The relation of prothrombin times to coronary heart disease risk factors among men aged 31-45 years.

Although levels of coagulation factor VII and fibrinogen are predictive of cardiovascular disease, relatively little data describe hemostatic characteristics in healthy populations. The cross-sectional associations between the prothrombin time, a measure of the activity of the extrinsic and common pathways of coagulation, and traits associated with the risk of cardiovascular disease were therefore examined among 3,604 white and 514 black, male, US Army veterans aged 31-45 years. The prothrombin time measurements, performed in 1985 and 1986, were precise, with an intraclass correlation of 0.98 (202 pairs). Overall, the mean prothrombin time was 12.4 seconds (standard deviation, 0.4 seconds), and 11 percent of the men had a value of less than 12 seconds. Many of the observed associations with the prothrombin time paralleled those that have been reported with clotting factor VII and fibrinogen. The mean prothrombin time was 0.15 seconds shorter among whites than among blacks and was 0.2 seconds shorter among current cigarette smokers than among men who had never smoked. Inverse associations were also seen with relative weight and with levels of total cholesterol and triglycerides (r = -0.09 to -0.16). All associations were statistically significant at the 0.01 level, and the examined characteristics could jointly account for about 12 percent of the variability in prothrombin times. Additional data on characteristics related to coagulation may help elucidate the natural history of cardiovascular disease and aid in the design of clinical trials.


Leukocyte count correlates in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study.

Cross-sectional associations between leukocyte count and sociodemographic and cardiovascular risk factors were investigated in 14,679 participants aged 45-64 years in the Atherosclerosis Risk in Communities Study carried out in four US communities in 1986-1989. Leukocyte count was strongly associated with present or past history of cigarette smoking and was higher in males than in females and in white subjects than in black subjects. Among never smokers, no sex differences were evident after adjustment for other risk factors. Race-associated differences were substantially reduced after other factors were taken into account in multivariate analyses. In never smokers, leukocyte count was higher in those who reported poor health, and it was inversely associated with high density lipoprotein cholesterol, forced expiratory volume at 1 second, physical activity, and, among whites, height and socioeconomic indicators. It was directly associated with indices of body weight and body fat, heart rate, blood pressure, hemoglobin, platelet count, uric acid, fasting insulin and glycemia, triglycerides, fibrinogen, antithrombin III, protein C, factors VII and VIII, and von Willebrand factor. The associations of leukocyte count with cardiovascular risk factors may either represent manifestation of subclinical disease or suggest that leukocyte count is part of the causal chain leading to atherosclerosis. Alternatively, the relation of leukocyte count to cardiovascular disease may be confounded by risk factors and thus be noncausal.


Postprandial lipemia: reliability in an epidemiologic field study.

Ten subjects from the Forsyth County, North Carolina, and Washington County, Maryland, field centers in the Atherosclerosis Risk in Communities Study had two fat tolerance tests within a 10-day period from September 1988 to February 1989 to determine the reproducibility of markers for postprandial lipemia. No significant differences between visits were found in fasting mean plasma lipids, lipoproteins, and apolipoproteins. Postprandial triglycerides and retinyl palmitate were measured at 3.5 and 9.0 hours after the test meal in whole plasma. There were no significant differences in the mean levels of these analytes between visits. The correlation of triglycerides between repeat visits at 9.0 hours (r = 0.87) was stronger than in fasting samples (r = 0.67) or at 3.5 hours (r = 0.69). The mean plasma retinyl palmitate level at 3.5 hours was 15% higher than at the 9.0-hour level. The correlation of repeat measures of retinyl palmitate at 9.0 hours (r = 0.94) was much stronger than at 3.5 hours (r = 0.79). In conclusion, estimates of reliability in postprandial measurements of 9.0-hour triglycerides and retinyl palmitate levels were as strong as fasting lipid measurements of total cholesterol, high density lipoprotein cholesterol, low density lipoprotein cholesterol, and high density lipoprotein cholesterol, and both postprandial triglyceride measurements exceeded that of fasting triglyceride (r = 0.67).


The relation of high density lipoprotein cholesterol and its subfractions to apolipoprotein A-I and fasting triglycerides: the role of environmental factors. The Atherosclerosis Risk in Communities (ARIC) Study.

Cross-sectional analysis of four general representative populations of middle-aged adults in the United States in 1986-1989 provides estimates of the close relation of high density lipoprotein cholesterol (HDL cholesterol) to its major structural apolipoprotein (apolipoprotein A-I) and to fasting plasma triglyceride levels. HDL cholesterol differences of approximately 0.4 mg were associated with 1-mg differences in apolipoprotein A-I; differences of 20% in HDL cholesterol (reductions) were associated with triglyceride doublings. Variation in apolipoprotein A-I and triglyceride concentration together accounted for 66% of the population variance in HDL cholesterol. The uniformity of this pattern in the four race-sex groups studied suggests an important role of triglyceride-cholesterol transfer as a determinant of HDL cholesterol. The fundamental relations observed among HDL cholesterol, apolipoprotein A-I, and triglycerides were unaltered by levels of factors under personal volition. The volitional factors appeared to influence HDL cholesterol indirectly: Obesity and physical activity were affected primarily through their associations with triglycerides, and alcohol use and smoking through associations with apolipoprotein A-I. The association of alcohol use with elevated HDL cholesterol was attenuated in persons with greater body mass.


Is stroke mortality on the decline in England?

This paper challenges the assumption that mortality from stroke will remain constant or decline over the next few decades. A decline in stroke mortality could be brought about by changes in factors acting close to the time of death (period effect) or by risk factors determined by the generation into which a person is born (cohort effect). Age-specific death rates for stroke (1931-1985) in England and Wales were analyzed to estimate the influence of these different effects. There were significant effects for age, period, and cohort on mortality from stroke with significantly different age and period effects in each sex. The effect of age was linear, with an increasing mortality with age in both sexes. Cohort analysis demonstrated a deceleration away from the previous trend in the mortality rates associated with birth cohorts born after 1880, followed by an acceleration in the trend of mortality rates in cohorts born after 1910. These relative increases in risk for cohorts born after 1910 were offset by a deceleration in mortality associated with periods from around 1951-1954. Since cohort effects are likely to be associated with a lifetime increase in risk of stroke mortality, it is difficult to predict the extent of any long-term fall in stroke incidence.


Agreement between maternal interview- and medical record-based gestational age.

Agreement between maternal interview- and medical record-based gestational age was assessed by using data from a case-control study of childhood strabismus. The sample consisted of 383 cases of strabismus and their age-matched controls, diagnosed between 1985 and 1986 in Baltimore, Maryland, who were under age 7 years when diagnosed. Medical record-based gestational age was derived, in order of priority, from early ultrasound examination, time from the last menstrual period, pediatric examination, and obstetric examination. The intraclass correlation coefficient, kappa, and mean difference were used to compare agreement between maternal interview- and medical record-based gestational age by maternal and pregnancy characteristics and characteristics related to study design. Overall, 86 percent of mothers were within 2 weeks of the gestational age reported in the medical record. The intraclass correlation coefficient comparing maternal and medical record-based gestational age was 0.83 (95% confidence interval 0.80-0.86). Agreement was positively associated with shorter length of recall, low birth order, and having a neonatal illness related to prematurity. Agreement was poor among mothers of healthy preterm infants. There was a weak positive association between recall and some sociodemographic covariates. There was greater misclassification of prematurity in the controls than in the cases. The results suggest that, in general, women recall gestational age well, which supports the use of gestational age derived from maternal interviews.


Maternal nutrition and spontaneous preterm birth.

Previous studies suggesting that maternal undernutrition increases the risk of preterm birth have suffered from several methodological shortcomings, including use of total gestational weight gain rather than net rate of gain in maternal tissue, inclusion of induced preterm deliveries, and error-prone gestational age measurements based solely on menstrual dates. The authors have attempted to overcome these shortcomings by investigating the potential etiologic roles of prepregnancy body mass index, net rate of maternal weight gain, height, and a number of other potential biological and sociodemographic determinants of spontaneous (i.e., noninduced) preterm birth in a cohort of 13,102 women with early ultrasound-confirmed gestational age who delivered at the Royal Victoria Hospital in Montreal, Quebec, Canada, between January 1, 1980 and March 31, 1989. Total weight gain, but not body mass index, was highly significantly associated with spontaneous preterm birth, averaging 14.6, 12.5, 9.9, and 9.1 kg, in women delivering at 37 or more, less than 37, less than 34, and less than 32 completed weeks, respectively. Although the relation persisted when weight gain was expressed as an overall rate, it disappeared when the analysis was based on net rate; mean net rates of gain were 0.28, 0.29, 0.27, and 0.27 kg/week, respectively. On the basis of multiple logistic regression analyses, significant determinants of birth at less than 37 weeks included maternal short stature; noncompletion of high school; unmarried status; smoking; diabetes; urinary tract infection within 2 weeks of delivery; prepregnancy hypertension; severe pregnancy-induced hypertension; and previous history of preterm delivery, low birth weight, or neonatal death. Most of these factors retained their significance for birth at less than 34 and less than 32 weeks. In fact, the effect of low maternal education was even stronger at these more severe "levels" of preterm birth. The authors conclude that prepregnancy weight-for-height and gestational weight gain are not important determinants of spontaneous preterm birth and that some previous studies have mistaken an effect of shortened gestation for its cause. Other biologic and social determinants, however, indicate priorities for future research and intervention.


The geographic structure of measles epidemics in the northeastern United States.

The incidence of disease across geographic space often produces distinctive regional patterns. In this paper, a modeling approach to the identification of the factors that shape the patterns is presented, and a procedure for fitting the model to observed data is given. The methodology is illustrated by an application to the geographic structure of measles epidemics among 22 states of the northeastern United States, New York City, and Washington, D.C., from 1962 to 1988. The patterns identified are interpreted in terms of the spatial behavior of measles epidemics in the region, and the implications of the methodology for surveillance and control are considered.


Prevalence and incidence of viral hepatitis in health workers in the prehepatitis B vaccination era.

