The role of home smoking bans in limiting exposure to secondhand tobacco smoke in Hungary.

Our objective was to assess how exposure to secondhand tobacco smoke occurs in Hungarian homes, particularly among non-smokers, and to examine the effectiveness of home smoking bans in eliminating exposure to secondhand smoke at home. In 2009, 2286 non-smokers and smokers aged 16-70 years, who were selected randomly from a nationally representative sample of 48 Hungarian settlements, completed paper-and-pencil self-administered questionnaires addressing tobacco-related attitudes, opinions and behaviors. Chi-square tests, one-way analysis of variance and multivariate logistic regression models were used to assess the effect of demographics, socio-economic characteristics and home smoking policies on the risk of exposure to secondhand tobacco smoke at home. Significantly higher risk of exposure was found among younger, lower educated and poorer people and among those having no or partial home smoking restrictions. There was a significant interaction between education level and home smoking policies: the effect of a smoking ban on exposure to secondhand tobacco smoke was stronger for the lower educated group than the higher educated group. The results suggest that Hungarians are making good progress in implementing home smoking bans, and that in the majority of population these bans are working. More can be done to promote the uptake of home smoking bans among poorer and less educated subpopulations.

Disaster management. U.S. policies pertaining to weather and climate extremes.

Climate and weather extremes--floods, drought, storms, severe weather--now have an impact on all levels of government and on the insurance industry. U.S. national policy has moved from structural approaches (building dams, levees, and irrigation ditches) to societal approaches: moving people out of hazardous areas, seeking improvements in building codes, and encouraging the use of crop and flood insurance. Federal relief assistance policies have been called into question, and renewed emphasis on personal responsibility is part of future policy.

Climate extremes: observations, modeling, and impacts.

One of the major concerns with a potential change in climate is that an increase in extreme events will occur. Results of observational studies suggest that in many areas that have been analyzed, changes in total precipitation are amplified at the tails, and changes in some temperature extremes have been observed. Model output has been analyzed that shows changes in extreme events for future climates, such as increases in extreme high temperatures, decreases in extreme low temperatures, and increases in intense precipitation events. In addition, the societal infrastructure is becoming more sensitive to weather and climate extremes, which would be exacerbated by climate change. In wild plants and animals, climate-induced extinctions, distributional and phenological changes, and species' range shifts are being documented at an increasing rate. Several apparently gradual biological changes are linked to responses to extreme weather and climate events.

Voluntary siting and equity: the MRS facility experience in Native America.

This article focuses on aspects of intragenerational and intergenerational equity in the context of a unique policy experiment: the effort of the U.S. government to site a monitored, retrievable storage (MRS) facility for high-level civilian nuclear waste. This process and its outcomes are examined from both normative and subjective perspectives. While the MRS siting process was designed to be equitable, its eventual focus on Native American communities raises profound questions about environmental justice, as well as procedural, outcome, and intergenerational equity in cross-cultural contexts. The diverse reactions among Native American tribes demonstrate that translating theoretical concepts of equity into practice is an extraordinarily complex exercise. The MRS siting process, instead of being a bold policy experiment that promoted equity, emerges substantially flawed after its implementation in the Native American context.

The vulnerability of the Nevada visitor economy to a repository at Yucca Mountain.

This article reviews the studies commissioned by the Nevada Nuclear Waste Project Office to estimate the economic impact of a high-level nuclear waste repository at Yucca Mountain. Case studies found that visitor impacts occur for some analogous facilities, but not for others. Assessments of behavioral intent indicate that at least some economic agents would avoid visiting Nevada under repository scenarios. A third set of studies tested the risk-aversion and negative-imagery models of visitor decision making; people avoid visiting places associated with either a significant health risk or negative imagery, but it has yet to be shown that a repository would induce these perceptions in nearby places. In sum, the NWPO-sponsored studies suggest the potential for visitor impacts, but do confirm that these effects will occur.

Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly: study II.

