breathing, including improvements in the ability to breathe upon awakening in the morning.
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Albuterol/análogos & derivados , Androstadienos/administración & dosificación , Bronquitis Crónica/complicaciones , Satisfacción del Paciente , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Administración por Inhalación , Albuterol/administración & dosificación , Combinación de Medicamentos , Femenino , Combinación Fluticasona-Salmeterol , Humanos , Masculino , Persona de Mediana EdadRESUMEN
2,3,7,8-Tetrachlorobenzo-p-dioxin (TCDD), a halogenated compound that binds the aryl hydrocarbon receptor, is a by-product of numerous industrial processes including waste incineration. Studies in rats and monkeys suggest that TCDD may affect ovarian function. We examined the relationship of TCDD and age at menopause in a population of women residing near Seveso, Italy, in 1976, at the time of a chemical plant explosion. We included 616 of the women who participated 20 years later in the Seveso Women's Health Study. All women were premenopausal at the time of the explosion, had TCDD levels measured in serum collected soon after the explosion, and were > or = 35 years of age at interview. Using proportional hazards modeling, we found a 6% nonsignificant increase in risk of early menopause with a 10-fold increase in serum TCDD. When TCDD levels were categorized, compared with women in the lowest quintile (< 20.4 ppt), women in quintile 2 (20.4-34.2 ppt) had a hazard ratio (HR) of 1.1 (p = 0.77), quintile 3 (34.3-54.1 ppt) had an HR of 1.4 (p = 0.14), quintile 4 (54.2-118 ppt) had an HR of 1.6 (p = 0.10), and quintile 5 (> 118 ppt) had an HR of 1.1 (p = 0.82) for risk of earlier menopause. The trend toward earlier menopause across the first four quintiles is statistically significant (p = 0.04). These results suggest a nonmonotonic dose-related association with increasing risk of earlier menopause up to about 100 ppt TCDD, but not above.
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Contaminantes Ambientales/sangre , Menopausia Prematura/sangre , Dibenzodioxinas Policloradas/sangre , Adolescente , Adulto , Factores de Edad , Industria Química , Niño , Preescolar , Relación Dosis-Respuesta a Droga , Explosiones , Femenino , Humanos , Lactante , Italia/epidemiología , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
OBJECTIVE: This study examined the relation of occupational solvent exposure to menopausal and other symptoms in midlife women. METHODS: We conducted a cross-sectional study of 480 Chinese and 494 white women, aged 40-55 years, in Northern California. Levels of exposure to organic solvents (none, low, medium, or high) were assigned to each current job using a job-exposure matrix. RESULTS: A lower proportion of women with low occupational organic solvent exposure reported hot flashes or night sweats than working women with no solvent exposure (adjusted prevalence odds ratio [APOR] = 0.48, 95% confidence interval [CI] = 0.19-1.21). A greater proportion of women with high solvent exposure reported forgetfulness than women with no exposure (APOR = 2.51, 95% CI = 1.12-5.63). CONCLUSIONS: Some symptom reporting in midlife women was related to their occupational organic solvent exposure.
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Sofocos/inducido químicamente , Menopausia/efectos de los fármacos , Exposición Profesional/efectos adversos , Ocupaciones , Solventes/efectos adversos , Salud de la Mujer , Adulto , California/epidemiología , China/etnología , Estudios Transversales , Femenino , Sofocos/epidemiología , Humanos , Persona de Mediana Edad , PrevalenciaRESUMEN
OBJECTIVE: To study whether dust exposure in California agriculture is a risk factor for respiratory symptoms. METHODS: A population-based survey of 1947 California farmers collected respiratory symptoms, occupational and personal exposures. Associations between dust and respiratory symptoms were assessed by logistic regression models. RESULTS: The prevalence of persistent wheeze was 8.6%, chronic bronchitis 3.8%, chronic cough 4.2%, and asthma 7.8%. Persistent wheeze was independently associated with dust in a dose-response fashion odds ratio, 1.2 (95% confidence interval[CI]=0.8-2.0) and 1.8 (95% CI=1.1-3.2) for low and high time in dust. A borderline significant association between chronic bronchitis and dust exposure was found. Asthma was associated with keeping livestock, but not with dust exposure. CONCLUSIONS: Occupational dust exposure among California farmers, only one third of whom tended animals, was independently associated with chronic respiratory symptoms.