To assess the impact of hepatitis B virus on health workers, the authors studied baseline prevalences of hepatitis B serologic markers and undertook prospective surveillance to assess hepatitis B attack rates in 837 health workers and 994 blood-donor controls between 1977 and 1982, before the introduction of hepatitis B vaccine. The baseline prevalence of all hepatitis B markers was 14% in health workers and 6% in controls (p < 0.001); exposure to hepatitis B virus was related to the intensity of blood exposure and its duration. In contrast, the frequency of exposure to hepatitis A virus, a nonblood-borne agent, was lower in health workers (11%) than in controls (16%) (p < 0.01) and increased as a function of age. Multivariate logistic regression analysis identified occupational categories with frequent blood contact, rather than duration of exposure, as being the dominant variable for exposure to hepatitis B virus; for hepatitis A virus exposure, age was the most significant variable. Among health workers susceptible to hepatitis B, the incidence of new definite hepatitis B infections was 1.0% per year in 362 health workers (804 person-years of follow-up observation) with frequent blood contact versus 0% per year in 258 health workers (534 person-years of observation) with limited blood contact (p = 0.017). For definite plus probable cases combined, the incidence of new hepatitis B infections was 1.5% per year versus 0.2% per year for the groups with frequent and limited blood exposures, respectively (p = 0.0013). There were no new cases of hepatitis A or B or seroconversions in controls and only one case of hepatitis A acquired outside the hospital by a health worker. These data confirm the high prevalence of hepatitis B exposure and document in a prospective study the high incidence over time of new hepatitis B virus infections in health workers unprotected by vaccination. Such findings reiterate the need for aggressive vaccination programs in health workers exposed to blood.


A foodborne outbreak of gastroenteritis involving two different pathogens.

On the evening of October 10, 1990, many of the 474 inmates of a state prison in Florida began to experience symptoms of gastroenteritis. An investigation included interviews with inmates, evaluation of the kitchen and food-handling practices, cultures of leftover food, stool cultures, and cultures from the nares and skin lesions of food handlers. Of the 331 inmates interviewed, 215 (65%) had diarrhea, vomiting, or both. The median incubation period was 5 hours (range, 1-41 hours). Cases with onset of illness 8 or more hours after the evening meal were more likely than those with earlier onset to have had only diarrhea without vomiting (p < 0.001). Eating turkey at the evening meal on October 10 was associated with risk of illness (relative risk = 4.8, 95% confidence interval 1.7-13.7). Cases who became ill within 8 hours of the evening meal and those who became ill later were both more likely to have eaten turkey than those who did not become ill (p < 0.001 and p < 0.007, respectively). Salmonella infantis and enterotoxin-producing Staphylococcus aureus were both isolated from samples of leftover turkey, and S. infantis was isolated from 18 of 20 stool specimens. Cultures of the anterior nares and skin lesions of food handlers grew S. aureus, but phage typing failed to link these strains to the outbreak. Improper food-handling practices contributed to the development of this outbreak. This report highlights the importance of recognizing multiple-organism outbreaks, since the authors' recommendations for prevention of more cases depended upon knowing the risks associated with the distinct organisms and the possible sources of contamination.


Preexisting lung disease and lung cancer among nonsmoking women.

Preexisting lung disease was examined as a risk factor for lung cancer in a population-based, case-control study of nonsmoking women in Missouri conducted between June 1, 1986, and April 1, 1991. A history of lung disease was reported by approximately 41% of 618 cases and 35% of 1,402 controls (odds ratio (OR) = 1.2; 95% confidence interval (Cl) 1.0-1.5. The risk was more pronounced when next-of-kin interviews were excluded (OR = 1.5). Previous lung disease was significantly related both to adenocarcinoma (OR = 1.4), which accounted for 62% of the cancers, and to all other cell types of lung cancer combined (OR = 1.8). Despite having discontinued smoking for more than 15 years, long-term ex-smokers were at a 2.2-fold risk of lung cancer compared with lifetime nonsmokers. Among lifetime nonsmokers, significant risks were noted for asthma (OR = 2.7) and pneumonia (OR = 1.5). Emphysema (OR = 2.6) and tuberculosis (OR = 2.0) were also significantly related to lung cancer, but only among former smokers. Chronic bronchitis was linked to elevated risks of nonadenocarcinomas only (OR = 2.3). Pleurisy was not reported more frequently by cases than by controls. Approximately 16% of all lung cancers among nonsmoking women could be attributed to previous lung diseases, most notably asthma, pneumonia, emphysema, and tuberculosis.


Longitudinal prediction of adult blood pressure from juvenile blood pressure levels.

The link between blood pressure measured at juvenile ages (3-18 years) and subsequent adult ages (30 and 50 years) was investigated in a community-based longitudinal study conducted in the San Francisco Bay Area from 1928 to the present. The original sample of 550 persons decreased 61 percent by age 50 years, leaving only 211 persons in the cohort. Blood pressure was measured annually up to age 18 years and each decade thereafter, providing a unique opportunity to link childhood and adult blood pressures over periods of up to 50 years. Juvenile blood pressure measured from age 6 years onward was a positive predictor of blood pressure at age 30 years. Blood pressure measured at age 50 years was predicted best by juvenile pressures measured at early school age and early puberty. The juvenile-adult blood pressure association was partly explained by controlling for smoking and parental history of cardiovascular disease, but was not explained by controlling for juvenile height or body mass. It was stronger in children from blue collar families. The reported correlations probably represent an underestimation of the true strength of the association because of a greater loss to follow-up among subjects with higher blood pressure and the effects of antihypertensive medication in adulthood.


Mortality trends in a cohort of homosexual men in New York City, 1978-1988.

Trends in mortality related to infection by human immunodeficiency virus type 1 (HIV-1) and to other causes were examined from 1978 to 1988 in a cohort of 8,906 homosexual men who participated in studies of hepatitis B virus infection in the late 1970s in New York City. HIV-related mortality rates increased from 1 per 10,000 person-years in 1980 to 181 per 10,000 person-years in 1986, followed by a plateau from 1986 to 1988. The standardized mortality ratio among white men in the cohort was 3.7 (95% confidence interval (Cl) 3.4-3.9) as compared with white men from across the United States. Higher HIV-related mortality rates were associated with a higher number of sexual partners, a history of gonorrhea and/or syphilis, and serologic markers of infection with hepatitis B virus. After adjustment for demographics and sexual behaviors, the relative risk of mortality for Hispanic men as compared with white men was 1.5 (95% Cl 1.1-1.9). This study illustrates the large excess in mortality among homosexual men over the last decade, with the excess accounted for by deaths from HIV-related diseases. The recent plateau in mortality may be due to the effect of new treatments and/or the decline in new HIV-1 infections among homosexual men. The excess in HIV-related mortality among Hispanic homosexual men was not explained by differences in demographics and factors associated with the sexual transmission of HIV-1.


Characteristics of mothers of live infants with congenital syphilis in Florida, 1987-1989.

The incidence of congenital syphilis in Florida increased sixfold from 1985 through 1989, and more than 80% of the cases occurred in metropolitan areas of southern Florida. To characterize the population of pregnant women in Florida at high risk of delivering an infant with congenital syphilis, the authors conducted a case-control study using birth certificates. Birth certificates were obtained for 256 of the 344 live infants reported as having congenital syphilis from 1987 through 1989 (74%); the 246 of these infants born in hospitals were matched for hospital and week of birth with an equal number of controls. In conditional multiple logistic regression, the following maternal characteristics were independent risk factors for congenital syphilis: young age, black race, single marital status, absence of a father's name on the birth certificate, previous pregnancy, substance abuse, and lack of prenatal care. Although the national origin of the mother was not a significant risk factor, the infants of black mothers born in the United States were at greater risk than the infants of black mothers born outside the United States. Mothers who had < or = 3 prenatal visits had an increased risk of delivering an infant with congenital syphilis as compared with mothers who had > 3 visits. This study suggests that targeted outreach efforts are necessary to control congenital syphilis and provides guidance for public health intervention activities.


Comparative behavioral epidemiology of gonococcal and chlamydial infections among patients attending a Baltimore, Maryland, sexually transmitted disease clinic.

Between April 1988 and May 1989, 400 males and 400 females attending a Baltimore, Maryland, sexually transmitted disease clinic were enrolled in a study evaluating and comparing behaviors associated with culture-proven gonococcal or chlamydial infection. The subjects were enrolled consecutively, and were all seen by the same clinician. Among participants of each sex, gonorrhea but not chlamydia was associated with increasing numbers of recent (the past 30 days) sexual partners. Compared with males with neither infection, factors independently associated with increased risk of gonorrhea included age less than 20 years (odds ratio (OR) = 1.93), the presence of genitourinary symptoms (OR = 8.07), and recent exposure to a new sexual partner (OR = 2.78); risk for chlamydial infection in males was associated with genitourinary symptoms (OR = 2.83) and was significantly reduced in those reporting multiple recent (OR = 0.19) or new (OR = 0.07) sexual partners. Among females, age less than 20 years was independently associated with gonococcal (OR = 1.86) and chlamydial (OR = 7.79) infections in comparison with females with neither infection. No other behavioral factors were associated with chlamydial infection for females in this study; however, having a regular sexual partner was associated with significantly elevated risk of gonorrhea (OR = 3.85), while the presence of genital tract symptoms was associated with diminished risk (OR = 0.29) for gonorrhea. These data suggest that there are differences in the behaviors associated with gonorrheal and chlamydial infections and that different strategies may be useful in efforts to control these infections.


Behavioral risk factors for injury among rural adolescents.

