Factors associated with workability in Spanish health centre workers.

BACKGROUND: The concept of workability provides a conceptual framework and proposes measures for the evaluation of relevant actions focused on a healthy workforce. In Spain, one of the countries with the highest life expectancy, there are practically no scientific studies on workability and its associated factors. AIMS: The objective of this study is to examine the associations between workability and variables related to health and work in a sample of workers from Spanish health centres. METHODS: Cross-sectional study including 1184 health centre workers who completed a questionnaire at baseline, comprising measures of workability, health and other work-related factors. Workability has been analysed as a one-factor construct, and as a two-factor construct. Multinomial logistic regression models were used to analyse factors associated with workability. RESULTS: As a one-dimensional construct, workability is associated with physical and mental health, number of hours of worked, insomnia, work and family life balance, adequate training, never having had an accident and type of contract. When the two-factor measure was used, sensitivity of findings increased, and it was identified that those participants who were older, lived alone and have more years of service in their profession also show worse workability. CONCLUSIONS: The present study identified factors associated with the workability of health centre workers. The two-factor workability index (WAI) has better psychometric properties and used in combination with the global measure of WAI, identifies important additional aspects, specifically, age and years of professional experience as additional considerations for the intervention.

Atmospheric pollutants and mortalities in English local authority areas.

OBJECTIVES: To measure geographical co-relationships between disease-specific standardised mortality ratios (SMR) and different atmospheric emissions in 352 English local authorities. To link specific exposures with specific causes of death and to identify responsible polluting sources. To see whether long-term moderate exposures have the same lethal effects as short-term high-pollution (ie, smog) episodes. DESIGN: Geographical distributions of SMR, atmospheric emissions and social hazards, extracted from three different sources, were converted to a congruent format. Correlation coefficients were calculated within and between these different datasets. Mortality/pollutant correlations were recalculated after additionally standardising the SMR for social differences between local authorities. SETTING: The 352 English local authority areas, 1996-2004. MAIN RESULTS: SMR for one group of diseases (including upper alimentary and respiratory cancers, ischaemic heart disease, peptic ulcer, pneumonia) were related to a range of combustion emissions and to multiple social deprivation, cigarette smoking, binge drinking and a northern location. Additional standardisation of all SMR for these social hazards left a small subgroup independently related to atmospheric pollution, mainly from oil combustion. Correlations with pneumonia deaths were exceptional. CONCLUSIONS: High mortality rates were observed in areas with elevated ambient pollution levels. The strongest single effect was an increase in pneumonia deaths. Road transport was the chief source of the emissions responsible, although it was not possible to discriminate between the different chemical components. Many "pneumonia" deaths were probably caused by direct chemical injury, as in the 1952 London smog and are better regarded as "acute respiratory distress syndrome" or "acute lung injury".

In-utero pulmonary drainage in the management of primary hydrothorax and congenital cystic lung lesion: a systematic review.

OBJECTIVE: To determine the effect of in-utero pulmonary drainage on perinatal survival in fetuses with primary hydrothoraces and/or congenital cystic lung lesions. METHODS: Relevant papers were identified by searching MEDLINE (1966-2004), EMBASE (1988-2004) and the Cochrane Library (2004 issue 2). Studies were selected if the effect of prenatal pulmonary drainage (shunt, surgery or drainage) on perinatal survival was compared with no treatment, in fetuses with ultrasonic evidence of lung pathology. Study selection, quality assessment and data abstraction were performed independently and in duplicate. RESULTS: Of a total number of 7958 articles, there were 16 controlled observational studies involving 608 fetuses. Study characteristics and quality were recorded for each study. Data were abstracted to generate 2 x 2 tables to compare the effect of pulmonary drainage vs. no drainage on perinatal survival. Pooled odds ratios (ORs) were used as summary measures of effect and the results were stratified according to predicted fetal prognoses. Pulmonary drainage did not improve perinatal survival in cystic lung lesions compared with no drainage (OR 0.56, 95% CI 0.32-0.97, P = 0.04) overall. However there was a marked improvement with this therapy in a subgroup of fetuses with fetal hydrops fetalis (OR 19.28, 95% CI 3.67-101.27, P = 0.0005) but not in the subgroup uncomplicated by fetal hydrops fetalis (OR 0.04, 95% CI 0.01-0.32, P = 0.002). CONCLUSION: Percutaneous, in-utero pulmonary drainage in fetuses with ultrasonic evidence of congenital pulmonary cystic malformations was associated with improved perinatal survival among fetuses with hydrops fetalis and therefore poor predicted survival.