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Enfermedades de los Trabajadores Agrícolas/epidemiología , Exposición Profesional , Enfermedades Respiratorias/epidemiología , California/epidemiología , Estudios Transversales , Polvo , Humanos , SueloRESUMEN
BACKGROUND: The career satisfaction and dissatisfaction physicians experience likely influence the quality of medical care. OBJECTIVE: To compare career satisfaction across specialties among US physicians. METHODS: We analyzed data from the Community Tracking Study of 12 474 physicians (response rate, 65%) for the late 1990s. Data are cross-sectional. Two satisfaction variables were created: very satisfied and dissatisfied. Thirty-three specialty categories were analyzed. RESULTS: After adjusting for control variables, the following specialties are significantly more likely than family medicine to be very satisfying: geriatric internal medicine (odds ratio [OR], 2.04); neonatal-perinatal medicine (OR, 1.89); dermatology (OR, 1.48); and pediatrics (OR, 1.36). The following are significantly more likely than family medicine to be dissatisfying: otolaryngology (OR, 1.78); obstetrics-gynecology (OR, 1.61); ophthalmology (OR, 1.51); orthopedics (OR, 1.36); and internal medicine (OR, 1.22). Among the control variables, we also found nonlinear relations between age and satisfaction; high satisfaction among physicians in the west north Central and New England states and high dissatisfaction in the south Atlantic, west south Central, Mountain, and Pacific states; positive associations between income and satisfaction; and no differences between women and men. CONCLUSIONS: Career satisfaction and dissatisfaction vary across specialty as well as age, income, and region. These variations are likely to be of interest to residency directors, managed care administrators, students selecting a specialty, and physicians in the groups with high satisfaction and dissatisfaction.
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Selección de Profesión , Satisfacción en el Trabajo , Medicina , Médicos/psicología , Especialización , Adulto , Factores de Edad , Anciano , Femenino , Humanos , Renta/estadística & datos numéricos , Modelos Logísticos , Masculino , Medicina/estadística & datos numéricos , Persona de Mediana Edad , Estados Unidos/epidemiologíaRESUMEN
2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD), a widespread environmental contaminant, is associated with delays in pubertal development in animal studies. On 10 July 1976, as a result of a chemical explosion, residents of Seveso, Italy, experienced the highest levels of TCDD exposure experienced by a human population. Twenty years later, we initiated the Seveso Women's Health Study (SWHS), a retrospective cohort study of female residents of the most contaminated areas, to determine whether the women were at higher risk for reproductive disease. We examined the association of TCDD serum levels, based on measurements in serum collected soon after the explosion, with reported age at menarche among the 282 SWHS women who were premenarcheal at the time of the explosion. We found no change in risk of onset of menarche with a 10-fold increase in TCDD (e.g., 10-100 ppt; hazard ratio = 0.95; 95% confidence interval, 0.83-1.09; p-value for trend = 0.46). When TCDD levels were categorized, there was also no evidence of a dose-response trend (p = 0.65). In summary, we found that individual serum TCDD measurements are not significantly related to age at menarche among women in the SWHS cohort. The women in this study experienced substantial TCDD exposure during the postnatal but prepubertal developmental period. Given that animal evidence suggests in utero exposure has the most significant effect on onset of puberty, continued follow-up of the offspring of the SWHS cohort is important.