This 3-year, longitudinal, prospective study examined behavioral risk factors for medically attended injuries among a cohort of 758 rural students from Maryland's Eastern Shore region who were 12-14 years of age in 1987. Students were surveyed annually in the eighth, ninth, and tenth grades with a self-administered questionnaire. Information was obtained on the number of injuries experienced, risk-taking behaviors, delinquency, alcohol and drug use, physical exercise and sports, parental supervision, and work experience. Information on the parents' education was obtained from a parental interview. Slightly more than half (53.5%) of the students reported having experienced one or more injuries in the eighth grade as compared with one-third of the students in ninth grade, and 38% of those in the tenth grade. Poisson regression analyses were conducted to examine the association of eighth grade variables with ninth grade injuries and ninth grade variables with tenth grade injuries. Results from these analyses indicated that, in addition to sex and race, a high degree of risk taking, frequent cruising, and having high and low parental supervision in the eighth grade significantly increased the number of injuries in ninth grade. In the tenth grade, risk taking continued to be associated with injuries. In addition, students who reported disciplinary problems in school, working 1-10 hours per week, drinking on 1-2 days during the past month, lifetime use of marijuana equal to 1-5 occasions, and involvement in sports experienced greater numbers of injuries in the tenth grade.


Weight loss and mortality in a national cohort of adults, 1971-1987.

Although obesity is a risk factor for mortality, evidence that weight loss improves survival is limited. The relation between self-reported previous maximum weight, weight loss, and subsequent mortality was examined in 2,140 men and 2,550 women aged 45-74 years who participated in the First National Health and Nutrition Examination Survey (1971-1975) and survived the next 5 years. Vital status was determined through 1987. Among men and women whose maximum body mass index (weight (kg)/height (m)2) was between 26 and 29, risk of death increased with increasing weight loss, after adjustment for age, race, smoking, parity, preexisting illnesses, and maximum body mass index. Subjects who lost 15% or more of their maximum weight had over twice the mortality risk of those who lost less than 5%. At maximum body mass indices of 29 or higher, mortality risk increased with the amount of weight lost in women, but weight loss of 5% to < 15% appeared to lessen mortality risk in men. Generalization from these results is limited by the older age range of the sample and the inability to adequately distinguish voluntary from involuntary weight loss in this study. However, these findings suggest that prevention of severe overweight may be more generally effective than weight loss in reducing obesity-related mortality in the US population.


Performance of two general job-exposure matrices in a study of lung cancer morbidity in the Zutphen cohort.

Data from a general population cohort of 878 men from the town of Zutphen, The Netherlands, were used to evaluate the performance of two general job-exposure matrices. Exposures generated by the job-exposure matrices on the basis of job histories were compared. The validity of those exposures was measured against exposures reported by the participants in 1977/1978. The performance of the different exposure measures was assessed in proportional hazards analyses of lung cancer morbidity incidence. The two general job-exposure matrices generally disagreed with regard to exposure classification because of differences in exposure assessment and level of detail of the job axis. When compared with self-reported exposures, the sensitivity of both job-exposure matrices was low (on average, below 0.51), while the specificity was generally high (on average, above 0.90). Self-reported exposures to asbestos, pesticides, and welding fumes showed elevated risk ratios for lung cancer which were absent for exposures generated by the two job-exposure matrices. Thus, a population-specific job-exposure matrix is proposed as an alternative to general job-exposure matrices developed elsewhere. Such a matrix can be constructed from the results of in-depth interviews of a job-stratified sample of cohort members. Sound validation and documentation of exposure assessment methods used in job-exposure matrices are recommended.


Proxy respondents and the validity of occupational and other exposure data. The Selected Cancers Cooperative Study Group.

As part of a multicenter cancer case-control study conducted in 1984-1988, a proxy interview was attempted for all cases who were initially interviewed for the study but who died during the 4-year data collection period. To assess the validity of using wives, other relatives, or other informants to obtain information about a subject, the authors compared occupational and other exposure data obtained from 270 male cancer cases and their proxy respondents. The primary focus of the case-control study was on Vietnam military service and exposure to phenoxy herbicides, but cases and their proxy respondents were also asked about occupational and other exposures relevant to the cancers. The accuracy of reporting for specific occupational exposures (e.g., asbestos and formaldehyde) and specific occupations (e.g., dry cleaning and meat packing or processing) was poor, although the latter improved somewhat when only case-spouse pairs were examined. Similarly, there was poor sensitivity in the reporting of herbicide exposure information in farming and other related occupations. In contrast, the reporting of certain demographic characteristics, childhood history characteristics, and use of alcohol and cigarettes was relatively good, and was even better when only case-spouse pairs were examined. The poor quality of proxy information for detailed exposure information suggests the need for careful use and interpretation of proxy information in epidemiologic studies.


Computation of relative risk based on simultaneous surveys: an alternative to cohort and case-control studies.

If the same information on the distribution of risk factors is available for both the general population and a subset distinguished by some disease outcome, it becomes possible to derive relative risk estimates applicable to the entire population with the assurance that the data upon which the estimates are based is representative of that population. To illustrate this approach, data from the 1986 National Mortality Follow-back Survey and the 1987 National Health Interview Survey were used to compute rate ratios for several causes of death for work in dirtyier as compared with cleaner occupations by three methods commonly employed in cohort and case-control studies: the usual standardized rate ratio, the Mantel-Haenszel estimate of the rate ratio, and a multiplicative model fit to an appropriate cross-classification. Properly placed questions in appropriate surveys might very well serve as a substitute for cohort studies and could be performed at less cost and with less overall effort, and completed in a shorter time. Moreover, this approach is less subject to problems of representativeness than cohort and case-control studies.


The analysis of regional patterns in health data. I. Distributional considerations.

Regional patterns of health data such as cancer incidence rates are often examined for evidence of environmental effects. In this paper, three measures of spatial clustering are evaluated for use with epidemiologic data. In particular, the effects of variation in regional population structure on the distribution of these measures is considered. It is shown that substantial bias occurs if variation in regional population size is ignored (as has occurred in previous analyses). On the other hand, the methods are robust to small case frequencies and to variation in the regional age distribution. It is recommended that these regional differences be routinely taken into account, which can be done with relatively little additional computation. A companion paper (Walter SD. The analysis of regional patterns in health data. II. The power to detect environmental effects.


The analysis of regional patterns in health data. II. The power to detect environmental effects.

Three measures of spatial clustering (Moran's I, Geary's c, and a rank adjacency statistic, D) were evaluated for their power to detect regional patterns in health data. The patterns represented various environmental effects: a latitude gradient; residence near a contaminated water supply; disease "hot spots"; relation to socioeconomic status and urbanization; and general spatial autocorrelation. While the methods had high power to detect certain patterns, they were also affected by factors such as the shape of the map, its regional structure, and the spatial distribution of explanatory variables. The power was sometimes low, even for strong geographic trends, particularly for D. Moran's I had the highest power most often. We conclude that use of these methods requires careful specification of the anticipated geographic pattern and awareness of idiosyncratic effects in the study of particular maps.


Epidemiology of the post-polio syndrome.

A late-onset syndrome, consisting of muscle weakness, muscle pain, and unaccustomed fatigue, has been reported with increasing frequency among former poliomyelitis patients. A population-based cohort of poliomyelitis patients from Allegheny County, Pennsylvania, was traced and surveyed to estimate the prevalence and incidence and to identify determinants of the post-polio syndrome. A questionnaire validated in clinical examinations of 40 cohort members was used in the survey. The prevalence of the post-polio syndrome was 28.5% of all paralytic cases (95% confidence interval 24.4-32.6). The risk of post-polio syndrome was significantly higher among patients who sustained substantial permanent impairment after polio and among females. The incidence did not vary with age at acute onset, acute severity, or level of physical activity after recovery. The strongest determinant of post-polio syndrome onset was the length of the interval following the acute illness, with incidence peaking at 30-34 years. Of all cases of post-polio syndrome, 79% reported no major change in impairment status since onset. This study demonstrates that poliomyelitis patients are not equally susceptible to post-polio syndrome within the interval of 30-40 years after the original illness. For syndrome cases, the onset was associated with new neuromuscular symptoms and functional changes but not with major new impairment.


Prevalence of gallstone disease in relation to smoking, alcohol use, obesity, and glucose tolerance: a study of self-defense officials in Japan.

Risk factors of gallstone disease were investigated in male self-defense officials who received, between October 1986 and December 1990, a retirement health examination at the Self-Defense Forces Fukuoka Hospital, Fukuoka, Japan. Gallbladder ultrasonography, successfully performed with 2,739 of 2,756 men, found 61 men with gallstones and 38 men with previous removal of the gallbladder; the overall prevalence of gallstone disease was 3.6%. Multiple logistic regression analysis assessed the risk of gallstone disease in relation to smoking, alcohol use, body mass index, glucose tolerance, and rank. Alcohol use was associated with a decreased risk, and body mass index was positively related to gallstone disease. Men with impaired glucose tolerance had a slightly elevated risk, whereas diabetes mellitus was not associated with gallstone disease. Analysis for prevalent gallstones and the postcholecystectomy state showed an inverse association of alcohol use with the latter; a positive association with impaired glucose tolerance was also confined primarily to the latter condition. These findings provide little support for a protective effect of alcohol use in the formation of gallstones. It was inconclusive whether impaired glucose tolerance was associated selectively with postcholecystectomy.


Blood pressure reactivity does not correlate with baseline blood pressure or blood pressure change over time in preschool children.

Few studies have examined the relation of blood pressure reactivity to subsequent change in blood pressure of preschool children. The authors investigated relations between measurement-induced reactivity, exercise reactivity, and change in blood pressure over 16 months among 140 preschool children (46-67 months of age at baseline, 50.7% female, 92.9% Hispanic). Within-session measurement-induced reactivity was defined as the change in blood pressure between the first and the mean of the fourth and fifth readings obtained at each of 11 sessions. Between-session measurement-induced reactivity was defined as the change between mean blood pressure at session 1 and the mean of sessions 2 and 3. Both indices of measurement reactivity displayed poor reproducibility. Exercise reactivity was measured using a treadmill on two occasions and was moderately reproducible. There was no association between measurement and exercise reactivity. The change in systolic blood pressure over time was not associated with any measure of reactivity. The mean diastolic blood pressure did not change over the study period. Neither blood pressure reactivity to measurement nor blood pressure reactivity to exercise appeared to be a useful predictor of change in blood pressure in preschool children during a 16-month period.


Physical activity and serum lipids: a cross-sectional population study in eastern Finnish men.