Roads, railways, and childhood cancers.

STUDY OBJECTIVES: To locate geographical sources of engine exhaust emissions in Great Britain and to link them with the birth addresses of children dying from cancer. To estimate the cancer initiating roles of nearby roads and railways and to measure effective ranges. DESIGN: Birth and death addresses of all children born between 1955 and 1980 in Great Britain, and dying from leukaemia or other cancer during those years, were linked to locations of railway stations, bus stations, ferry terminals, railways, roads, canals, and rivers. Nearest distances to births and deaths were measured, and migration data relating to children who had moved house were analysed. Excesses of close to hazard birth addresses, compared with close to hazard death addresses, indicate a high prenatal or early postnatal risk of cancer initiation. SETTING AND SUBJECTS: Child cancer birth and death addresses and their map references were extracted from an earlier inquiry. Map references of putative hazards were downloaded from the Ordnance Survey national digital map of Great Britain. These data are recorded to a precision of one metre and have ground accuracies around 20 metres. MAIN RESULTS: Significant birth excesses were found within short distances of bus stations, railway stations, ferries, railways, and A,B class roads, with a relative risk of 2.1 within 100 m, tapering to neutral after 3.0 km. About 24% of child cancers were attributable to these joint birth proximities. Roads exerted the major effect. CONCLUSIONS: Child cancer initiations are strongly determined by prenatal or early postnatal exposures to engine exhaust gases, probably through maternal inhalation and accumulation of carcinogens over many months. The main active substance is probably 1,3-butadiene.

The use of high resolution magnetic resonance imaging in the prenatal diagnosis of fetal nuchal tumors.

Fetal magnetic resonance imaging (fetal MRI) is an important adjunct to antenatal imaging especially when neonatal surgery is contemplated. We report two cases of fetal nuchal tumors, which were diagnosed incidentally on an ultrasound scan and had fetal MRI to aid diagnosis, prognosis, counseling and management planning. In the first case, fetal MRI aided diagnosis and prenatal multidisciplinary management of a cervical teratoma. Tracheal involvement could not be excluded and an ex-utero intrapartum treatment procedure was planned. Postnatal MRI and angiography provided further information prior to surgery. In the second case, fetal MRI assisted thorough counseling following the finding of a cervical lesion thought to be a cervical teratodermoid, a multicystic hygroma or congenital lymphectasia. The parents opted for termination of the pregnancy. Postmortem findings confirmed the extent of involvement of surrounding structures diagnosed prenatally. The mass was found to be a hamartomatous hemangiolymphangioma.

Oil combustion and childhood cancers.

STUDY OBJECTIVES: To identify specific toxic atmospheric emissions and their industrial sources in Great Britain. To link them with each other and with the birth addresses of children dying from cancer. To identify specific causal agents and sources. DESIGN: Birth and death addresses of children dying from cancer were linked to emissions hotspots for specific chemicals: and to related source installations. Among those who moved house, distances from each address to the nearest hazard were compared. Relative excesses of close-to-hazard birth addresses showed high prenatal or early postnatal risks. Relative risks for individual and for combined exposures were measured. SETTING AND SUBJECTS: Atmospheric emissions hotspots (UK, 2001) published as maps on the internet, were converted to coordinates. Industrial sites were identified through trade directories and map inspections. Child cancer addresses for 1955-80 births were extracted from an earlier inquiry and their postcodes converted to map references. MAIN RESULTS: There were excess relative risks (RR) within 0.3 km of hotspots for carbon monoxide, PM10 particles, nitrogen oxides, 1,3-butadiene, benzene, dioxins, benzo(a)pyrene, and volatiles; and within 1.0 km of bus stations, hospitals, heavy transport centres, railways, and oil installations. Some excesses were attributable to mutual confounding, but 1,3-butadiene and carbon monoxide, mainly derived from engine exhausts, were powerful independent predictors. They were strongly reinforced when associated with bus stations, hospitals, railways, oil installations, and industrial transport centres; RR = 12.6 for joint <0.5 km exposure to bus stations and 1,3-butadiene. CONCLUSIONS: Childhood cancers are strongly determined by prenatal or early postnatal exposures to oil based combustion gases, especially from engine exhausts. 1,3-butadiene, a known carcinogen, may be directly causal.

Childhood cancers and atmospheric carcinogens.