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Exposición a Riesgos Ambientales , Contaminantes Ambientales/sangre , Menarquia , Dibenzodioxinas Policloradas/sangre , Accidentes de Trabajo , Adolescente , Adulto , Edad de Inicio , Niño , Preescolar , Estudios de Cohortes , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Lactante , Italia , Estudios Retrospectivos , Medición de RiesgoRESUMEN
2,3,7,8-Tetrachlorodibenzo-(italic)p(/italic)-dioxin (TCDD or dioxin), a widespread environmental contaminant, has been shown to disrupt multiple endocrine pathways. The International Agency for Research on Cancer classified TCDD as a known human carcinogen, primarily based on occupational studies of increased mortality from all cancers combined. Using data from the Seveso Women's Health Study (SWHS), we examined the association between individual serum TCDD levels and breast cancer risk in women residing around Seveso, Italy, in 1976, at the time of an industrial explosion that resulted in the highest known population exposure to TCDD. The SWHS cohort comprises 981 women who were infants to 40 years old in 1976, resided in the most contaminated areas at the time of the explosion, and had archived sera that was collected soon after the explosion. For each woman, serum TCDD exposure was measured by high-resolution mass spectrometry. Cancer cases were identified during interview and confirmed by medical record. At interview, 15 women (1.5%) had been diagnosed with breast cancer and serum TCDD levels for cases ranged from 13 to 1,960 ppt. Cox proportional hazards modeling showed that the hazard ratio for breast cancer associated with a 10-fold increase in serum TCDD levels (log(subscript)10(/subscript) TCDD) was significantly increased to 2.1 (95% confidence interval, 1.0-4.6). Covariate-adjusted results were not different. Individual serum TCDD is significantly related with breast cancer incidence among women in the SWHS cohort. Continued follow-up of the cohort will help shed light on the possible role of TCDD in the pathogenesis of breast cancer.
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Neoplasias de la Mama/etiología , Exposición a Riesgos Ambientales , Contaminantes Ambientales/efectos adversos , Dibenzodioxinas Policloradas/efectos adversos , Adolescente , Adulto , Neoplasias de la Mama/epidemiología , Niño , Preescolar , Estudios de Cohortes , Contaminantes Ambientales/sangre , Femenino , Humanos , Lactante , Recién Nacido , Italia/epidemiología , Persona de Mediana Edad , Dibenzodioxinas Policloradas/sangre , Factores de RiesgoRESUMEN
2,3,7,8-Tetrachlorodibenzo-(italic)para(/italic)-dioxin (TCDD), a ubiquitous environmental contaminant, is associated with increased fetal loss and reduced birth weight in animal studies. In 1976, an explosion at a trichlorophenol plant near Seveso, Italy, resulted in the highest TCDD exposure known in human residential populations. In 1996, we initiated the Seveso Women's Health Study, a retrospective cohort study of women who resided in the most contaminated areas, zones A and B. We examined the relation of pregnancy outcome in 510 women (888 total pregnancies) to maternal TCDD levels measured in serum collected shortly after the explosion. Ninety-seven pregnancies (10.9%) ended as spontaneous abortions (SABs). There was no association of log(subscript)10(/subscript) TCDD with SAB [adjusted odds ratio (OR) = 0.8; 95% confidence interval (CI), 0.6-1.2], with birth weight (adjusted beta = -4 g; 95% CI, -68 to 60), or with births that were small for gestational age (SGA) (adjusted OR = 1.2; 95% CI, 0.8-1.8). However, associations with birth weight (adjusted beta = -92 g; 95% CI, -204 to 19) and with SGA (adjusted OR = 1.4; 95% CI, 0.6-2.9) were stronger for pregnancies within the first 8 years after exposure. TCDD was associated with a 1.0-1.3 day nonsignificant adjusted decrease in gestational age and a 20-50% nonsignificant increase in the odds of preterm delivery. It remains possible that the effects of TCDD on birth outcomes are yet to be observed, because the most heavily exposed women in Seveso were the youngest and the least likely to have yet had a pregnancy.