The authors studied the association of the type, amount, and intensity of physical activity with serum lipids in 2,492 randomly selected eastern Finnish men aged 42-60 years during 1984-1989, controlling for the major confounding factors. High density lipoprotein cholesterol (HDL cholesterol) and HDL2 cholesterol were associated positively and triglycerides inversely with total, occupational, and leisure time activity in a multivariate regression model (p < 0.001). HDL3 cholesterol was associated positively only with total activity (p < 0.001). The adjusted relative differences in HDL cholesterol, HDL2 cholesterol, HDL3 cholesterol, and triglycerides between extreme total (occupational, leisure time) activity quartiles were 10.7% (9.0%, 5.7%), 12.2% (10.3%, 9.5%), 5.9% (2.9%, 0%), and 22.7% (9.2%, 10.4%), respectively. HDL cholesterol and HDL2 cholesterol were the highest and triglycerides the lowest at a conditioning activity intensity of more than 6 metabolic units (p < 0.001). The strongest associations were found for the 24-Hour Recording, which suggests short-term effects of physical activity on serum lipids. The beneficial effects of physical activity on serum lipids appear to be mediated partially by a reduced serum insulin concentration and decreased body adiposity. These data provide further confirmation for the concept that both regular or at least moderate intensity leisure time activity and occupational physical activity have a favorable impact on serum lipids.


Does recent alcohol consumption reduce the risk of acute myocardial infarction and coronary death in regular drinkers?

This study, conducted in Auckland, New Zealand, over 2 years from March 1986, used a case-control design to investigate the hypothesis that alcohol acutely increases the risk of both nonfatal myocardial infarction and coronary death in the 24 hours after drinking, among regular drinkers. The nonfatal myocardial infarction analyses included 278 male and 60 female cases identified from a population-based coronary heart disease surveillance program and 458 male and 266 female controls randomly selected from the same population matched by age and sex. In the coronary death analyses, 172 male and 16 female coronary death cases from the same surveillance program and a population-based sample of 294 males and 165 females who were age and sex matched were examined. Information on alcohol consumption in the 24 hours before the coronary event in cases and a comparable 24-hour period in controls was collected. Study subjects all drank alcohol regularly at least once per month and were aged 25-64 years. Controls were more likely than cases to report a drinking episode in the 24-hour period examined in both sexes and for fatal and nonfatal disease. After controlling for possible confounding, the authors found that drinkers had a consistently lower estimated risk of both fatal and nonfatal coronary heart disease than participants reporting no alcohol in the previous 24 hours. The odds ratios ranged from 0.75 (95% confidence interval 0.62-0.90) for nonfatal myocardial infarction in men to 0.46 (95% confidence interval 0.19-1.10) for coronary death in women. There were no clear differences in estimated acute risk among those who drank one or two drinks, three or four drinks, or more than four drinks in the 24-hour period. These findings suggest that, contrary to previous speculation, alcohol consumption may acutely reduce coronary heart disease risk.


Comparison of long-term dietary recall between cancer cases and noncases.

A quantitative history of current dietary intake based on 83 food items was administered by interview to a representative sample of 4,809 subjects in Hawaii in 1977-1979. In 1983-1987, this history was readministered to the 131 original respondents who had subsequently developed cancer, as well as 413 randomly selected subjects who remained cancer free. A surrogate was interviewed when the original subject was unavailable. The repeat interview elicited information about diet at the time of the original interview. The authors found that recall values for macronutrients were consistently higher than original levels for both cases and noncases, which may be due in part to a modification in the administration of the repeat questionnaire. Although there were no marked differences overall between cases and noncases in the ability to recall past diet, differences between the two groups were seen in certain subsets of the sample. In the subgroup with the longest recall interval (8-10 years), cases were not able to recall their diets as well as noncases. Also, the difference between original and recall values was larger for cases with colorectal cancer and all cases diagnosed with distant stage disease, compared with noncases. This was not true for cases of breast and prostate cancer and those with localized or regional disease. The following variables were found to have no significant effect on recall for cases or noncases: sex, age, education, and type of respondent (surrogate or subject). Of the five major ethnic groups included in the study, Japanese had the best recall of their past diets, while respondents reporting a diet change between the interviews had poorer recall than did those who reported no change. These results suggest that differential misclassification in dietary case-control studies may pose a significant problem in certain instances, but that these studies can yield meaningful results with certain constraints on the study population.


Cancer of the pancreas and drinking water: a population-based case-control study in Washington County, Maryland.

A case-control study was done to assess a potential association between drinking water and pancreatic cancer in Washington County, Maryland. Cases of pancreatic cancer occurring from 1975 through 1989 were identified from the cancer registry. Controls were selected from the private 1975 census of Washington County. There were 101 cases and 206 controls. Chlorinated municipal water was used as a source of drinking water by 79% of cases and 63% of controls, yielding a significant odds ratio of 2.2. Adjustment for age and smoking had almost no effect on the risk, although both age and smoking were independently associated with an increased risk of pancreatic cancer. Although these findings must be interpreted with caution because of limitations in exposure assessment, these results have implications for the prevention of pancreatic cancer because chlorination of water is so widely practiced.


Lymphohematopoietic cancer in styrene-butadiene polymerization workers.

1,3-Butadiene and styrene are suspected carcinogens and common chemicals used in the synthesis of rubber. To investigate any potential human hazards from exposure to these chemicals, a case-control study of 59 lymphohematopoietic cancers was conducted within a cohort of male workers employed between 1943 and 1982 in eight North American styrene-butadiene rubber polymer-producing plants. A total of 193 controls were matched to the cases by plant, age, year of hire, duration worked, and survival to time of death of the case. Each job was assigned an estimated exposure rank, and each worker's cumulated rank score was calculated on the basis of the time spent in each job throughout his employment. "Exposure" as a dichotomous variable was defined as a log rank score above the mean of the log scores for the total population of cases and controls within a subtype of cancer. Matched-pair analysis identified a strong association between leukemia and butadiene, with an odds ratio of 9.36 (95% confidence interval 2.05-22.9) and an association between styrene and leukemia (odds ratio = 3.13, 95% confidence interval 0.84-11.2) that did not achieve statistical significance. When exposure to both styrene and butadiene was included in a conditional logistic regression model, the odds ratio for butadiene remained high (odds ratio = 7.39), but the estimated association of leukemia with styrene was small. The results of this study support the hypothesis that exposure to butadiene is associated with the risk of leukemia. There also appears to be an additional risk from work in specific subdivisions of the industry.


Use of multiple-cause mortality data in epidemiologic analyses: US rate and proportion files developed by the National Institute for Occupational Safety and Health and the National Cancer Institute.

The authors have created US mortality rates (age, sex, race, and calendar-time specific) and proportions, using multiple cause-of-death data, for the years 1960-1989. Multiple cause-of-death data include the usual underlying cause of death from the death certificate as well as contributory causes and other significant conditions. US multiple-cause rates and proportions enable the user to calculate the expected occurrences of disease on the death certificates of a cohort under study. There is an average of 2.66 causes and/or contributory conditions listed on US death certificates, increasing over time from 2.54 in the 1960s to 2.76 in the 1980s. The ratio of multiple-cause listings to underlying cause listings varies by disease, from low ratios for cancers to high ratios for diseases such as diabetes, arthritis, prostate disease, hypertension, pneumoconiosis, and renal disease. Use of these data is illustrated with two cohorts. Multiple-cause analysis (but not underlying cause analysis) revealed twofold significant excesses of renal disease and arthritis among granite cutters. For workers exposed to dioxin, neither multiple-cause nor underlying cause analysis indicated any excess of diabetes, an outcome of a priori interest. Good candidates for multiple-cause analysis are diseases that are of long duration, not necessarily fatal, yet serious enough to be listed on the death certificate.


Unspecified injuries on death certificates: a source of bias in injury research.

Protective gear (for example, helmets and bulletproof vests) shields certain body regions from damaging energy. Failure to specify on death certificates the body region and nature of fatal injuries compromises the utility of mortality data for epidemiologic or prevention research. Of fatally injured California motorcyclists, 41% had no specific injuries listed on their death certificates in 1988. To examine the implications of this problem, the authors abstracted 186 coroner's or medical examiner's reports from four California counties with over 60% nonspecific injuries and one county with few such injuries. These data were merged with computerized death certificate files and with the Fatal Accident Reporting System. Among the 99 cases with nonspecific injury codes, 68% had head injuries, 63% had chest injuries, 58% had abdominal injuries, and 58% had extremity injuries. Reporting sensitivity in the four problem counties varied from 36% for head injury to less than 5% for abdominal, spinal, and extremity injury. The association between head injury and failure to wear a helmet was statistically significant using the coroner's diagnoses (p = 0.02), but not using death certificate diagnoses (p = 0.17). The value of mortality data to injury researchers would be enhanced by better reporting of the nature of injury on death certificates.


Psychoactive drugs and the risk of injurious motor vehicle crashes in elderly drivers.

To determine whether commonly used psychoactive drugs increase the risk of involvement in motor vehicle crashes for drivers > or = 65 years of age, the authors conducted a retrospective cohort study. Data were obtained from computerized files from the Tennessee Medicaid program, driver's license files, and police reports of injurious crashes. Cohort members were Medicaid enrollees 65-84 years of age who had a valid driver's license during the study period 1984-1988 and who met other criteria designed to exclude persons unlikely to be drivers and to ensure availability of necessary study data. There were 16,262 persons in the study cohort with 38,701 person-years of follow-up and involvement in 495 injurious crashes. For four groups of psychoactive drugs (benzodiazepines, cyclic antidepressants, oral opioid analgesics, and antihistamines), the risk of crash involvement was calculated with Poisson regression models that controlled for demographic characteristics and use of medical care as an indicator of health status. The relative risk of injurious crash involvement for current users of any psychoactive drug was 1.5 (95% confidence interval (CI) 1.2-1.9). This increased risk was confined to benzodiazepines (relative risk = 1.5; 95% CI 1.2-1.9) and cyclic antidepressants (relative risk = 2.2; 95% CI 1.3-3.5). For these drugs, the relative risk increased with dose and was substantial for high doses: 2.4 (95% CI 1.3-4.4) for > or = 20 mg of diazepam and 5.5 (95% CI 2.6-11.6) for > or = 125 mg of amitriptyline. Analysis of data for the crash-involved drivers suggested that these findings were not due to confounding by alcohol use or driving frequency.


