Implementation of an active, clinic-based child tuberculosis contact management strategy in western Kenya.

Tuberculosis (TB) is a leading cause of childhood mortality. Isoniazid preventive therapy significantly reduces progression to TB disease. The World Health Organization recommends that high TB burden countries conduct child contact management (CCM) to identify exposed child contacts aged <5 years for screening and appropriate treatment. An active, clinic-based CCM strategy incorporating transport/screening reimbursement, monitoring and evaluation tools, and health care worker education was implemented in western Kenya. Among 169 identified child contacts aged <5 years, 146 (86%) underwent successful screening, of whom 43 (29%) were diagnosed with active TB. We describe our CCM strategy and its potential for enhancing screening and treatment efforts.

La tuberculose (TB) est une cause majeure de mortalité des enfants. Le traitement préventif par isoniazide réduit significativement la progression vers la TB maladie. L'Organisation Mondiale de la Santé recommande aux pays durement frappés par la TB de réaliser une prise en charge des enfants contacts (CCM) afin d'identifier les enfants contacts âgés de <5 ans exposés en vue d'un dépistage et d'un traitement appropriés. Une stratégie active de CCM basée sur la clinique incorporant le transport/le remboursement du dépistage, les outils de suivi et évaluation et l'éducation du personnel de santé a été mise en œuvre dans l'Ouest du Kenya. Sur 169 enfants contacts identifies âgés de <5 ans, 146 (86%) ont eu un dépistage réussi, dont 43 (29%) ont eu un diagnostic de TB active. Nous décrivons notre stratégie de CCM et son potentiel d'aMÉlioration des efforts de dépistage et de traitement.

La tuberculosis (TB) es una causa mayor de mortalidad en la niñez. El tratamiento preventivo con isoniazida disminuye de manera considerable la progresión hacia la enfermedad activa. La Organización Mundial de la Salud recomienda a los países con alta carga de morbilidad por TB que practiquen la gestión de los contactos pediátricos (CCM), con el fin de reconocer a los niños menores de 5 años de edad expuestos, realizar la detección de la TB y ofrecer el tratamiento apropiado. En Kenya occidental se introdujo en los consultorios una estrategia activa de gestión de los contactos pediátricos, que comportaba el reembolso de los gastos de transporte y detección, instrumentos de supervisión y evaluación y educación de los profesionales de salud. De los 169 contactos pediátricos menores de 5 años de edad encontrados, se practicó una detección adecuada en 146 (86%) y se diagnosticó TB activa en 43 (29%). En el presente artículo se describe la estrategia CCM y se analiza su capacidad para fortalecer los esfuerzos de detección sistemática y tratamiento.

The Hierarchy of Proinflammatory Cytokines in Ocular Inflammation.

PURPOSE: The concept of tissue-dependent cytokine hierarchy has been demonstrated in a number of diseases, but it has not been investigated in ophthalmic diseases. Here, we evaluated the functional hierarchy of interleukin-1ß (IL-1ß), IL-6, IL-17A, and tumor necrosis factor (TNF) in the induction of ocular inflammation. MATERIALS AND METHODS: We delivered adeno-associated virus (AAV) vectors expressing IL-1ß, IL-6, IL-17A, or TNF intravitreally in naïve C57/BL6 mice and compared and contrasted the inflammatory effects in the eye 5 weeks after AAV-mediated gene transfer. We also used an in vitro human system to test the effect of cytokines on barrier function. RESULTS: We found that IL-1ß had the highest ability to initiate ocular inflammation. The continuous overexpression of IL-1ß resulted in a significant upregulation of additional proinflammatory mediators in the eye. Using scanning laser ophthalmoscope and optical coherence tomography imaging techniques, we showed that a low dose of AAVIL-1ß was sufficient and was as pathogenic as a high dose of TNF in inducing vascular leakage, retinal degeneration, and cellular infiltration. Furthermore, only a marginal increase in IL-1ß was enough to cause cellular infiltration, thus confirming the highly pathogenic nature of IL-1ß in the eye. Contrary to our expectation, IL-6 or IL-17A had minimal or no effect in the eye. To examine the clinical relevance of our findings, we used an impedance assay to show that IL-1ß alone or TNF alone was able to cause primary human retinal endothelial cell barrier dysfunction in vitro. Again, IL-6 alone or IL-17A alone had no effect on barrier function; however, in the presence of IL-1ß or TNF, IL-17A but not IL-6 may provide additive proinflammatory effects. CONCLUSIONS: Our studies demonstrate the existence of a functional hierarchy of proinflammatory cytokines in the eye, and we show that IL-1ß is the most pathogenic when it is continuously expressed in the eye.