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Exposición a Riesgos Ambientales/efectos adversos , Exposición Materna/efectos adversos , Dibenzodioxinas Policloradas/sangre , Resultado del Embarazo , Aborto Espontáneo/inducido químicamente , Adulto , Industria Química , Estudios de Cohortes , Explosiones , Femenino , Humanos , Italia , Dibenzodioxinas Policloradas/envenenamiento , Embarazo , Efectos Tardíos de la Exposición PrenatalRESUMEN
In 1976, a chemical plant explosion near Seveso, Italy, resulted in the highest known exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) in residential populations. In 1996, we initiated the Seveso Women's Health Study (SWHS), a historical cohort study of females who were 40 years old at the time of explosion and residents of the most heavily contaminated areas, zones A and B. Serum samples collected near the time of the explosion were analyzed for TCDD. We also analyzed pooled serum samples collected in 1976 from females who resided in zone non-ABR, the "unexposed" zone, to assess concurrent background exposures to other dioxins, furans, and coplanar polychlorinated biphenyls (PCBs). The median lipid-adjusted TCDD level for residents of zones A and B combined was 56 ppt (range = 2.5-56,000 ppt). Zone A residents had 5-fold higher TCDD levels (n = 67, median = 272 ppt) than did zone B residents (n = 814, median = 47 ppt). The youngest children had the highest TCDD levels, which decreased with age at explosion until approximately 13 years of age and were constant thereafter. Therefore, children living in zones A and B received a disproportionately higher exposure to TCDD as a result of the explosion. Zone of residence and age were the strongest predictors of TCDD level. Chloracne, nearby animal mortality, location (outdoors vs. indoors) at the time of explosion, and consumption of homegrown food were also related to serum TCDD levels. The serum pools from zone non-ABR residents had an average TCDD concentration of 20.2 ppt, and average total toxic equivalent (TEQ) concentration of 100.4 ppt. Therefore, background exposure to dioxins, furans, and PCBs unrelated to the explosion may have been substantial. As a consequence, previous SWHS studies that considered only TCDD exposure may have underestimated health effects due to total TEQ concentrations.
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Exposición a Riesgos Ambientales , Dibenzodioxinas Policloradas/sangre , Teratógenos/análisis , Accidentes de Trabajo , Adolescente , Adulto , Factores de Edad , Industria Química , Niño , Protección a la Infancia , Preescolar , Estudios de Cohortes , Dieta , Explosiones , Femenino , Contaminación de Alimentos , Humanos , Lactante , Recién Nacido , Italia , Medición de RiesgoRESUMEN
Dioxin, a ubiquitous contaminant of industrial combustion processes including medical waste incineration, has been implicated in the etiology of endometriosis in animals. We sought to determine whether dioxin exposure is associated with endometriosis in humans. We conducted a population-based historical cohort study 20 years after the 1976 factory explosion in Seveso, Italy, which resulted in the highest known population exposure to 2,3,7,8-tetrachlorodibenzo-(italic)p(/italic)-dioxin (TCDD). Participants were 601 female residents of the Seveso area who were (3/4) 30 years old in 1976 and had adequate stored sera. Endometriosis disease status was defined by pelvic surgery, current transvaginal ultrasound, pelvic examination, and interview (for history of infertility and pelvic pain). "Cases" were women who had surgically confirmed disease or an ultrasound consistent with endometriosis. "Nondiseased" women had surgery with no evidence of endometriosis or no signs or symptoms. Other women had uncertain status. To assess TCDD exposure, individual levels of TCDD were measured in stored sera collected soon after the accident. We identified 19 women with endometriosis and 277 nondiseased women. The relative risk ratios (RRRs) for women with serum TCDD levels of 20.1-100 ppt and >100 ppt were 1.2 [90% confidence interval (CI) = 0.3-4.5] and 2.1 (90% CI = 0.5-8.0), respectively, relative to women with TCDD levels (3/4) 20 ppt. Tests for trend using the above exposure categories and continuous log TCDD were nonsignificant. In conclusion, we report a doubled, nonsignificant risk for endometriosis among women with serum TCDD levels of 100 ppt or higher, but no clear dose response. Unavoidable disease misclassification in a population-based study may have led to an underestimate of the true risk of endometriosis.