Depressive symptoms and other psychosocial factors as predictors of stroke in the elderly.

The aim of this paper is to assess the influence of selected psychosocial factors as predictors of stroke incidence in a probability sample of noninstitutionalized elderly. The main psychosocial factor of interest was depression. Marital status, social support, social networks, and religiousness were also assessed as potential antecedent or mediating factors. The data were obtained from a prospective longitudinal study based on 2,812 individuals aged 65 years and over living in New Haven, Connecticut. The incidence of stroke was monitored from the baseline interview in 1982 until December 1988. Depression, measured by the Center for Epidemiologic Studies Depression Scale (CES-D), was measured at baseline as were other predictor variables. Univariate Cox regression analyses revealed that higher CES-D scores were predictive of greater stroke incidence (p < 0.05). More frequent attendance at religious services was associated with lower incidence (p < 0.001). CES-D scores were also correlated with many measures of sociodemographic, health, and physical function factors in our multivariate analysis (p < 0.05). When combined with other significant predictor variables such as age, sex, hypertension, diabetes, physical function, and smoking, neither depression nor religious attendance retained its significance.


Prevalence and risk determinants of human immunodeficiency virus type 2 (HIV-2) and human immunodeficiency virus type 1 (HIV-1) in west African female prostitutes.

The authors studied the prevalence and risk determinants for human immunodeficiency virus type 1 (HIV-1) and type 2 (HIV-2) in female prostitutes from Dakar (1985-1990), Ziguinchor (1987-1990), and Kaolack (1987-1990), Senegal, West Africa. Each cohort showed a distinct distribution of HIVs: 10.0% HIV-2 and 4.1% HIV-1 in Dakar, 38.1% HIV-2 and 0.4% HIV-1 in Ziguinchor, and 27.4% HIV-2 and 1.3% HIV-1 in Kaolack. In 1,275 female prostitutes from Dakar, increase years of sexual activity and a history of scarification were associated with HIV-2 seropositivity. In contrast, HIV-1 seroprevalence was associated with a shorter duration of prostitution and a history of hospitalization. In 278 female prostitutes from Ziguinchor, HIV-2 seroprevalence was associated with women of Guinea-Bissau nationality and increased years of sexual activity. In 157 female prostitutes from Kaolack, HIV-2 seroprevalence was associated with increased years of sexual activity and a history of never using condoms. The authors also studied the risk determinants for HIV-2 in the 1,280 Senegalese prostitutes pooled from all three sites. Controlling for ethnic group, women from Ziguinchor and Kaolack were more likely to be HIV-2 seropositive as compared with women from the Dakar site. Increased years of sexual activity were associated with HIV-2 seropositivity, while a history of excision and BCG vaccinations decreased the risk of HIV-2 infection.


The kidney in hypertensive pregnancies--victim and villain.

Many changes in renal function occur in normal pregnancy. Without a proper understanding of these changes, routine clinical investigations may easily be misinterpreted. Women with preeclampsia have further alterations in renal function and, in occasional cases, develop acute renal failure. Understanding of abnormal renal physiology and hormonal changes in these women allows the clinician to interpret biochemical tests appropriately and make proper use of vasodilator therapy with careful attention to volume homeostasis. Women who undertake pregnancy with a primary renal disease, most commonly glomerulonephritis or reflux nephropathy, have a higher risk of adverse fetal and maternal outcomes. Awareness of these risks provides a basis for proper preconceptual counseling, as well as careful monitoring of maternal blood pressure and renal function and fetal growth during such pregnancies. These strategies will optimize the chances of a successful pregnancy outcome for both mother and baby.


A randomized, double-blind, placebo-controlled trial to evaluate the effect of enalapril in patients with clinical diabetic nephropathy.

It is unknown if the antiproteinuric effect of angiotensin-converting enzyme (ACE) inhibitors reflects attenuation in the rate of progression of diabetic nephropathy. We report the results of a randomized, double-blind clinical trial designed to evaluate the longitudinal (18-month) effect of the ACE inhibitor, enalapril (5 to 40 mg/d), versus a placebo on 24-hour urinary protein excretion and on the rate of progression of renal disease in 33 patients with clinical diabetic nephropathy. Systemic blood pressure was controlled throughout the trial with conventional antihypertensive drugs. Glomerular filtration rate (GFR), determined by Tc99mDTPA renal clearance, and urinary protein excretion were monitored at 3-month intervals. Enalapril, in contrast to placebo therapy, was associated with an initial (40%) and sustained (33%) decrease in urinary protein excretion. Patients randomized to both enalapril or placebo experienced mean decreases in GFR, from 1.01 mL/s/1.73 m2 (61 mL/min/1.73 m2) to 0.85 mL/s/1.73 m2 (51 mL/min/1.73 m2), and from 1.06 mL/s/1.73 m2 (64 mL/min/1.73 m2) to 0.97 mL/s/1.73 m2 (58 mL/min/1.73 m2), respectively. Eleven of 18 patients (61%) randomized to enalapril, and 10 of 15 (66%) patients randomized to placebo, had a decrease in GFR; their rates of progression were -1.18 mL/min/1.73 m2/mo and -1.00 mL/min/1.73 m2/mo, respectively. In the absence of changes in blood pressure, the addition of an ACE inhibitor to patients with clinical diabetic nephropathy could not be shown to confer a unique renal protective effect. A prolonged decrease in 24-hour protein excretion could not be shown to predict attenuation in the progression of established clinical diabetic nephropathy.


Lupus anticoagulant in systemic lupus erythematosus: a clinical and renal pathological study.

Circulating lupus anticoagulant (LA) is associated with thrombosis in large and small vessels. To determine how often the presence of LA is associated with thrombosis within the renal microcirculation, 33 patients with systemic lupus erythematosus (SLE), renal dysfunction, and LA were identified over a 25-year period (LA group) and 32 patients with renal SLE but with normal gross coagulation screen were matched for age, sex, and biopsy timing (C group). Prevalences of serositis, neuropsychiatric illness, leukopenia, thrombocytopenia, hemolysis, anti-DS-DNA elevation, and complement reduction were similar. Arthritis was less and biologic false-positive (BFP) syphilis serology more common in LA. More LA patients had thrombotic events (LA 39% v C 13%; P = 0.014); bleeding episodes, including postbiopsy, were similar. At biopsy, hypertension (LA 55%, C 41%), serum creatinine (mean +/- SD: LA 186 +/- 168 mumol/L [2.1 +/- 1.9 mg/dL] v C 150 +/- 168 mumol/L [1.7 +/- 1.9 mg/dL]) and proteinuria (LA 2.6 +/- 3.1 g/24 h v C 3.1 +/- 2.7) were similar. Lesions by World Health Organization (WHO) class, activity, and chronicity indices, as well as immunofluorescence (IF) and electron microscopy (EM) findings, were not significantly different. Occlusive glomerular, arteriolar, and arterial fibrin thrombi, along with varying degrees of renal thrombotic microangiopathy, were seen in five of 33 patients with LA, but zero of 32 C patients (P = 0.053); three of these five patients died soon after biopsy. Overall, mortality was not different between LA and C. We conclude that the majority of patients with SLE, renal dysfunction, and LA exhibit renal morphologic findings indistinguishable from patients without LA. However, a significant minority of LA patients have thrombotic microangiopathy in their biopsy, which is accompanied by a worse prognosis.


Short-term responsiveness of membranous glomerulopathy to cyclosporine.

We administered a 12-week course of cyclosporine (CsA) (4 to 6 mg/kg/24 h) to nephrotic patients with membranous glomerulopathy (MG). Nephrotic patients with minimal change nephropathy (MCN) served as a comparison group. We evaluated the effects of CsA on proteinuria, glomerular function, and the release of cytokines by peripheral blood mononuclear cells in culture. Proteinuria was restored to normal levels within 2 to 4 weeks in MCN. Proteinuria declined from nephrotic to subnephrotic levels (< 3,500 mg/24 h) in 10 of 14 patients with MG, also within 2 to 4 weeks of onset of therapy. The four nonresponders exhibited a rapidly progressive and presumably irreversible form of MG culminating in renal failure. On average, fractional clearances of albumin and IgG declined by 59% and 73% in MG (P < 0.005); corresponding declines in MCN were by 99% (P < .0001). Corresponding rates of glomerular filtration in each glomerular injury remained unchanged. A strong trend for proteinuria to relapse after CsA was withdrawn was evident in both disorders. The release of tumor necrosis factor (TNF)-alpha by mononuclear cells in culture was enhanced in each glomerular injury, both before and after the course of CsA. We conclude that the proteinuria in most cases of MG exhibits a responsiveness to CsA that is qualitatively similar to, but less complete than, that in MCN. The rapidity with which barrier function improves suggests a possible role for cell-mediated immune injury in MG.


Dermal patch anesthesia: pain-free puncture of blood access in hemodialysis patients.

Clinical application of dermal patch anesthesia to relieve pain at venous cannulation of blood-access was studied in hemodialysis patients. Aqueous gel of 10% lidocaine base with 3% glycyrrhetinic acid monohemiphthalate disodium (GA MHPh 2Na) was applied for 60 minutes to the skin of the patients. Degree of pain was expressed as a pain score. Analgesic effect of the lidocaine gel was evaluated in 16 patients in a placebo-controlled, double-blind, cross-over design by comparing the gel with lidocaine with a placebo gel without lidocaine. The mean pin-prick pain score (1.0 +/- 0.5) in the lidocaine gel patch (n = 16) was significantly lower than that (2.3 +/- 0.3) in the placebo gel patch (P < 0.01). In 8.8% of the patients, blood pressure was elevated after venous cannulation, but this tendency was modified by dermal patch anesthesia with the lidocaine gel. Plasma concentration of lidocaine was under the detection limit of assay (< 0.05 micrograms/mL) after dermal patch anesthesia in six subsequent dialysis treatments.


Fungal peritonitis in continuous ambulatory peritoneal dialysis--the Auckland experience.