Breast cancer expression of YKL-40 correlates with tumour grade, poor differentiation, and other cancer markers.

BACKGROUND: Serum levels of a secreted glycoprotein YKL-40 are elevated in patients with a wide range of cancers including breast, colorectal, and ovarian cancers. Furthermore, these increased levels correlate with poorer survival of cancer patients, suggesting that serum levels of YKL-40 might be a prognostic biomarker. However, the tissue expression of YKL-40 and its relationship with clinical outcomes and other potential markers are poorly understood. METHODS: Tissue samples from invasive breast cancers, breast ductal carcinoma in situ (DCIS), and cancer-free reduction mammoplasty were enrolled. YKL-40 expression was measured using immunohistochemistry and evaluated by a semi-quantification assay. Statistical analyses explored the relationship of YKL-40 with clinical outcome and other breast cancer biomarkers. RESULTS: Breast ductal carcinoma in situ expressed low and moderate levels of YKL-40. In the subset of 203 patients with invasive cancer, YKL-40 levels were positively correlated with tumour grade (P<0.0001) and Her2/neu (P<0.01), but negatively correlated with oestrogen (P<0.0001) and progesterone receptor (P<0.0001). YKL-40 levels were inversely correlated with expressions of GATA3 (P=0.0137) and E-cadherin (P=0.0417). CONCLUSION: These data demonstrate that expression levels of YKL-40 are associated with tumour grade, poor differentiation, and other breast cancer markers, highlighting that tissue levels of YKL-40 serve as a valuable biomarker for breast cancer diagnosis and prognosis.

Therapeutic potential of valproic acid for retinitis pigmentosa.

BACKGROUND/AIM: To examine the efficacy and safety of valproic acid (VPA) in patients with retinitis pigmentosa (RP). METHODS: Thirteen eyes were examined before and after brief treatment (average 4 months) with VPA. Visual fields (VF) for each eye were defined using digitised Goldmann Kinetic Perimetry tracings. VF areas were log-transformed and VF loss/gain relative to baseline was calculated. Visual acuity was measured using a Snellen chart at a distance of 20 feet (6.1 m). Values were converted to the logarithm of the minimum angle of resolution (logMAR) score. RESULTS: Nine eyes had improved VF with treatment, two eyes had decreased VF and two eyes experienced no change, with an overall average increase of 11%. Assuming typical loss in VF area without treatment, this increase in VF was statistically significant (p<0.02). An average decrease (0.172) in the logMAR scores was seen in these 13 eyes, which translates to a positive change in Snellen score of approximately 20/47 to 20/32, which was significant (p<0.02) assuming no loss in acuity without treatment. Side effects were mild and well tolerated. CONCLUSION: Treatment with VPA is suggestive of a therapeutic benefit to patients with RP. A placebo-controlled clinical trial will be necessary to assess the efficacy and safety of VPA for RP rigorously.

YKL-40, a secreted glycoprotein, promotes tumor angiogenesis.