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Endometriosis/inducido químicamente , Exposición a Riesgos Ambientales , Contaminantes Ambientales/efectos adversos , Dibenzodioxinas Policloradas/efectos adversos , Adulto , Industria Química , Estudios de Cohortes , Endometriosis/epidemiología , Contaminantes Ambientales/sangre , Explosiones , Femenino , Humanos , Italia/epidemiología , Persona de Mediana Edad , Dibenzodioxinas Policloradas/sangre , Factores de RiesgoRESUMEN
OBJECTIVES: To determine the self-selected exercise intensity of older adults who report that they walk briskly for exercise. An additional aim of the study was to assess the contribution of self-reported physical activity to self-selected exercise intensity. DESIGN: Observational. SETTING: walking path. PARTICIPANTS: Subjects consisted of 212 participants in the Study of Physical Performance and Age-Related Changes in Sonomans who stated in a detailed home interview that they walked briskly for exercise. MEASUREMENTS: Observed brisk walking speed was measured as the time it took participants to walk half a mile at "normal brisk walking speed." Self-reported physical activity was categorized as metabolic equivalent of the task (MET) in minutes of exercise reported in the previous 7 days. Physiological measures and body composition were obtained through laboratory evaluation. RESULTS: Men walked at an average speed+/-standard deviation of 5.72+/-0.69 km/h and women walked at an average speed of 5.54+/-0.64 km/h. Self-reported physical activity was not associated with brisk walking speed when adjusted for age and ratio of lean to fat mass. CONCLUSION: This study found that older adults who report that they walk briskly for exercise do so at a pace considered moderate or greater in absolute intensity as indicated by their walking speed (4.83 km/h). Ninety-eight percent of men (93/95) and 97% of women (113/117) had an observed walking speed equivalent to 3 or more METs based on their calculated walking speed.
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Caminata/normas , Anciano , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: Asthma is an important cause of morbidity, absence from school, and use of health services among children. Computer-based educational programs can be designed to enhance children's self-management skills and to reduce adverse outcomes. OBJECTIVE: To assess the effectiveness of an interactive device programmed for the management of pediatric asthma. DESIGN: A randomized controlled trial (66 participants were in the intervention group and 68 were in the control group). SETTING: Interventions conducted at home and in an outpatient hospital clinic. PARTICIPANTS: Inner-city children aged 8 to 16 years diagnosed as having asthma by a physician. INTERVENTION: An asthma self-management and education program, the Health Buddy, designed to enable children to assess and monitor their asthma symptoms and quality of life and to transmit this information to health care providers (physicians, nurses, or other case managers) through a secure Web site. Control group participants used an asthma diary. MAIN OUTCOME MEASURES: Any limitation in activity was the primary outcome. Secondary outcomes included perceived asthma symptoms, absence from school, any peak flow reading in the yellow or red zone, and use of health services. RESULTS: After adjusting for covariates, the odds of having any limitation in activity during the 90-day trial were significantly (P =.03) lower for children randomized to the Health Buddy. The intervention group also was significantly (P =.01) less likely to report peak flow readings in the yellow or red zone or to make urgent calls to the hospital (P =.05). Self-care behaviors, which were important correlates of asthma outcomes, also improved far more for the intervention group. CONCLUSION: Compared with the asthma diary, monitoring asthma symptoms and functional status with the Health Buddy increases self-management skills and improves asthma outcomes.