Fungal infection is an uncommon cause of peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD). We report our center's experience with 38 episodes of fungal peritonitis occurring in 33 patients, out of a total of 503 patients managed on CAPD over 11 1/2 years, and review the relevant literature. Our usual management philosophy has been one of early peritoneal catheter removal without antifungal therapy. In those with worsening clinical features, and in those with persistence of signs and symptoms beyond 48 hours after catheter removal, antifungal drugs were administered. Only five patients received antifungal therapy initially, followed by later catheter removal. Seventy-six percent of patients treated by catheter removal alone (N = 21) and 64% of patients treated by catheter removal followed by antifungal therapy (N = 11) were successfully reestablished on CAPD. A policy of early catheter removal, usually alone, but followed by antifungal therapy in select cases, can be associated with a mortality rate of less than 15% and a high rate of return to effective peritoneal dialysis.


Inguinal herniorrhaphy in the continuous ambulatory peritoneal dialysis patient.

Inguinal hernia repair in the patient on continuous ambulatory peritoneal dialysis (CAPD) is complicated in theory by an increased potential for recurrence. In addition to the constant increased intraabdominal pressure, chronic renal failure has been shown to impair tissue healing. Controversy exists regarding the waiting period before resuming CAPD postoperatively. A retrospective review of all CAPD patients undergoing inguinal herniorrhaphy was performed. The patient's age, type of repair, duration of renal failure preoperatively, length of time on CAPD postoperatively, and date of resumption of CAPD were recorded. An inpatient and outpatient chart review was performed on all patients. Telephone follow-up was performed on surviving patients. From April 1981 to June 1989, 30 patients underwent 36 inguinal herniorrhaphies while on CAPD. One immediate postoperative death occurred due to underlying cardiac disease. The mean follow-up for surviving patients was 34 months (range, 16 to 91) and for those deceased was 25 months (range, 1 to 60). No recurrent hernias were identified either by extensive inpatient and outpatient chart review, or by direct patient telephone contact in all surviving patients. We conclude that inguinal herniorrhaphy can be safely performed in CAPD patients. Peritoneal dialysis can be initiated immediately after repair in this high-risk group of patients. There is a low risk of recurrence; however, long-term patient survival is not expected due to concurrent underlying medical problems.


Fibromuscular dysplasia of the renal arteries associated with antiphospholipid autoantibodies: two case reports.

A relationship appears to exist between antiphospholipid autoantibodies (APLA) and vascular occlusion, although the exact mechanism is still a matter of debate. We present and comment on two cases of renal artery occlusion in patients with concomitant presence of arterial fibromuscular dysplasia and high APLA titers.


Treatment of antineutrophil cytoplasmic autoantibody-positive systemic vasculitis and glomerulonephritis with pooled intravenous gammaglobulin.

Antineutrophil cytoplasmic autoantibody (ANCA) is considered a serological marker for disease activity in patients with ANCA(+) systemic vasculitis. Recently, ANCA has been implicated as a pathogenic antibody that may be associated with neutrophil degranulation and release of lytic enzymes. Since intravenous gammaglobulin (IVIG) is known to contain antiidiotypic antibodies to ANCA, which could decrease the activity of the later, we chose to treat two patients with symptomatic ANCA(+) systemic vasculitis and glomerulonephritis with high-dose IVIG. The first patient, a 66-year-old man, developed rapidly progressive renal failure despite treatment with intravenous (IV) cyclophosphamide. The second patient, a 14-year-old boy, had relapsed 3 months after cessation of treatment with prednisone and cyclophosphamide. Both patients improved dramatically after treatment with IVIG, with the former recovering renal function within 11 days of therapy. In both patients, a concomitant reduction in serum ANCA titers was also observed. The second patient is currently in a sustained remission 14 months after his last IVIG dose on no other medication. These cases provide clinical evidence that IVIG has therapeutic benefit in modifying the immune-mediated injury associated with ANCA(+) systemic vasculitis and glomerulonephritis. In addition, IVIG may provide an additional safe therapeutic option to clinicians treating patient's with ANCA(+) vasculitis and glomerulonephritis who are not responsive to or are experiencing toxicity from conventional therapy.


Severe arteriosclerosis in the kidney of a cocaine addict.

Cocaine abuse has been associated with sudden cardiac death with coronary artery thrombosis with or without underlying vessel disease. Additional vascular beds thus far implicated in cocaine-associated arteriopathy include thoracic and abdominal aorta, and pulmonary, cerebral, and placental vessels; abnormalities include vasospasm, thrombosis, and accelerated atherosclerosis. We report the case of an adult male cocaine user with severe arteriosclerosis of renal vessels, and suggest that cocaine may also affect the renal vasculature.


Unusual glomerular lesion in a patient receiving long-term interferon alpha.

A 60-year-old man with long-standing chronic myelogenous leukemia presented with renal insufficiency and proteinuria after more than 6 years of therapy with daily interferon alpha injections. He also manifested unusual skin lesions and a low-titer antinuclear antibody (ANA). Percutaneous renal biopsy disclosed an unusual glomerular lesion characterized by global, diffuse, and marked widening of the lamina rara interna, and focal segmental mesangial proliferation. Discontinuation of the drug resulted in resolution of the proteinuria, but not the renal insufficiency. These glomerular changes have not been reported previously as a complication of this form of malignancy and are similar to lesions reported in newborn rats and mice receiving interferon alpha. The potential role of interferon alpha in the development of this glomerular disease is discussed.


The natriuretic peptides and their receptors.

Atrial natriuretic factor (ANF) is released from the cardiac atrium in response to stretch and acts through receptors to cause an increase in urinary flow and sodium excretion, vasodilatation, and a reduction in blood volume. Recently, two new natriuretic peptides, brain natriuretic peptide (BNP) and C-type natriuretic peptide (C-typeNP), have been isolated, and three different natriuretic peptide receptors have been identified. Two of the receptors, ANP-RGC(A) and ANP-RGC(B), mediate biologic actions. The natural ligand of ANP-RGC(A) is ANF, whereas that of ANP-RGC(B) is C-typeNP. In view of clear differences in ligand specificity and tissue distribution of these receptors, it has been proposed that ANF and its receptor, ANP-RGC(A), and C-typeNP and its receptor, ANP-RGC(B), represent two distinct natriuretic peptide regulatory systems. Whether a separate system exists that incorporates BNP awaits clarification of its natural receptor that mediates a biologic action. The third receptor, ANP-Rc, binds all three natriuretic peptides. Its messenger RNA lacks the guanylyl cyclase sequence present in the mRNA of the other natriuretic peptide receptors, suggesting that the principal function of ANP-Rc is to remove natriuretic peptides from the circulation, that is, to regulate plasma levels of the natriuretic peptides. However, ANP-Rc may also mediate a biologic effect. These findings raise several intriguing questions about the functional role of this family of natriuretic peptides.


Patient selection to peritoneal dialysis versus hemodialysis according to comorbid conditions.

An historical prospective sample of 2,420 non-diabetic and 1,738 diabetic Medicare patients incident from 1986-87 was analyzed for the selection of patients to peritoneal dialysis (PD) and hemodialysis (HD) according to comorbid factors. Data measuring the degree of comorbidity, describing the major diagnosis leading to end-stage renal disease (ESRD), and reporting other sociodemographic factors for incident ESRD patients were collected in a special study of the USRDS. Patients selected to PD were more likely to be white (greater mortality risk), diabetic (greater mortality risk), and younger (lower mortality risk) than patients assigned to HD. Estimates of the overall level of comorbidity with adjustment for race, gender, diabetes, and age provided evidence of a reduced total count of comorbid factors for PD compared to HD, particularly among diabetic patients under 60 years of age (p < 0.01). Assessment of selected risk factors, with adjustment for age and diabetes, indicated that patients selected to PD were not at greater comorbid risk according to cardiovascular factors but demonstrated a 20 percent increase in the likelihood of peripheral vascular disease (p = 0.02).


Mortality of blacks and whites with end-stage renal disease attributed to hypertension.

Demographic and mortality analyses were performed for all Medicare black (26,100) and white (31,859) ESRD patients from the USRDS database who were incident between 1977 and 1988, and for whom the reported cause of ESRD was hypertension. Over the years 1977-88, the incidence rates increased markedly. The median age for both black and white incident patients also increased, while the percent of patients who were black decreased over time. Percent survival at one year and five years after onset of ESRD was significantly higher and statistically significant in black patients whose ESRD developed in the middle and older ages, compared to white patients of the same age group.


Comorbid conditions and correlations with mortality risk among 3,399 incident hemodialysis patients.

The percent distribution of selected comorbid conditions from a national sample of 3,399 Medicare patients starting maintenance hemodialysis in 1986-87 is described. Using the Cox proportional hazards model, the relative mortality risk (RR) was assessed for comorbid conditions at time of ESRD while adjusting for the other comorbid and demographic covariates. Coronary artery disease and congestive heart failure, each present in 41 percent of patients, were associated with RR of 1.22 and 1.26 respectively (p < 0.0005 each). Fifty percent of patients had a serum albumin concentration at onset of ESRD of less than 3.5 gm/dl, and an increased risk of dying. Additionally, patients recorded as undernourished had an elevated risk (RR = 1.34, without adjustment for serum albumin, p < 0.0001). Other factors associated with a statistically significant increased mortality risk (p < 0.005) included older age, diabetes as cause of ESRD (particularly if insulin dependent), history of neoplasm, active smoker, and relatively low serum creatinine concentration. By describing the magnitude of risk associated with comorbid conditions, this study emphasizes the need for preventive efforts during the pre-ESRD stages of renal impairment. Studies are needed to document whether improvement in serum albumin or other comorbid factors before ESRD leads to reduction in mortality risk for ESRD patients.


Characteristics of dialysis prescriptions in the US, 1986-1987.