Tumor angiogenesis is of paramount importance in solid tumor development. Elevated serum levels of YKL-40, which is a secreted heparin-binding glycoprotein, have been associated with a worse prognosis from various advanced human cancers. Yet the role of YKL-40 activity in these cancers is still missing. In this study, we showed that ectopic expression of YKL-40 in MDA-MB-231 breast cancer cells and in HCT-116 colon cancer cells led to larger tumor formation with an extensive angiogenic phenotype than did control cancer cells in mice. Affinity-purified recombinant YKL-40 protein promoted vascular endothelial cell angiogenesis in vitro, the effects of which are similar to the activities observed using MDA-MB-231 and HCT-116 cell-conditioned medium after transfection with YKL-40. Furthermore, YKL-40 was found to induce coordination of membrane-bound receptor syndecan-1 and integrin alpha(v)beta(3) and to activate an intracellular signaling cascade, including focal adhesion kinase and mitogen-activated protein kinase extracellular signal-related kinase1/2 in endothelial cells. Moreover, blockade of YKL-40 using small-interfering RNA gene knockdown suppressed tumor angiogenesis in vitro and in vivo. Immunohistochemical analysis of human breast cancer showed a correlation between YKL-40 expression and blood vessel density. These findings provide novel insights into angiogenic activities and molecular mechanisms of YKL-40 in cancer development.

Variation in endophyte-plant associations influence black cutworm (Lepidoptera: Noctuidae) performance and susceptibility to the parasitic nematode Steinernema carpocapsae.

This study examined how variability in Neotyphodium endophyte-grass associations influences black cutworm Agrotis ipsilon Hufnagel performance and susceptibility to the entomopathogenic nematode Steinernema carpocapsae (Weiser). Second-instar cutworm larvae were confined to greenhouse pots containing four different tall fescue Schedonorus phoenix (Scop.) Holub cultivars. After 1 wk, larvae were recovered from the pots, weighed, and individually exposed to 20 infective juvenile nematodes. Nematode-induced mortality was monitored for 72 h after exposure. Endophyte infection levels and ergot alkaloid concentrations varied between tall fescue cultivars, but endophyte infection level was not a significant predictor of ergot alkaloid concentrations in above-ground plant tissue. Larval survival also varied between cultivars, but neither endophyte infection level nor ergot alkaloid concentration was a significant covariate. Larval susceptibility to the entomopathogenic nematode varied between cultivars at 48 and 72 h after exposure. In all but one cultivar (Plantation), cumulative mortality at 72 h decreased significantly as ergot alkaloid concentrations increased. Neither larval biomass nor endophyte infection levels in tall fescue were significant predictors of larval susceptibility to the nematode. Results show that variation in endophyte-plant associations can influence black cutworm performance and susceptibility to entomopathogenic nematodes and that susceptibility to the nematode H. bacteriophora may be partially tied to ergot alkaloid levels in the insects' food. Findings further support the assertion that black cutworm may use certain endophyte-mediated toxins, particularly ergot alkaloids, as a form of acquired chemical defense against nematode-induced septicaemia.

Risk factors for occupational knee related disability among enlisted women in the US Army.

AIMS: To identify sociodemographic and occupational determinants of knee related disability discharge from the US Army among enlisted women, and to investigate effect modification. METHODS: A case-control study of 692 cases of knee related disability discharge and 2080 incidence density matched controls nested within the population of all 244 000 enlisted women on active duty in the US Army, 1980-97. We used logistic regression to identify determinants of disability, stratified to explore effect modification by demographic and work characteristics. RESULTS: The risk of disability discharge was twice as high (odds ratio (OR) 2.4, 95% confidence interval (CI): 1.71 to 3.47) for the oldest (33-60 years) versus the youngest (17-21 years) women. Non-whites had lower risk than whites (OR 0.5, 95% CI: 0.41 to 0.60), as did married (OR 0.7, 95% CI: 0.54 to 0.81) relative to non-married women. Those of lower rank (pay grades E1-E3) were at five times the risk of disability discharge compared to those of higher ranks (pay grades E4-E9, OR 5.0, 95% CI: 2.86 to 8.33), while ORs were highest for those with longer duration of service compared to women on active duty for a year or less (OR 1.4, 95% CI: 0.8 to 2.55 after 12 years). Race modified several effects, including that of rank. Age, duration of service, and pay grade were too highly correlated to draw firm conclusions about their independent modifying effects on risk of disability discharge from the Army. CONCLUSIONS: Sociodemographic factors had larger effects than occupational characteristics on risk of knee related disability discharge from the US Army. Interactions suggest subgroups at differing risk levels that might be targeted for more detailed investigations.