STUDY OBJECTIVES: To retest previous findings that childhood cancers are probably initiated by prenatal exposures to combustion process gases and to volatile organic compounds (VOCs); and to identify specific chemical hazards. DESIGN: Birth and death addresses of fatal child cancers in Great Britain between 1966 and 1980, were linked with high local atmospheric emissions of different chemical species. Among migrant children, distances from each address to the nearest emissions "hotspot" were compared. Excesses of outward over inward migrations show an increased prenatal or early infancy risk. SETTING AND SUBJECTS: Maps of emissions of many different substances were published on the internet by the National Atmospheric Emissions Inventory and "hotspots" for 2001 were translated to map coordinates. Child cancer addresses were extracted from an earlier inquiry into the carcinogenic effects of obstetric radiographs; and their postcodes translated to map references. MAIN RESULTS: Significant birth proximity relative risks were found within 1.0 km of hotspots for carbon monoxide, PM10 particles, VOCs, nitrogen oxides, benzene, dioxins, 1,3-butadiene, and benz(a)pyrene. Calculated attributable risks showed that most child cancers and leukaemias are probably initiated by such exposures. CONCLUSIONS: Reported associations of cancer birth places with sites of industrial combustion, VOCs uses, and associated engine exhausts, are confirmed. Newly identified specific hazards include the known carcinogens 1,3-butadiene, dioxins, and benz(a)pyrene. The mother probably inhales these or related materials and passes them to the fetus across the placenta.

An epidemic pattern of murder.

The dates and places of 105 suspected or proven murders committed by Dr H. Shipman of Hyde in Greater Manchester between 1984 and 1998 were subjected to epidemiological analysis. These interim data were assembled through a variety of media sources and were based upon court proceedings and police investigations. The analysis revealed a significant excess of case pairs separated jointly by distances <0.6 km and by times <7 days. These sequences were also associated with purely geographical groupings within spatial diameters <0.2 km, but with longer time intervals. This was confirmed by an extended analysis of case triplets occurring within short times and distances. They showed a significant excess. These clusters were probably generated by a combination of psychopathic obsession, of local opportunity, and of caution; and in similar circumstances could occur again. The findings demand the regular display of mortality data in a format permitting the intuitive recognition of similar phenomena elsewhere.

Perinatal factors associated with severe intracranial hemorrhage.

OBJECTIVE: The purpose of this study was to assess the incidence of perinatal factors that are associated with severe intracranial hemorrhage in a large and recent multicenter experience. STUDY DESIGN: Retrospective analyses of nonanomalous newborns who were admitted to 100 neonatal intensive care units from 23 to 34 6/7 weeks' gestation were analyzed by multiple regression. RESULTS: There were 12,578 premature newborns with a mean (+/- SD) gestational age of 31.3 +/- 2.9 weeks and a birth weight of 1685 +/- 571 g, respectively. The overall incidence of severe intracranial hemorrhage was 2.9%; in 4575 newborns who weighed < or = 1500 g the incidences of intracranial hemorrhage was 7.1%. Factors with positive and negative associations with severe intracranial hemorrhage are listed in order of decreasing statistical significance: gestational age (negative), surfactant (positive), antenatal indomethacin (positive), neonatal transport (positive), cesarean birth (negative), poor prenatal care (positive), 5-minute Apgar score of < 7 (positive), chorioamnionitis (positive), antenatal terbutaline (negative), preterm premature rupture of fetal membranes (negative), and abruption (positive). CONCLUSION: The incidence of severe intracranial hemorrhage has dramatically declined over the past 2 decades. Antenatal steroids were not associated with reductions in severe intracranial hemorrhage.

Follow-up of children attending infant language units: outcomes at 11 years of age.

A large cohort of 242 children who had been attending infants language units at 7 years of age was followed up when the children were in their final year of primary school. Two hundred (83%) of the children were reassessed at 11 years of age on a wide battery of language and literacy measures, on a test of non-verbal ability, an autism checklist and a communication checklist. In total, 89% of children still scored < 1 SD from the mean on at least one test of language and the majority (63%) scored poorly on three or more assessments demonstrating widespread difficulties. Compared with non-verbal abilities at 7 years of age, a large proportion of the cohort also performed poorly on performance IQ subtests (28%). A further 10 children scored highly on a checklist for autistic spectrum disorder. Thus, only 115 (58%) children could be said to meet criteria for specific language impairment. A small group of 16 children appeared to have entirely resolved their difficulties. These outcomes and their implications for education and long-term impact of the disorder are discussed.