We analyzed the dialysis prescription parameters for 4,532 randomly chosen incident Medicare patients who reached end-stage renal disease (ESRD) in 1986-87. Data were abstracted from the patient's record by the ESRD Networks. Dialysis prescription was assessed at one month following onset of ESRD. Eighty-four percent (3,823) of these patients were initially treated with hemodialysis, while the remaining 16 percent (709) were treated initially with continuous ambulatory peritoneal dialysis (CAPD). Average age for hemodialysis patients was 58, which was five years older than the average found for CAPD patients. Black patients were heavier than white patients by three kilograms, on average; black patients also had a somewhat higher body mass index. Hemodialysis prescriptions averaged 2.9 treatments per week, for a total of 9.8 hours of hemodialysis per week. Black patients had a four percent longer hemodialysis prescription (hours) per week than did white patients. Although black patients were heavier than white patients, their prescribed Kt/V was similar to that prescribed for white patients. On average, the prescribed Kt/V was 1.0. Twenty-two percent of patients had a prescribed Kt/V of less than 0.80. Compared to ESRD patients treated in the European Dialysis and Transplant Association (EDTA), the prescription for this sample of incident US hemodialysis patients was 25 percent shorter in total hours per week. Dialyzers were reused in approximately 65 percent of hemodialysis patients. CAPD patients had an average prescription of 52 liters of exchange per week with typically four exchanges per day and two liters per exchange.


Catheter-related factors and peritonitis risk in CAPD patients.

In a national study of essentially all patients starting CAPD therapy at home during January through June, 1989 (n = 2,807), the peritonitis risk was assessed by patient demographics, connection techniques, and catheter-related factors. The present report focuses on several CAPD catheter-related factors, while adjusting for other patient and facility characteristics using Cox proportional hazards models. This study also provides a description of the actual practice, utilization, and insertion of peritoneal catheters. The relative peritonitis risk, assessed during the 10.5 to 21 month follow-up in days to first peritonitis episode, was increased for single-cuff versus double-cuff catheters (RR = 1.20, p = 0.01) and with use of intraperitoneal drugs (RR = 1.14, p = 0.08). A lateral catheter placement was associated with a reduced relative risk, but this finding deserves further study. No significant association with peritonitis risk was found for catheter design, insertion technique or operator, nor for antibiotic prophylaxis at time of catheter placement. This study defines the magnitude of relative risks in a national sample, and helps direct future work towards reducing the risk of peritonitis and/or catheter loss in CAPD patients.


Mortality rate comparisons of never, previously, and currently transplanted ESRD patients.

Based on analysis of data for 68,683 end-stage renal disease (ESRD) patients per year (on average) prevalent between 1987-89, we report mortality rates for never (NTD) and previously (PTD) transplanted dialysis patients and for patients with a first functioning cadaveric transplant (Tx). Data are for black and white patients between the ages of 20 and 65. Using death rates for all ESRD patients as the standard and adjusting for age, race, and diagnosis, the standardized mortality ratios (SMRs) were 1.24, 1.35, and 0.37 for NTD, PTD, and Tx patients, respectively (significantly different from 1.0, p < 0.001). In a direct comparison between NTD and PTD patients, the mortality rate among PTD patients was typically 91 percent (p < 0.001) of the rate among NTD patients, although the size of the ratio varied by race, being 81 percent (p < 0.001) and 96 percent (ns) for black and white patients, respectively. This indicates that part of the reduction in mortality among transplant patients relative to dialysis patients might be attributable to selection of healthier patients for transplant, since PTD patients have lower death rates than do similar NTD patients; and that the overall selection mechanism varies by race.


Simultaneous kidney-pancreas transplantation versus kidney transplantation alone: patient survival, kidney graft survival, and post-transplant hospitalization.

This study compared patient survival, kidney graft survival, and post-transplant hospitalization between patients who received simultaneous kidney and pancreas (SKP) transplants and those who received a kidney transplant alone (KTA). A total of 3,168 diabetic end-stage renal disease (ESRD) patients, ages 18-45, who began their first ESRD treatment between 1981 and 1989 and received their first cadaveric kidney transplant between 1986 and 1989 were selected for study; patient and kidney graft survival were followed until 1 March 1990. Twelve percent (380) of these patients received SKP transplants. No statistically significant difference in patient survival was found between SKP and KTA patients (p = 0.86). Kidney graft survival was statistically significantly higher for SKP patients than KTA patients (p = 0.008). Post-transplant hospitalization rates were statistically significantly higher for SKP patients (p < 0.001), indicating potentially higher post-transplant morbidity among this group.


How good are the data? USRDS data validation special study.

Four national samples, totaling 1,692 cases selected from ESRD patients incident in 1986 and 1987, were analyzed to document the reliability of the USRDS database. For these cases, the reported data in the USRDS database were compared with on-site source documents (medical records, hospital discharge summary records, transplant summaries, and billing records). The results show an overall agreement rate of 90.6 percent for over 50 variables. Agreement rates on the most important fields range from a low of 87.0 percent for point-in-time variables (eg, modality of treatment at the end of the year), to a high of 94.9 percent for dates (eg, date of birth, death, first ESRD service). The study concludes that (1) appropriate definitions and protocols are needed in the assessment of the primary disease causing ESRD, and (2) formal definition of when the patient becomes an ESRD patient needs review. This study points to the strengths and limitations of the USRDS database and indicates areas that need to be addressed to improve current and future data collection efforts.


Completeness and reliability of USRDS data: comparisons with the Michigan Kidney Registry.

A census of 12,730 Medicare-eligible ESRD patients identified in the USRDS database as living in Michigan or as having received treatment in Michigan between 1977 and 1987 was compared to the 13,424 ESRD patients listed in the Michigan Kidney Registry (MKR) who were alive between 1977 and 1987. Of 7,600 USRDS patients with both residence and ESRD treatment in Michigan, 97.8 percent were also found in the MKR, thus providing evidence that the USRDS is not overstating the size of the ESRD population. Overall, 11.4 percent of the cases in the MKR could not be matched to the USRDS; however, the rate of matching showed a slight upward trend over time. Subsequent analysis shows that after excluding those cases expected not to be captured by the Medicare system, only 5 percent of MKR cases were left unmatched to USRDS cases. Some of these unmatched cases from the MKR were found to have short follow-ups, while others belong to groups not covered by Medicare without being noted as such by the MKR database. A high level of exact agreement on data elements for cases found in both databases was documented for demographic variables, above 90 percent. However, differences were found between the USRDS and the MKR databases on elements related to treatment history. It is likely that a lower precision of the dates associated with treatment episodes and difficulty in recording short term treatment episodes in the USRDS could account for the differences found.(ABSTRACT TRUNCATED AT 250 WORDS)


Improvements in data quality in the USRDS database: determining treatment modalities.

Past USRDS estimates of the prevalent ESRD population have exceeded the counts reported by the HCFA Annual Facility Surveys. One expects the USRDS estimates to be lower because the Facility Surveys include non-Medicare patients generally not in the USRDS database. The methodology for determining the treatment histories of patients has been modified to define lost to follow-up periods as periods of at least one year during which the patient has no dialysis data and does not have a functioning transplant. Patients are not counted as prevalent when they are in such a lost to follow-up period. This change brings the USRDS year end prevalent counts down to about 94 percent of the Facility Survey counts of total dialysis patients and slightly over the Facility Survey counts of Medicare dialysis patients. This change raises prevalent mortality rates by about seven percent over the rates reported in the 1991 USRDS Annual Data Report. We expect to make further refinements in this methodology.


Use of death certificates in epidemiological studies, including occupational hazards: discordance with clinical and autopsy findings.

There has long been evidence of frequent inaccuracy of death certificates, with significant discordance between such designations and clinical and autopsy data. This exists for occupational diseases as well. The use of statistical rates based on death certificates has been seriously questioned despite their utility for total mortality. Programs to supplement death certificate data, particularly in occupational disease studies, may be helpful, and are reviewed.


Use of death certificates in epidemiological studies, including occupational hazards: variations in discordance of different asbestos-associated diseases on best evidence ascertainment.

There is extensive information on discordance in general between accuracy of medical diagnoses on death certificate categorization of cause of death and available clinical and histopathological data. This is as true for occupational disease as for other conditions. But occupational illnesses bear a special problem. Discordance is not equal across the board--it may vary with each occupationally related disease, and no single formula can be applied. It may be high for angiosarcoma and low for acute hydrogen sulfide poisoning, low for bladder cancer, high for unsuspected methyl mercury poisoning. We have found that for one agent--asbestos--there were different rates of discordance for different asbestos-related diseases (e.g., lung cancer, mesothelioma, asbestosis, kidney cancer) among 4,951 deaths studied prospectively from 1967 to 1986. Caution is therefore required before accepting generalizations concerning (unstudied) discordance in occupational mortality studies, and in their use in risk assessment models.


Death certificates in epidemiological studies, including occupational hazards: inaccuracies in occupational categories.

We compared death certificates for asbestos-associated diseases (mesothelioma, lung cancer, asbestosis) in two asbestos workers' cohorts. One (insulation workers) had current or recent employment and a strong, continuing union support system which gave them much information about the effects of asbestos exposure. The second cohort, asbestos factory workers, had no such advantage. The factory had closed almost 30 years before, and its workers had dispersed into many areas of the state and nation. Accuracy of medical diagnosis was comparable in the two groups, but occupational listings were not. Three-quarters of the insulators' death certificates told of asbestos work, while virtually none of the factory workers' certificates provided such information, even for deaths of mesothelioma and asbestosis. The data indicate that disease categories, based on medical and pathological diagnoses, at least for asbestos-associated disease, tend to be accurate. Attempts to identify groups at risk by sorting occupational categories can give variable results, good for those with current exposures, much less satisfactory for those with long-past occupational exposures.


A case-control study of cancer of the nose and paranasal sinuses and occupational exposures.