ALA- and ALA-hexylester-induced protoporphyrin IX fluorescence and distribution in multicell tumour spheroids.

Synthesis of protoporphyrin IX (PpIX) in intact murine mammary cancer cell spheroids is reported from optical sections obtained using a laser scanning confocal fluorescence microscope. EMT6 spheroids 275-350 microm in diameter were incubated in 0.1-15 mM aminolevulinic acid (ALA) or 0.001-2 mM ALA-hexylester (h-ALA) to test the ability of both pro-drugs to diffuse into the spheroids and induce PpIX production. Spheroids incubated with ALA show significant fluorescence nonuniformity for all concentrations, with the outermost cells exhibiting greater porphyrin fluorescence. Comparable levels of fluorescence throughout the optical section are achieved with approximately 100-fold lower h-ALA concentrations, indicating that the interior cells maintain esterase activity and porphyrin synthesis and that h-ALA diffuses efficiently to the spheroid interior. Fluorescence gradients are less pronounced with h-ALA incubation, in part because of apparent saturation of esterase activity in the spheroid perimeter. Proliferating (Ki67 positive) and quiescent cell populations exhibit remarkably different h-ALA concentration dependencies. The incubation concentration resulting in maximum fluorescence with ALA is 10 mM, while the optimal concentration for h-ALA is 200-fold lower at 0.05 mM. Exceeding these optimal concentrations for both pro-drugs leads to an overall loss of fluorescence.

Antisocial behavioral syndromes and return to drug use following residential relapse prevention/health education treatment.

This study compared residential addiction treatment clients meeting full DSM-III-R criteria for antisocial personality disorder (ASPD) with those reporting syndromal levels of antisocial behavior only in adulthood (AABS) on time to and severity of first posttreatment drug use. Antisocial syndrome and selected other mental disorders were assessed using the Diagnostic Interview Schedule, Revised for DSM-III-R, and validity of self-reported posttreatment drug behavior was measured against results of hair analysis. Among subjects followed within 180 days after treatment exit, individuals with ASPD were at modestly increased risk of a first lapse episode compared to those with AABS. However, the two groups did not differ in severity of lapse. Participants with ASPD demonstrated poorer agreement between self-reported posttreatment drug behavior and hair data. These results add to the evidence suggesting that the DSM requirement for childhood onset in ASPD may be clinically important among substance abusers in identifying a severely antisocial and chronically addicted group at elevated risk for early posttreatment recidivism. Our findings support the importance of careful classification of antisocial syndromes among substance abusers and the identification of characteristics of these syndromes that underlie clients' risks for posttreatment return to drug use to provide optimally individualized treatment planning.

Recognition of vertebral fracture in a clinical setting.