Effects at age nine of maternal smoking in pregnancy: experimental and observational findings.

OBJECTIVES: To compare long term outcomes of a randomised controlled trial of anti-smoking education in pregnancy and to examine the same outcomes according to maternal pregnancy smoking behaviour. DESIGN: Follow up of the population included in the randomised controlled trial nine years later and of ex-smokers and non-smokers within the same hospital population. SETTING: A maternity hospital in Birmingham with follow up of children in schools and mothers at home. POPULATION: 1218 smokers recruited to the trial; also 191 ex-smokers at booking and 414 non-smokers throughout pregnancy. METHODS: Children were assessed individually by psychologists in schools, and mothers interviewed at home to obtain additional information relevant to cognitive development and growth. Information on smoking during pregnancy was obtained from mothers and obstetric data from computerised case-notes, both recorded immediately following delivery. MAIN OUTCOME MEASURES: Height, weight, IQ and neurological soft signs at 9.4 years. RESULTS: Differences in birthweight and length between the intervention and control groups were confirmed but no intervention-control differences were found at age 9.4 for weight, height, IQ or neurological soft signs. Differences were found for height and IQ according to mothers pregnancy smoking behaviour, but smoking did not remain an independent predictor after taking account of confounding factors. Alternative classifications of smoking behaviour, taking account of the gestation at stopping and mean cigarette consumption throughout pregnancy likewise showed no effect. CONCLUSIONS: The well established early hazards of smoking during pregnancy seem to be resolved by later childhood, with no evidence of direct long term effects on growth or cognitive functioning.

Predicting pathways of specific language impairment: what differentiates good and poor outcome?

A group of 117 children who met criteria for Specific Language Impairment (SLI) at 7 years of age were reassessed at 11 years of age. The data gathered from both stages were used to identify predictors of good and poor outcome from earlier test assessments. Results of logistic regressions indicated that measures of narrative retelling skills and expressive syntax were the strongest predictors of overall prognosis. This finding persisted when a nonverbal measure was included as a predictor alongside language measures in the regression model. There was found to be a lack of independent predictive contribution of early measures of articulation to later overall prognosis. Demographic factors (maternal education and family income) were not differently distributed across outcome groups. The theoretical and practical implications of the findings are discussed.

Nutritional status and intermediate chain-length fatty acids influence the conservation of essential fatty acids in the milk of northern Nigerian women.

The milk of 89 women in northern Nigeria was analyzed for the fatty acid composition of the total milk lipids, and assessed for the effect nutritional status has on the conservation of essential and non-essential fatty acids when the proportions of C(10)-C(14)fatty acids are increased. The women were stratified on the basis of their body mass index, and calculations were made to estimate the effects of a 3.3-fold increase in the proportion of C(10)-C(14)fatty acids on the proportion of alpha-linolenic acid, docosahexaenoic acid, linoleic acid and arachidonic in total milk lipids. In the well-nourished group (group III, body mass index >23 kg/m(2)), the critical n-3 and n-6 fatty acids were not conserved, while in poorly nourished women (group I, body mass index <19 kg/m(2)), marked conservation of alpha-linolenic acid, docosahexaenoic acid, arachidonic acid, and palmitic acid was seen. Poor nutritional status of the mother appears to promote selective retention of critical essential and non-essential fatty acids in the milk lipid fraction.

Childhood cancers, birthplaces, incinerators and landfill sites.

BACKGROUND: In all, 70 municipal incinerators, 307 hospital incinerators and 460 toxic-waste landfill sites in Great Britain were examined for evidence of effluents causing childhood cancers. Municipal incinerators had previously shown significant excesses of adult cancers within 7.5 and 3.0 km. The relative risks for adults had been marginal and an analysis of childhood cancers seemed to offer a more sensitive approach. METHODS: A newly developed technique of analysis compares distances from suspect sources to the birth addresses and to the death addresses of cancer-children who had moved house. A localized hazard, effective at only one of these times, must be preferentially associated with the corresponding address. This creates an asymmetry of migrations towards or away from age-restricted effective sources. RESULTS: The child-cancer/leukaemia data showed no systematic migration-asymmetries around toxic-waste landfill sites; but showed highly significant excesses of migrations away from birthplaces close to municipal incinerators. Relative risks within 5.0 km of these sites were about 2:1. Hospital incinerators gave analogous results. The ratios greatly exceed findings around 'non-combustion' urban sites. CONCLUSIONS: Because of their locations, the specific effects of the municipal incinerators could not be separated clearly from those of adjacent industrial sources of combustion-effluents. Both were probably carcinogenic. Landfill waste sites showed no such effect.