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Asma/terapia , Conductas Relacionadas con la Salud , Cooperación del Paciente , Autocuidado/métodos , Adolescente , California , Niño , Computadores , Femenino , Humanos , Masculino , Educación del Paciente como Asunto , Población UrbanaRESUMEN
OBJECTIVE: To assess recent trends in professional satisfaction, perceptions of ability to provide high-quality care, and perceptions of ability to obtain needed services for patients in a national sample of obstetricians and gynecologists; to compare obstetrician-gynecologists with physicians in other specialties; and to identify demographic, professional, and practice characteristics associated with high career satisfaction. METHODS: We used data from the 1996-1997 (n=12,385; response rate, 65%) and 1998-1999 (n=12,280; response rate, 61%) waves of the nationally representative Community Tracking Study physicians' survey. The principal outcome measures were one item related to overall career satisfaction, six items measuring physicians' perceptions of their ability to provide high-quality care, and five items measuring physicians' perceptions of their ability to obtain needed services for patients. All results were weighted and adjusted to reflect the complex survey design. RESULTS: In 1996-1997, 34% of obstetrician-gynecologists (n=545) were very satisfied with their careers, and 24% were very or somewhat dissatisfied. Up to 45% perceived significant barriers to the delivery of high-quality care, and up to 58% were unable to "almost or almost always" obtain necessary services for patients. Results in 1998-1999 (n=484 obstetricians and gynecologists) were similar, except for a deterioration in perceived amount of time with patients and ability to obtain high-quality ancillary services. In comparison with primary care physicians, obstetrician-gynecologists were less satisfied (P=.001); in comparison with both primary care physicians and general surgeons, they had more problems delivering high-quality care (P<.001) and greater difficulties obtaining needed services for patients (P<.001). Controlling for selected demographic and professional characteristics, higher career satisfaction was associated with age greater than 65 years, practicing in small metropolitan areas and in academic settings, and having better perceptions of quality and ability to obtain services (P<.05). CONCLUSION: Although most obstetricians and gynecologists are satisfied with their careers, many are experiencing significant professional distress.
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Actitud del Personal de Salud , Competencia Clínica , Ginecología/normas , Satisfacción en el Trabajo , Obstetricia/normas , Calidad de la Atención de Salud , Adulto , Femenino , Ginecología/tendencias , Encuestas de Atención de la Salud , Humanos , Masculino , Medicina/normas , Medicina/tendencias , Persona de Mediana Edad , Obstetricia/tendencias , Médicos Mujeres , Pautas de la Práctica en Medicina , Autonomía Profesional , Especialización , Encuestas y Cuestionarios , Estados UnidosRESUMEN
OBJECTIVE: To determine the association between dyspareunia, dysmenorrhea, and noncyclic pelvic pain and the presence and characteristics of uterine fibroids. DESIGN: Population-based cross-sectional study. SETTING: Desio, Italy. PATIENT(S): Six hundred thirty-five non-care-seeking participants of the Seveso Women's Health Study with an intact uterus who underwent transvaginal ultrasound. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Ultrasound-detected presence of uterine fibroids and fibroid characteristics including volume, number, location, and position. Current dyspareunia, dysmenorrhea, and noncyclic pelvic pain was measured by self-report on a visual analog scale. RESULT(S): Uterine fibroids were detected in 96 women (15%). Women with fibroids were more likely to report moderate or severe dyspareunia (adjusted odds ratio [OR] = 2.8, 95% confidence interval [CI] = 0.9-8.3, statistically significant trend) and moderate or severe noncyclic pelvic pain (adjusted OR = 2.6, 95% CI = 0.9-7.6, statistically significant trend) than women without fibroids. Moderate or severe dysmenorrhea was not associated with the presence of fibroids (adjusted OR = 1.1, 95% CI = 0.5-2.6). Number and total volume of fibroids were not related to pain. CONCLUSION(S): This is the first population-based study of gynecologic pain symptoms and fibroids. Dyspareunia and noncyclic pelvic pain, but not dysmenorrhea, increased in severity with the presence of uterine fibroids. Fibroid-associated pain symptomatology in a non-care-seeking population may be different from that of a clinic population.