Osteoporosis-related vertebral fractures have important health consequences for older individuals, including disability and increased mortality. Because these fractures can be prevented with appropriate medications, recognition and treatment of high-risk patients is warranted. A cross-sectional survey was carried out in a large, regional hospital in New England to examine the frequency with which vertebral fractures are identified and treated by clinicians in a population of hospitalized older women who have radiographic evidence of fractures. The study population consisted of 934 women aged 60 years and older who were hospitalized between October 1, 1995 and March 31, 1997, and who had a chest radiograph obtained. Vertebral fractures in the thoracic region were identified by two radiologists. Discharge diagnoses, medical record notes and radiology reports were compared with the results of the radiologists' readings to determine the frequency with which fractures were identified and appropriate, osteoporosis-preventing medications prescribed. Moderate or severe vertebral fractures were identified for 132 (14.1%) study subjects, but only 17 (1.8%) of the 934 participants had a discharge diagnosis of vertebral fracture. Of these 132, only 17% had fracture noted in the medical record or discharge summary; 50% of contemporaneous radiology reports identified a fracture as present; and 23% of the time it was found in the radiologist's summary impression. Only 18% of medical records indicated that fracture patients had been prescribed calcium, vitamin D, estrogen replacement or an antiresorptive agent. Relatively few hospitalized older women with radiographically demonstrated vertebral fractures were thus identified or treated by clinicians, suggesting a need for improved recognition.

Historical cohort study of 10 109 men in the North American vinyl chloride industry, 1942-72: update of cancer mortality to 31 December 1995.

OBJECTIVES: To update and assess mortality from neoplasms to 31 December 1995 among 10 109 men employed in a job exposed to vinyl chloride for at least 1 year between 1942 and 1972 at any of 37 North American factories. Previous analyses indicated associations between employment in vinyl production and increased mortality risk from cancers of the liver and biliary tract, due to increased mortality from angiosarcoma of the liver, and brain cancer. METHODS: Standardised mortality ratio (SMR) analyses, overall and stratified by several work related variables, were conducted with United States and state reference rates. Cox's proportional hazards models and stratified log rank tests were used to further assess occupational factors. RESULTS: 895 of 3191 deaths (28%) were from malignant neoplasms, 505 since the previous update to the end of 1982. Mortality from all causes showed a deficit (SMR 83, 95% confidence interval (95% CI) 80 to 86), whereas mortality from all cancers combined was similar to state referent rates. Mortality from cancers of the liver and biliary tract was clearly increased (SMR 359, 95% CI 284 to 446). Modest excesses of brain cancer (SMR 142, 95% CI 100 to 197) and cancer of connective and soft tissue (SMR 270, 95% CI 139 to 472) were found. Stratified SMR and Cox's proportional hazard analyses supported associations with age at first exposure, duration of exposure, and year of first exposure for cancers of the liver and soft tissues, but not the brain. CONCLUSIONS: Excess mortality risk from cancer of the liver and biliary tract, largely due to angiosarcoma, continues. Risk of mortality from brain cancer has attenuated, but its relation with exposure to vinyl chloride remains unclear. A potentially work related excess of deaths from cancer of connective and soft tissue was found for the first time, but was based on few cancers of assorted histology.

Quantitative analysis of the loss of distinction between gray and white matter in comatose patients after cardiac arrest.

BACKGROUND AND PURPOSE: Anecdotal reports suggest that a loss of distinction between gray (GM) and white matter (WM) as adjudged by CT scan predicts poor outcome in comatose patients after cardiac arrest. To address this, we quantitatively assessed GM and WM intensities at various brain levels in comatose patients after cardiac arrest. METHODS: Patients for whom consultation was requested within 24 hours of a cardiac arrest were identified with the use of a computerized database that tracks neurological consultations at our institution. Twenty-five comatose patients were identified for whom complete medical records and CT scans were available for review. Twenty-five consecutive patients for whom a CT scan was interpreted as normal served as controls. Hounsfield units (HUs) were measured in small defined areas obtained from axial images at the levels of the basal ganglia, centrum semiovale, and high convexity area. RESULTS: At each level tested, lower GM intensity and higher WM intensity were noted in comatose patients compared with normal controls. The GM/WM ratio was significantly lower among comatose patients compared with controls (P:<0.0001, rank sum test). There was essentially no overlap in GM/WM ratios between control and study patients. The difference was greatest at the basal ganglia level. We also observed a marginally significant difference in the GM/WM ratio at the basal ganglia level between those patients who died and those who survived cardiac arrest (P:=0. 035, 1-tailed t test). Using receiver operating characteristic curve analysis, we determined that a difference in GM/WM ratio of <1.18 at the basal ganglia level was 100% predictive of death. At the basal ganglia level, none of 12 patients below this threshold survived, whereas the survival rate was 46% among patients in whom the ratio was >1.18. The empirical risk of death was 21.67 for comatose patients with a value below threshold. CONCLUSIONS: The ratio in HUs of GM to WM provides a reproducible measure of the distinction between gray and white matter. A lower GM/WM ratio is observed in comatose patients immediately after cardiac arrest. The basal ganglia level seems to be the most sensitive location on CT for measuring this relationship. Although a GM/WM ratio <1.18 at this level predicted death in this retrospective study, the difference in this study is not robust enough to recommend that management decisions be dictated by CT results. The results, however, do warrant consideration of a prospective study to determine the reliability of CT scanning in predicting outcome for comatose patients after cardiac arrest.