Prosthetic foot roll-over shapes with implications for alignment of trans-tibial prostheses.

Roll-over shape is introduced as a significant characteristic of prosthetic feet. The roll-over shapes of the Flexwalk, Quantum, SACH, and SAFE prosthetic feet were determined using three methods; two involving quasi-static loading and one dynamic loading. The results show that foot roll-over shape properties obtained by quasi-static and by dynamic methods are similar. Relationships between foot roll-over shape and the alignment of trans-tibial prostheses are introduced that suggest ways to align trans-tibial prostheses without walking trials and iterations. The relationships may explain what prosthetists attempt to accomplish when they dynamically align a trans-tibial limb. They also explain why prosthetic feet with different mechanical properties usually necessitate different alignments, and may explain why a number of gait studies of trans-tibial amputees do not show major gait differences when walking is executed on various kinds of prosthetic feet.

Changing the records.

The aim of this study was to audit the documentation of pressure sore risk in a group of patients in a teaching hospital. This was done using a retrospective checklist assessment of patients in care of the elderly and orthopaedic wards. The study found there were delays in completing documentation on admission, that risk assessment was absent in 54% of patient documentation and that assessment of pressure areas was inadequate.

Geographical distribution of birth places of children with cancer in the UK.

Using birth addresses, we examined the geographical variation in risk for all types of childhood cancers in the UK, on a scale corresponding to the 10-km squares of the National Grid. The effects of socioeconomic and environmental factors, including natural background radiation, were investigated and their relative importance assessed using Poisson regression. Data came from a national collection of all fatal cancers between 1953 and 1980 in children aged 0-15 years and consisted of 9363 children of known place of birth from 12 complete annual cohorts born in the period 1953-64. For solid cancers, as well as for leukaemias and lymphomas, there was marked variation of cumulative mortality according to place of birth. High mortalities were associated with areas characterized as having high social class, higher incomes and good housing conditions, but also with high population densities (births per hectare). Each of these contrasting social indicators operated independently of the other, indicating complex determining mechanisms. Mortalities increased with increased radon exposure, and the relationship operated independently of the socioeconomic factors. At this scale of analysis, we found no increased mortality in industrialized areas. A population-mixing infective hypothesis, which postulates high rates of leukaemia when highly exposed urban populations are introduced to isolated rural areas, was supported by observations of high mortalities in 'growth areas' and New Towns, but was not readily reconcilable with the high rates seen in the high-density areas. If these correlations do indeed represent an infective mechanism, then the outcomes are not limited to malignancies of the immune system alone.

Migration patterns of children with cancer in Britain.

OBJECTIVES: To investigate the early migration patterns of children who later developed cancer. To test a prior hypothesis that some cancers are initiated by early exposures to toxic atmospheric pollutants from point sources. DESIGN: Address changes in children dying from cancer are examined in relation to potentially hazardous sites of several different types. The relative proximities of birth addresses and death addresses to these sites, are compared. The approach is based upon the premise that a local exposure, effective only at an early age, must be preferentially linked with an early address. SETTING AND SUBJECTS: Records of 22,458 children dying from leukaemia or other cancer under the age of 16 years in Great Britain between 1953 and 1980: including 9224 who moved house between birth and death. The migration analysis was based upon birth and death addresses, converted first to postcodes and thence to map coordinates. The geographical locations of potentially toxic industrial sites were obtained through direct map searches and from commercial directories. RESULTS: Systematic asymmetries were found between measured distances from birth and death addresses to sources emitting volatile organic compounds, or using large scale combustion processes. The children had more often moved away from these hazards than towards them. Many of the sources had already been identified as hazardous using other methods. There was also a birth association with areas of dense habitation; possibly because of unidentified toxic sources contained within them. All forms of cancer were involved although some effluents were associated preferentially with specific types. CONCLUSIONS: The main findings of an earlier study, based upon a different and independent method, were confirmed. Proximities to several types of industrial source, around the time of birth, were followed by a raised risk of childhood cancer. Combustion products and volatile organic compounds were especially implicated. Within the 16 year limit of the study, the increased risk did not decay with advancing age. Low atmospheric concentrations of many carcinogenic substances suggest that the mother acts as a cumulative filter and passes them to the fetus across the placenta or in breast milk.