The association between nasal cancer and various occupations was investigated in a case-control study in the provinces of Verona and Vicenza (northeastern Italy) and Siena (central Italy). Cases of malignant epithelial neoplasm of the nasal cavities and paranasal sinuses diagnosed in the years 1982-1987 in the hospitals of Verona, Legnago, Bussolengo, Vicenza, and Siena comprised the study. Controls were patients admitted to the same hospitals as the cases, with any diagnosis except chronic rhino-sinusal disease and nasal bleeding. Age, gender, residency, and date of admission were taken into account by matching. Cases and controls, or their next of kin, were interviewed or required to fill in a mailed questionnaire; the overall response rate was 70%. Altogether, 78 cases and 254 controls provided information on occupational history. Significantly increased risks were associated (in males) with work in the wood industry (odds ratio [O.R.]: 5.8; 90% confidence interval [C.I.]: (2.2-16) and in the leather industry (6.8; 1.9-25). Textile workers, furnacemen, construction workers, and workers with possible exposure to organic dusts showed increased risks even if statistical significance was not reached.


Malignant mesothelioma of the pleura in Trieste, Italy.

One hundred and seventy malignant pleural mesotheliomas seen at necropsy at the Institute of Pathological Anatomy of the Trieste University during the period 1968-1987 were reviewed. The series included 153 men and 17 women, aged between 33 and 92 years (median 70 years). Lifetime work histories were obtained from the patients' relatives by personal or telephone interviews in 162 cases. A majority of the male subjects had been employed in "naval" work, 99 people having worked in the ship-building industry, 19 in the navy and merchant marine, and 7 in docks. A variety of trades appeared in the remaining histories. Work histories were indicative of occupational exposure to asbestos in 150 cases. A further 5 patients with negative or insufficient data showed asbestos bodies in routine lung sections and 5 women had a history of domestic exposure. A majority of the patients had had their first exposure before 1950. The intervals between first exposure and death ranged from 14 to 71 years (median 48 years).


Acute high dose exposure to benzene in shipyard workers.

Fifteen degassers were acutely exposed over several days to high concentrations (> 60 ppm) of benzene during removal of residual fuel (degassing) from shipboard fuel tanks. Medical surveillance evaluation mandated by the Occupational Safety and Health Administration's (OSHA) Benzene Standard initially revealed 11 workers (73%) reporting neurotoxic symptoms while degassing. Workers with more than 2 days (16 hours) of acute exposure were significantly more likely to report dizziness and nausea than those with 2 or fewer days of acute exposure. Repeated laboratory analyses performed over a 4-month period after the acute exposure revealed at least one hematologic abnormality consistent with benzene exposure in 9 (60%) of these degassers. One year later, 6 workers (40%) had persistent abnormalities; an additional worker with normal hematologic parameters at the time of our initial evaluation subsequently developed an abnormality consistent with benzene exposure. Numerous large granular lymphocytes were observed on 6 (40%) of the peripheral blood smears. Despite these laboratory findings, there were no significant associations between the presence of hematologic abnormalities and either the number of hours of acute benzene exposure or the duration of employment as a degasser. Volatilization of benzene from the residual fuel was the suspected source of benzene in the headspace of tanks. Confined space exposure to petroleum products may be exposing workers to benzene at levels above the OSHA Short-Term Exposure Limit (STEL). This situation warrants further study.


Study of sperm characteristics in persons occupationally exposed to lead.

The sperm characteristics of 38 male workers exposed to lead in a battery factory were studied. Sperm analysis was performed after 4 days of sexual abstinence. Parameters analyzed were: volume, sperm count, motility, and morphology. Exposure levels were estimated by measuring the concentration of lead and delta-aminolevulinic acid in the serum. Based on blood lead levels, the tested individuals were divided in three groups: A (12), B (11), and C (15). Significant levels of asthenospermia and teratospermia were found in exposed workers when compared with unexposed controls. Long-term exposure to lead may lead to changes in sperm characteristics and function.


Epidemiologic evidence of cancer in aluminum reduction plant workers.

This paper reviews the epidemiologic evidence of cancer risks among workers in aluminum reduction plants with emphasis on associations with specific work areas and exposures. Studies of workers manufacturing carbon products outside the aluminum industry were also reviewed since the work environment is similar to that encountered in the carbon area of aluminum plants. We obtained 22 reports from references cited in earlier reviews, through compact disc literature search 1980-1990, and from the Nordic Aluminum Industry's Secretariat for Health, Environment and Safety. Six reports were excluded because the material was included in later studies or because a critical evaluation was impossible. This left 16 publications from 11 separate studies. Work in potrooms with Söderberg electrolytic cells was associated with increased risk of bladder cancer, and the increase was correlated to duration of tar exposure. There was a suggestion of increased risk of leukemias and pancreatic cancers in potroom workers, and of kidney and brain cancers without any clear association with specific exposures or work areas. Singular results showed associations between lung cancer risk and tar exposure in Söderberg plants, and between lung cancer and work in prebake or carbon plants, but interpretation was limited by inadequate data on smoking and asbestos exposure, and by problems connected with the choice of reference populations in these studies.


Health and safety education for worker empowerment.

This article introduces a special issue of the American Journal of Industrial Medicine dedicated to innovative approaches to worker education in health and safety. Contributors to this issue describe applications of an "empowerment approach" in a wide variety of institutions and settings throughout the United States and Canada. In this article, empowerment education is presented and contrasted with other training methodologies. The article offers suggestions on how to implement this approach discusses evaluation issues, and summarizes the articles contained in this issue. Explored are preliminary outcomes of using this methodology and implications for developing educational programs in the future.


Workshops are not enough: making Right-to-Know training lead to workplace change.

The underlying intent of Right-to-Know laws and regulations is to improve workplace conditions through worker empowerment. These regulations require employers to educate their employees about the nature and hazards of toxic substances found in the workplace, and methods to reduce exposure. This paper describes a Right-to-Know training program for over 4,000 local government employees which involved workers, their union, and management in the planning, implementation, and evaluation of the program. A combination of quantitative and qualitative evaluation determined the program was successful at individual, group, and structural levels. The evaluation results suggest that Right-to-Know training programs can make an important contribution to improving workplace health and safety when they are a well-integrated component of a comprehensive safety and health program: they use participatory training methods, they are tailored to address specific conditions faced by the participants, and there is active labor-management collaboration.


A participatory workplace health and safety training program for ethylene oxide.

The Occupational Safety and Health Administration (OSHA) has regulated ethylene oxide (EtO) on the basis of its acute toxicity and its potential carcinogenic and reproductive effects since 1971. OSHA's 1984 EtO standard and its 1988 revisions focused new attention on health and safety training and other preventive measures. An EtO health and safety training program for hospital sterilization workers was developed by the staff of an independent occupational and environmental health clinic. Participatory and empowerment training methods were central to the approach. Also included were hands-on, demonstration, interactive presentation, and other methods. An EtO Health and Safety Training Manual was developed based on the training experiences. This paper presents the challenges, benefits, and limitations of incorporating participatory and empowerment approaches in the design, implementation, and evaluation of EtO health and safety training.


Teaching health and safety: problems and possibilities for learner-centered training.

The University of Massachusetts at Lowell Work Environment Department, working jointly with four New England coalitions on occupational safety and health (COSH) groups, has developed and is delivering participatory and learner-centered health and safety training for hazardous waste site workers and emergency responders throughout New England. This consortium has created a technical curriculum for hazardous waste workers accessible to the nonspecialist and which, more importantly, draws upon workers' own experience and knowledge as a source of information, education, and experiential resources. In this article, we examine the goals of the consortium, the applicability of the training method, its successes and failures, and the wider implications such pedagogical techniques have for effective and empowering health and safety training. We conclude that such a teaching technique is a successful means of providing technical knowledge and skills in a positive and rewarding atmosphere. We also conclude, however, that the extent to which this form of education is empowering, as is claimed by many of its proponents, is less clear-cut.


Problem-solving in the fields: an action-oriented approach to farmworker education about pesticides.

This paper describes two educational programs initiated to address the problems of farmworker pesticide poisoning in Nicaragua and in the United States and Puerto Rico. Both programs utilize a participatory and action-oriented educational methodology known as popular education. The methodology is presented using examples to demonstrate its application to the planning, delivery and evaluation of pesticide education programs. Preliminary outcomes of using this methodology are also explored as well as implications for developing future training programs in the field.


Hardware to hard hats: training workers for action (from offices to construction sites).

A university-based labor education program provides training to unionists, emphasizing the skills needed by workers and their representatives in order to promote their rights to health and safety on the job. The article describes two examples of this training approach. The first example is a training program for video display terminal (VDT) operators which prepares them to take a leadership role in advancing policies to regulate working conditions for VDT users. The second is a program designed to improve the quality of safety, or "tailgate" meetings in the construction industry by promoting an approach that encourages active worker participation in identifying potential hazards and developing solutions. The methodologies used to achieve action-oriented outcomes are described.


"Let's Talk Back": a program to empower laundry workers.

Laundry workers have traditionally been offered little input into the ergonomic and health and safety aspects of their jobs. The "Let's Talk Back" program was developed in response to worker demands, in order to empower them to effectively address some of these concerns. The program, endorsed by the union and administered by a hospital ergonomist, provided formal educational sessions, physical demand analyses, and a forum in which to communicate concerns and suggestions for improvements. Language and/or literacy barriers required innovative educational approaches. Management's reluctance to allow the program to interfere with production schedules hindered the efficiency of the program, but probably contributed to the sense of empowerment in the workforce. Through active participation in ergonomic assessments as well as the educational program, workers were able to demonstrate to management that changes were needed.


Human immunodeficiency virus/acquired immunodeficiency syndrome training from a union perspective.

The authors developed a union sponsored 2-day human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) "train the trainer" program for healthcare workers in the San Francisco Bay Area. The program incorporated the "education for action" approach in an effort to respond to the inadequacies in many traditional, institutional trainings. Service Employees International Union (SEIU) and Labor Occupational Health Program (LOHP) conducted the HIV/AIDS "train the trainer" program for approximately 100 healthcare workers in county public hospitals and community health clinics. After completing the program, these workers went back to their healthcare facilities, or community organizations, and led additional classes on HIV/AIDS transmission and prevention for approximately 600 more people. The goal of the program was to empower healthcare workers to: 1) identify the occupational risks associated with exposure to blood and potentially infectious body fluids at the workplace; 2) develop strategies to reduce those risks; 3) discuss their feelings about caring for an HIV/AIDS patient; and, 4) conduct HIV/AIDS workshops at the workplace.