This study examined age differences in the timing of the decision to seek medical care. The data were obtained from a longitudinal study of 366 community dwelling adults aged 45 to 93 years. Subjects were paired for age, gender, and health status, and both members of a pair were interviewed when either one initiated a medical visit for a new problem. This allowed the authors to examine delay in care-seeking for individuals with new symptoms who did not seek care as well as those who did. Survival analysis was used to test hypotheses respecting age differences for total delay (the time from first noticing symptoms until calling for care) and its two constituent phases: appraisal delay (symptom onset until deciding one was ill) and illness delay (decision one was ill until calling for care). Older persons were expected to be more avoidant of uncertainty and conserving of physical and psychic resources and thus quicker to seek care. The results and findings on reasons for delay support the uncertainly avoidance hypothesis but did not replicate signs of higher levels of avoidance behavior by middle-aged subjects than by older subjects.

Conservation of energy, uncertainty reduction, and swift utilization of medical care among the elderly.

This study examined age differences in the timing of the decision to seek medical care. Two cohorts, one of middle-aged (40 to 55 years, n = 88) and one of older patients (65 and over, n = 80), who sought medical care when symptomatic were interviewed at the time of their visit. Age differences were examined with respect to total delay (the time from first noticing symptoms until calling for care), as well as its two constituent phases: appraisal delay (symptom onset until deciding one was ill) and illness delay (decision one was ill until calling for care). Older persons were expected to be more conserving of physical and psychic resources, and thus quicker in seeking care. The cohort effect was expected to be most visible for symptoms judged to be of uncertain seriousness. The delay results and ancillary findings on reasons given for delay are generally supportive of the hypotheses, with the caveat that the cohort difference also reflects higher levels of avoidance behavior by the middle-aged than by the older subjects.

Estimation of perimortal percent carboxy-heme in nonstandard postmortem specimens using analysis of carbon monoxide by GC/MS and iron by flame atomic absorption spectrophotometry.

In decomposed, formalin-fixed, embalmed, exhumed, and some fire-dried cases in which normal blood is unavailable, the usual methods for determination of carboxyhemoglobin saturation frequently fail. To address these specimens, a method utilizing both gas chromatography/mass spectrometric (GC/MS) determination of carbon monoxide (CO) and flame atomic absorption spectrophotometry (FAAS) determination of iron (Fe), in the same specimen, was developed. The method is reported here, along with its application to seven pertinent forsensic death investigations. The CO analytical methodology involves acid liberation of the gas from the specimen aliquot in a headspace vial. After heating and equilibrating, a sample of the headspace vapor is injected into the GC/MS system with a gastight syringe. Quantitation is achieved by standard addition comparison utilizing the ideal gas law equation. Iron is quantified by FAAS analysis of the same aliquot used for the CO determination, following nitric acid digestion. The concentration is determined by comparison to a standard curve. A formula for determining the minimum percent carboxy-heme saturation was derived by using the ratio of the amount of CO to the amount of Fe in the aliquot analyzed. Tissue types analyzed include spleen, liver, muscle, dried blood, and unspecified decomposed tissue.

Contribution of concrete cognition to emotion: neutral symptoms as elicitors of worry about cancer.

The relationship between worry about cancer and judged cancer risk was examined among 54 expatients who had been cured of breast cancer and 81 women with no history of cancer. Worry required both a perception of substantial risk and the presence of concrete perceptual cues. Worry promoters include visits to a physician and concrete, noncancerlike symptoms (e.g., fever, pain). Supporting analyses indicate that the symptom effects are not due to self-report biases or attributions of symptoms to cancer but are the result of a reminder process whereby vulnerability beliefs are aroused by somatic cues. Judged cancer risk was unrelated to affective cues, suggesting that across-time variation in worry about cancer reflects the onset and offset of symptom episodes rather than a shift in risk appraisals. Expatients were more worried overall than nonpatient controls. The results have implications for controlling disease worry and initiating preventive behaviors.

Pharmacokinetics and metabolism of a 4'-methylthio derivative of propranolol in the dog.