Video display terminal workstation improvement program: I. Baseline associations between musculoskeletal discomfort and ergonomic features of workstations.

Associations between selected sites of musculoskeletal discomfort and ergonomic characteristics of the video display terminal (VDT) workstation were assessed in analyses controlling for demographic, psychosocial stress, and VDT use factors in 273 VDT users from a large administrative department. Significant associations with wrist/hand discomfort were seen for female gender; working 7+ hours at a VDT; low job satisfaction; poor keyboard position; use of new, adjustable furniture; and layout of the workstation. Significantly increased odds ratios for neck/shoulder discomfort were observed for 7+ hours at a VDT, less than complete job control, older age (40 to 49 years), and never/infrequent breaks. Lower back discomfort was related marginally to working 7+ hours at a VDT. These results demonstrate that some characteristics of VDT workstations, after accounting for psychosocial stress, can be correlated with musculoskeletal discomfort.

Video display terminal workstation improvement program: II. Ergonomic intervention and reduction of musculoskeletal discomfort.

The effects of an ergonomic intervention on musculoskeletal discomfort in 118 video display terminal (VDT) users were assessed 1 year after intervention. The intervention consisted of recommended changes to workstations, which were based on the evaluation of 15 ergonomic characteristics. Compliance with the intervention was at least 75% for most workstation characteristics. Reduction in discomfort was substantial and was highest for the wrist/hand (57%), lower back (43%), and neck/shoulder (41%) severity of discomfort outcomes. Neither compliance with intervention on individual workstation characteristics nor summary intervention scores were associated with reduction in discomfort. Our results demonstrate that although reduction of musculoskeletal discomfort may be observed in the context of an intervention study, it may be difficult to link these benefits to specific interventions.

Cancer control knowledge, attitudes, and perceived skills among medical students.

BACKGROUND: The Cancer Prevention and Control Education (CPACE) program aims to strengthen and coordinate curriculum offerings in cancer prevention and control for medical, graduate nursing and public health students. METHODS: Students were surveyed on cancer-related knowledge and confidence as part of needs assessment and evaluation efforts. The students completed self-administered surveys (response rate 78%). Descriptive and stratified analysis and ANOVA were conducted. RESULTS: Knowledge and confidence generally increased with each successive class year, but confidence varied markedly across specific counseling scenarios and by gender. While the students overall reported greater confidence in performing an examination than in interpreting the results, confidence varied significantly across specific types of examinations. CONCLUSIONS: Understanding of basic information about common cancers was disappointing. Confidence to perform and interpret examinations could be higher, especially for opposite-gender screening examinations. Implications of the findings for CPACE curriculum development are discussed.

Case-control study of discharge from the U.S. Army for disabling occupational knee injury: the role of gender, race/ethnicity, and age.

