Access to heart disease and stroke care in Tennessee.

Tennessee is ranked fourth-worst in the United States for deaths caused by stroke and third-worst in the nation for cardiovascular deaths. Two recent surveys provide information about the geographic distribution of hospital-based, primary and secondary care promotion, and of emergency medical services for these disease conditions. This article is a synthesis of selected findings from these surveys to identify priority populations for interventions to reduce cardiac and stroke mortality in Tennessee. Twenty-three counties have a medical facility with a formal clinical pathway or system for implementing cardiovascular disease prevention strategies. Sixty-three of the state's 95 counties have no designated specialty center for an EMS service to transport cardiac and stroke patients. Fifty-six counties, comprising 38 percent of the state's population, lie between 20 and 50 miles from the nearest state-of-the-art stroke care. Twenty-one counties, containing nearly 10 percent of the state's population, are greater than 50 miles from advanced stroke care facility. Some health districts are faring better than the state proportion (86.8 percent) for people indicating they would call 911 for a suspected cardiac or stroke emergency, while many are performing much poorer. The Shelby district (Memphis) is much higher (p < 0.01), while Madison and South Central districts are well below the state's prevalence (p < 0.001). The fact that these "less-likely-to-call-911" areas are also in mostly rural settings poses priority challenges for public education. To combat this trend, coordinated efforts are in progress to incentivize the development of cardiac and stroke centers or, alternatively, the formation of regional collaborative networks affiliated with a specialty center.

Occupational exposure to trichloroethylene and cancer risk for workers at the Paducah Gaseous Diffusion Plant.

OBJECTIVE: The Paducah Gaseous Diffusion Plant (PGDP) became operational in 1952; it is located in the western part of Kentucky. We conducted a mortality study for adverse health effects that workers may have suffered while working at the plant, including exposures to chemicals. MATERIALS AND METHODS: We studied a cohort of 6820 workers at the PGDP for the period 1953 to 2003; there were a total of 1672 deaths to cohort members. Trichloroethylene (TCE) is a specific concern for this workforce; exposure to TCE occurred primarily in departments that clean the process equipment. The Life Table Analysis System (LTAS) program developed by NIOSH was used to calculate the standardized mortality ratios for the worker cohort and standardized rate ratio relative to exposure to TCE (the U.S. population is the referent for ageadjustment). LTAS calculated a significantly low overall SMR for these workers of 0.76 (95% CI: 0.72-0.79). A further review of three major cancers of interest to Kentucky produced significantly low SMR for trachea, bronchus, lung cancer (0.75, 95% CI: 0.72-0.79) and high SMR for Non-Hodgkin's lymphoma (NHL) (1.49, 95% CI: 1.02-2.10). RESULTS: No significant SMR was observed for leukemia and no significant SRRs were observed for any disease. Both the leukemia and lung cancer results were examined and determined to reflect regional mortality patterns. However, the Non-Hodgkin's Lymphoma finding suggests a curious amplification when living cases are included with the mortality experience. CONCLUSIONS: Further examination is recommended of this recurrent finding from all three U.S. Gaseous Diffusion plants.

Time-period mortality patterns in a Gaseous Diffusion Plant workforce.

BACKGROUND: We sub-divided a cohort of 6820 workers at the Paducah (KY) Gaseous Diffusion Plant (PGDP) which was traced from 1953 to 2003. The subdivisions were made to assess the mortality risks in a sub-group of workers employed solely during the plant's refit period, a time of suspected higher exposure to metal dusts (nickel, arsenic, chromium and uranium) and trichloroethylene. METHODS: This article describes a comparison of exposures and causes of death for 754 workers employed exclusively during the period of 1975-1979, with 1554 workers who worked in this period as well as other years. This interval was when the gaseous diffusion cascade facilities were re-fit. The workers employed 'only' during this period have a variety of deterministic factors (age-at-hire, duration of employment) that distinguish this sub-group of employees from the 'long-term' workforce. RESULTS: The 'only 1975-1979' workers had a larger fraction of minorities and female workers. This 'only' sub-group was disproportionately employed in unskilled labor positions. The 'only' workers were younger than the referent group, and a 14-year earlier mean age at death. The all-cause mortality standardized rate ratio [SRR] was 1.58 [95% Cl: 0.97-2.42]. The 'only' group was significantly different from the 'ever' workers with respect to suicides, SRR = 3.74 [95% Cl: 1.86-6.69], and for homicides, SRR = 11.71 [95% Cl: 3.20-30.03]. CONCLUSIONS: These elevated mortality risks do not seem to be due to PGDP employment exposures to metal dusts or trichloroethylene. Socio-economic factors may be a determinant for the patterns of suicides and murders described for this sub-group of employees. These findings provide guidance for communities with a dominant local employer. Persons who experience short-term hiring may warrant public health services to mitigate their risk of tragic deaths. A case-control study of these deaths is recommended to clarify individual risk behaviors.

Cohort follow-up: the 21st century procedures.

The basic logic of designing an occupational cohort study has changed little since William R. Gaffey outlined the issues of follow-up, measurement of exposure, and analysis of data. However, many new avenues of tracking workers for epidemiological studies have been developed since Gaffey wrote his paper in 1973. Many disease registries also perform follow-up of subjects for vital status determination, so the procedures used with this process are common to the two applications. This article speaks to cohort construction for this occupational research as well as describes the 2007 methods for vital status follow-up. Rises in concern about work-related disease risks and the scientific resources for performing these studies coincided with the computer revolution. Government and private sources of data on vital status have changed in several ways over the 35 years since Gaffey's seminal paper. Some systems make the process of follow-up more rapid and productive, and some barriers have been imposed as societal concerns for privacy have risen. We describe the process of linking 5 sources of data to compile a roster of 6,820 workers employed at the Paducah Gaseous Diffusion Plant from 1953 to 2003. The record linkage processes achieved a final death cohort of 1672 deaths--the ascertainment of these deaths (by time period) was 1379 (1979-2003) and 293 (1953-1978); follow-up then was 100% for this cohort.