The purpose of this study was to examine the effect of a methylthio substituent in the metabolically most active position of propranolol, i.e. the 4'-position, on the pharmacokinetics and metabolism of this drug in the dog. The kinetics of 4'-methylthiopropranolol (MTP) were compared to those of propranolol following simultaneous iv doses of labeled drug and oral doses of unlabeled drug. MTP had a significantly larger volume of distribution and a longer half-life, and demonstrated a greater accumulation by red blood cells and cardiac conductile tissue than propranolol, effects which presumably are due to a higher lipophilicity of MTP. The greatest effect was on the oral clearance, which was substantially lower for MTP (1.6 vs. 5.5 liters/min) with an associated higher bioavailability (23.1 vs. 10.9%). Studies of MTP metabolism using radiolabeled drug showed that MTP, like propranolol, was eliminated entirely by metabolism. About 70% of the urinary radioactivity was extractable into ethyl acetate at pH 9.8 and pH 2.0. The extractable metabolites were separated by HPLC and identified by GC/MS, direct probe MS, and comparison with authentic compounds. Eleven metabolites were identified as sulfoxides and, in particular, sulfones of MTP and its N-dealkylated and subsequently deaminated glycollic and lactic acid metabolites. The nonextractable urinary radioactivity (30%) was isolated by DEAE-Sephadex chromatography and identified by HPLC/MS as four glucuronic acid conjugates. In contrast to propranolol, there was no evidence of aromatic carbon oxidation for MTP. These observations suggest that the markedly decreased oral clearance of MTP compared to propranolol is due to qualitatively altered metabolism from a highly efficient aromatic carbon oxidation for propranolol to a less efficient sulfur oxidation for MTP.

Active coping reduces reports of pain from childbirth.

Two studies were conducted in which pain and negative moods during labor were examined in relation to two key, independent variables: instructions to monitor labor contractions given to parturients on admission to the labor service and attendance at LaMaze (childbirth preparation) classes. In Study 1 (N = 48) pain and negative moods showed a sharp decline at Stage 2 (active labor) for women told to monitor and those who had attended classes; there was no decline for the control group. In Study 2 (N = 29), women attending LaMaze classes reported a similar decline in pain during active labor and were more energetic and less tired at admission. Of the three different mechanisms used to derive hypotheses, schema-directed coping provided the best account for the decline in pain and distress during active labor. A second mechanism, accurate expectations, seemed to account for the enhanced energy at the point of admission, in anticipation of birth.

Changes in the location of death after passage of Medicare's prospective payment system. A national study.

We reviewed age-specific national mortality data for the years 1981 through 1985 to evaluate changes in the location of death among the nation's elderly after implementation of Medicare's prospective payment system (PPS). Although it was unchanged in 1981 and 1982, the percentage of deaths occurring in the nation's nursing homes increased from 18.9 percent in 1982 to 21.5 percent in 1985. The increases in nursing home deaths were greatest between 1983 and 1984, when 33 states showed larger-than-expected increases when compared with a base period before implementation of PPS. These changes were accompanied by a decline in the percentage of deaths that occurred in hospitals. These changes in the location of death were most pronounced in the Midwest, South, and West; they were very small in the Northeast and in states not affected by the PPS. Furthermore, the states with high population enrollments in health maintenance organizations and with large declines in the mean hospital length of stay in 1984 showed the greatest shifts in the location of death. We conclude that Medicare's PPS resulted in the increased transfer of terminally ill patients from hospitals to nursing homes. Further study is required to determine whether such transfer is medically appropriate.

Side effects and emotional distress during cancer chemotherapy.