BACKGROUND: Occupational injuries are responsible for more lost time from work, productivity, and working years of life than any other health condition in either civilian or noncombat military sectors. Injuries, not illnesses, are the leading cause of morbidity and mortality among U.S. Army personnel. We examined the separate and joint roles of gender, race/ethnicity, and age in the odds of discharge from the Army for disabling knee injury. METHODS: A total of 860 women and 7868 men were discharged from the Army between 1980 and 1995 for knee-related disability and met all inclusion criteria for this study. All women and a subsample of 1005 men were included in these analyses, along with a simple random sample of three controls per case, stratified by gender, drawn from the population of all active-duty enlisted soldiers in each year from 1980 to 1995. We identified predictors of the occurrence or nonoccurrence of discharge from the Army for disabling knee injury using unconditional multiple logistic regression analyses. RESULTS: We found relations between the risk of knee-related disability and age and race, with marked effect modification by gender. Non-Caucasian men and women were at lower risk than Caucasians at all ages. At most ages, Caucasian women were at higher risk than Caucasian men, and non-Caucasian women were at lower risk than non-Caucasian men. Within race/ethnicity and gender, the risks for men showed an inverted "U" shape with increasing age, and the risks for women showed a "J" shape with increasing age. CONCLUSIONS: Age, race/ethnicity, and gender interactions are important in occupational injury. Differences in risk may be related to differences in work assignments, leisure activities, physical or physiological differences, or the ways in which disability compensation is granted.

Evaluating risk of re-injury among 1214 army airborne soldiers using a stratified survival model.

BACKGROUND: Many factors interact to influence an injured individual's risk of sustaining a second injury. However, the quantitative assessment of subsequent injury risk has been limited, primarily due to methodologic constraints. The purpose of this study is to present analytical methodology not previously employed in injury epidemiology to identify risk factors for subsequent injury. METHODS: Data were collected from a retrospective cohort of 1214 U.S. Army Airborne soldiers. Lower extremity and low-back musculoskeletal injuries were identified from outpatient medical records. The Prentice, Williams, and Peterson (PWP) model, stratified by injury event, was used to identify risk factors for initial and subsequent injuries. A Cox proportional hazards model to the time of last injury was used to determine the magnitude of the increased risk associated with having a previous injury history. RESULTS: Risk factors for initial injuries were similar to those seen in other epidemiologic studies of military populations. However, this study found that race/ethnicity, physical fitness, medical provider training, and initial injury types (traumatic versus other) were associated with subsequent injury risk. Additionally, the observed risk of injury was seven times greater among previously injured individuals. CONCLUSIONS: In this population, the risk factors for injury differed by event (initial or subsequent injury), and prior injury history was a risk factor for subsequent injury. The associations between demographic characteristics, the nature of the initial injury, and risk of subsequent injury suggest that changes in the evaluation and medical management of injured individuals may decrease the risk of subsequent injury.

Risk factors for psychological stress among international business travellers.

OBJECTIVES: This study investigated sources of self reported psychological stress among international business travellers at the World Bank, following up on a previous study showing that travellers submitted more insurance claims for psychological disorders. Hypotheses were that work, personal, family, and health concerns, as well as time zone travel, contribute to travel stress. METHODS: A travel survey was developed from focus groups and consisted of questions about these potential sources of travel stress. Surveys were sent to a random sample of staff, stratified by number of travel missions, age range, and sex. Canonical correlation analyses estimated the association between key survey items on sources of stress and two measures of travel stress. RESULTS: 498 staff completed the survey. More than a third reported high to very high travel stress. Correlations between predictors and travel stress showed that social and emotional concerns (such as impact of travel on family and sense of isolation) contributed the most to such stress, followed by health concerns, and workload upon return from travel. Surprisingly, time zone travel did not contribute to the self reported stress of these travellers. There were few modifiers of stress, although respondents suggested that a day of rest after travel and reduced workloads would help. CONCLUSIONS: The current study confirms clinical impressions about several correlates of travel stress. Similar research with travellers in other organisations could help to determine whether the findings from this study are valid and what measures can be taken to reduce the psychological health risks to travellers.