Chemotherapy side effects, patient distress, and patient-practitioner communication were evaluated in an inception sample of 238 patients with breast cancer or malignant lymphoma. Participants were interviewed at five points during their first six cycles of therapy, and a subsample kept brief daily symptom diaries. Nausea, hair loss, and tiredness were each experienced by more than 80% of patients. By cycle 6, 46% of patients had thoughts about quitting therapy, but only a few had told medical staff. Patients' ratings of the objective difficulty of treatment increased over time, varied by treatment regimen, and were predicted by the experience of side effects, with the number of different side effects serving as the best predictor. In contrast, emotional distress was less sensitive to the directly assessable characteristics of treatment. Communication between patient and practitioner was found to be inadequate in a number of respects (i.e., patients did not fully anticipate the toxicities of treatment and did not report their concerns to medical staff). Communication may be impeded by inaccuracies in a patient's recall of treatment difficulties and by a patient's inability or unwillingness to attend to all presented information. More frequent opportunities for patient-practitioner discussion are necessary.

An evaluation of increased mortality rates in Wisconsin nursing homes.

We reviewed mortality data from 80 nonprofit and government-owned skilled nursing facilities (SNFs) to evaluate previously reported increases in deaths occurring in Wisconsin nursing homes since 1983. Comparing nursing home mortality data for 1982 and 1985, we found a 16.6% increase in overall nursing home mortality rates. The increased mortality rates occurred in the sample SNFs regardless of ownership, Medicare certification, bed size, metropolitan area and hospital affiliation. There were two explanations for the increased mortality rates. First, the number of residents dying within 30 days after nursing home admission increased 59%. The majority of these short-lived residents had been discharged from hospitals indicating a transfer of terminally ill patients into nursing homes just prior to death. Second, there was a 27% increase in the mortality rate of residents living in the nursing home for 1 to 5 years suggesting that the population had become sicker between 1982 and 1985. These data reflect both the impact of Medicares Prospective Payment System (PPS) on the study nursing homes and an increase in the severity of illness of Wisconsin's nursing home population between 1982 and 1985. The findings document an increased role for nursing homes in caring for more acutely ill patients since the passage of the PPS, and have implications for nursing home reimbursement policies and quality of care.

The role of motion sickness in predicting anticipatory nausea.

Susceptibility to motion sickness has been demonstrated to be a predictor of anticipatory nausea in cancer patients receiving chemotherapy. However, previous research did not test whether motion sickness increases anticipatory nausea only by increasing the base rate of posttreatment nausea and vomiting (which has traditionally served as the unconditioned stimulus in the conditioning model for anticipatory nausea) or, alternatively, whether motion sickness might facilitate the association of external stimuli to posttreatment nausea and vomiting. Using two different analytic approaches--a series of logistic analyses that controlled for drug-induced nausea and vomiting following the initial injection, along with an event history analysis which allows for updating on the posttreatment nausea and vomiting factors--motion sickness was found to be an independent predictor of anticipatory nausea. Further, the predictive power of motion sickness is also independent of the effects of pretreatment anxiety, taste during injection, and age.

Recontacting subjects in mutagen-exposure-monitoring studies: II. Results of a questionnaire study of mutagenesis researchers, with review of the pertinent literature.

A questionnaire on the attitudes of mutagenesis researchers regarding the health significance of and the use of data from tests of human mutagen exposure or genetic damage was completed by 71 of 312 (23%) individuals who had been participants in meetings or organizations concerned with mutagenesis research. On a point scale of 0 to 10, with 0 indicating strong disagreement, 5 indicating uncertainty, and 10 indicating strong agreement, the average respondent felt (8.31 +/- 2.27) that data indicating a probable health hazard should be shared automatically with the subjects, but was also moderately concerned about psychological distress of subjects learning of study results indicating abnormally high mutagen exposure (6.14 +/- 2.57) or genetic damage (6.94 +/- 2.48). The average respondent felt that follow-up of subjects could improve the quality of mutagen-exposure-monitoring studies (8.33 +/- 1.49), disagreed that subjects whose laboratory data suggested unusually severe exposure or damage should not be asked about possible sources of exposure (1.15 +/- 1.32), and disagreed that it was ethical to follow up but not discuss results with subjects having laboratory evidence of abnormal mutagen exposure (3.78 +/- 3.43) or genetic damage (3.06 +/- 3.17) to see how many developed cancer relative to a control group. Fifteen specific tests for measuring mutagen exposure or genetic damage were rated on a scale of 0 to 10, with 0 being "totally experimental" and 10 being "absolutely diagnostic of degree of exposure or genetic damage." Values ranged from 6.13 +/- 2.67 for karyotyping leukocytes to 3.43 +/- 2.43 for quantifying frequency of rare red cells with mutant protein. This study may help in decision making regarding follow-up of mutagen-exposed subjects.

The impact of Medicare's prospective payment system on Wisconsin nursing homes.

To assess the impact of Medicare's prospective payment system (PPS) on nursing homes, we reviewed hospitalization and mortality data for Wisconsin's Medicaid and general elderly populations. During the 12 months following implementation of the PPS, Wisconsin's institutionalized elderly Medicaid population experienced a 72% increase in the rate of hospitalization and a 26% decline in hospital length of stay. Two explanations for the increased hospitalization include physician manipulation of the PPS and increased rehospitalization of nursing home residents who may have been discharged prematurely from hospitals. Between 1982 and 1985, analysis of mortality data revealed a 26.2% increase in the rate of deaths occurring in nursing homes. The increase in nursing home deaths began in 1983 and was associated with a 10.3% decline in hospital deaths during the same period. Using a series of logistic analyses, the shift in location of death from hospitals to nursing homes was found to be more pronounced after implementation of the PPS. This change in location of death may reflect both a less aggressive use of hospital resources by physicians caring for terminally ill patients and a transfer of seriously ill patients to nursing homes for terminal care.

Psychosocial consequences of cancer chemotherapy for elderly patients.

The purpose of this study was to determine whether elderly patients receiving cancer chemotherapy experience more emotional distress, difficulty with side effects, and disruption in activities than younger patients. A sample of 217 patients receiving initial chemotherapy treatment for breast cancer or lymphoma was interviewed several times over the first 6 months of treatment. Patients ranged in age from 19 to 83. Included in the interviews were questions on presence, duration, and severity of side effects; response of disease to treatment; and 0-10 ratings of emotional distress, difficulty, and life disruption due to chemotherapy. Information on drugs given, doses, and schedules was obtained from medical charts. In general, elderly patients reported no more difficulty with treatment or emotional distress than did younger patients. This general pattern held across disease types, with some exceptions. These results, combined with previously published studies on the physiological effects of chemotherapy in the elderly, indicate that aggressive treatment should not be withheld from older patients simply because of their age.

Anxiety and drug taste as predictors of anticipatory nausea in cancer chemotherapy.

Interview data from 192 patients receiving cytotoxic chemotherapy for the first time were analyzed to identify factors predictive of the development of anticipatory nausea. Posttreatment nausea and vomiting (particularly vomiting), tastes of drugs during injections, and anxiety before injections were all associated with an increased probability of anticipatory nausea. An index consisting of those three variables, plus age, was found to have good predictive power, even when the predictor variables were assessed only at the first chemotherapy administration and the index was used to predict the development of anticipatory nausea at any time during the first six chemotherapy cycles.

Determination of codeine in plasma by high-performance liquid chromatography.

An automated, sensitive, and selective reverse-phase high-performance liquid chromatographic assay has been developed to measure codeine in plasma. The analysis requires only 1 ml plasma and is accomplished by detection of the fluorescence of codeine following extraction and concentration. The method is simple and rapid, involving a one-step extraction of codeine from alkalinized (pH 10.0) plasma into an organic layer of hexane/dichloromethane, 2/1. The organic layer was evaporated under nitrogen and the residue reconstituted with the mobile phase. The samples were chromatographed on a reverse-phase C-18 column using a mobile phase of acetonitrile-phosphate buffer, 80/20 (pH 5.80). The codeine and internal standard, N-allylnorcodeine, peaks were detected using a fluorescence detector. The retention times were 8.6 min for the internal standard and 11.3 min for codeine. Standard curves were linear from 10 to 250 ng/ml. The assay was validated by direct comparison with a gas chromatographic procedure that employed nitrogen-phosphorus detection. The assay has been employed for the analysis of several codeine studies using human, dog, and rat plasma.