Circumpolar maternal blood contaminant survey, 1994-1997 organochlorine compounds.

During the past 20 years a number of studies have found neurological and immunological effects in the developing fetus and infants exposed to background or only slightly elevated levels of persistent organic pollutants (POPs) such as polychlorinated biphenyls (PCBs). To address concerns arising from possible increased human exposure in the Arctic and possible effects of POPs, all circumpolar countries agreed in 1994 to monitoring of specific human tissues for contaminants in the Arctic under the Arctic Monitoring and Assessment Program (AMAP). Mothers in eight circumpolar countries contributed blood samples that were analysed at a single laboratory for 14 PCB congeners (IUPAC No. 28, 52, 99, 105, 118, 128, 138, 153, 156, 170, 180, 183, 187) and 13 organochlorine pesticides (aldrin, beta-hexachlorocyclohexane (beta-HCH), dichlordiphenyltrichloroethane (p,p'-DDT), diphenyldichloroethylene (p,p'-DDE), dieldrin, heptachlorepoxide, hexachlorobenzene (HCB), mirex, and the chlordane derivatives alpha-chlordane, gamma-chlordane, cis-nonachlor, oxychlordane and trans-nonachlor). Inuit mothers from Greenland and Canada have significantly higher levels of oxychlordane, transnonachlor and mirex than mothers from Norway, Sweden, Iceland and Russia. Inuit mothers from Greenland also have significantly higher levels of these contaminants than Inuit mothers from Canada and Alaska. These differences among Inuit groups may represent regional dietary preferences or different contaminant deposition patterns across the Arctic. Levels of PCBs are also elevated among some arctic populations due to their consumption of marine mammals and are in the range where subtle effects on learning and the immune system have been reported. The Russian mothers who consume mainly food imported from southern Russia have elevated levels of DDT, DDE, beta-HCH and a higher proportion of lower chlorinated PCB congeners. This study has allowed an assessment of the variation of contaminants such as PCBs and various organochlorine pesticides (DDT, chlordane, etc.) in human populations around the circumpolar north.

Development of community psychiatry in Bosnia-Herzegovina with focus on support from Sweden.

The mental health reform basically means a movement of patients from the former institutions into the society. The driving forces have been human rights and economical reasons. In Bosnia-Hercegovina the war became a starting point for the mental health reform. With support from major international organisations such as WHO, The World Bank and Unicef and minor NGOs such as SweBiH, and HNI Bosnia-Hercegovina has done a remarkable progress in a few years time. SweBiH has co-operated with HNI and focused on training of personnel from different professions during four years and examples are given. The future support might be a Training Centre for Community Psychiatry in Sarajevo. SweBiH plans to continue with support of sustainable research activities.

Assessment of community mental health care in the Federation of Bosnia-Hercegovina (FBH) after the 1992-95 war.

Bosnia-Hercegovina is in the process of reforming its health care system. One realises that this is a complex matter that will cost a great deal of time and effort. The findings suggest that the highest priority now is the development of the 'mental health strategic and action 'plan', which includes (as a component of the overall PHC strategy) legislation, financing mechanisms, a clear statute for the CMHCs and staff, and to define the relationship with other PHC services. In addition, it is recommended that the authorities should take a more decisive co-ordinating and leading role. To this end, a special Mental Health Task Force assisted by a professional advisory group on mental health and/or professional consultants could be established. In order to realise a real cost-effective community-based care, it is inevitable to allocate enough funds to these primary mental health care services and initiatives such as sheltered living and family support initiatives (eventually to reallocate funds from expenditures on hospital-based care). A mental health reform does not happen in a vacuum and therefore can not be accomplished without 'negotiating' with other sectors/ministries, e.g., Ministries of Finances, Social Affairs/Displaced Persons and Refugees, International Trade and Economy. A multi-sector approach is considered indispensable. Overall management of CMHCs should be strengthened. In addition, it is important that CMHCs exchange information and promote standardised protocols and procedures to enhance comparability and structured referral. The planned Management Information System is a good example, but should be implemented as soon as possible in all CMHCs. Other initiatives to improve professional networking might include (community mental health) newsletters, round table conferences, etc. Further skills training of CMHC staff and management might be difficult to define as long as it is not clear what practical skills are required. Technical Assistance to the (mental) health sector should primarily focus on the overall framework and policy. Training should be tailored to the actual needs and focus primarily on local capacity building via training-of-trainers. Health prevention and promotion, i.e. information provision to the general public and community participation in terms of support for self-help groups and consumer groups, deserve more attention than it has received so far.

Rehabilitation of war victims in the Federation of Bosnia and Hercegovina with special reference to physical injuries.

The number of war victims in need of physical rehabilitation in Bosnia and Hercegovina is not exactly known but less than one per cent of the population. Anyhow physical rehabilitation services needs to be reorganized in the community taking care of about 70-80% of the patients. The rest are partly in need of institutional care, which is also important for training and research purposes. The reorganization of services for the mentally ill is aimed at both war victims and others and reorganized at Community Mental Health Centers. The number of mentally ill war victims is definitely exceeding the number of physically injured from the war.

Refugees, returnees and rehabilitation.

Health and social security services are the basic elements which people have the right to ask for from their community. Strong efforts are made to reform the function of this support system all over Bosnia-Hercegovina. With a mutual effort made by Ministry of Health and mental health professionals the Community Mental Health Centres might be an excellent support for people with mental health problems in the society. This is true even for the heavy influx of returnees. The Community Mental Health Centres are expected to handle about 80% of people with mental health problems in the society where people live, or in the new establishments for returnees. However there is a great need for Ministry of Health to design the policy and edict precise rules. The same is true for Ministry of Social Affairs which in co-operation with social workers and other professionals have to reform the Centres for Social Work. However, even if resources are slowly growing, there still seems to lack in communication of the two basic elements, health and social security. Respective ministries in The Federation of Bosnia-Hercegovina need to co-operate and the Ministry of Health and Social Affairs in Republika Srpska needs to strong in developing a co-operation between the centres in the field.

Rehabilitation research under fire.

Catastrophes in the health area are frequent. A template for conduct and reporting of research in disaster responses has recently been published. The WHO Rehabilitation of War Victims Project basically followed these principles in former Yugoslavia to estimate defined needs, prioritise and evaluate methods used. Around 30% of war victims reported to be wounded were found to be in need of physical rehabilitation. Priority was given to the 5% with severe disabilities caused by amputations, spinal cord injuries and traumatic brain injuries. Most of the infrastructure was destroyed and WHO supported a community based rehabilitation approach (CBR). Evaluating this type of service delivery became extremely difficult under present circumstances. Waves of refugees rolled both within the republics and over the borders demonstrating both the needs and problems listed in the template referred to. The CBR service delivery worked out satisfactorily with high patient satisfaction. Limited medical training greatly improved the situation for the personnel. Even in a disaster situation research is needed for proper decision-making and to gain experiences for future aid.

War victims in need of physical rehabilitation in Croatia.

A Rehabilitation Information System was created in July 1993 in order to register war victims in need of physical rehabilitation all over Croatia. The system is currently operating and presented data covers the period from July 1991 to July 1995. Approximately 15,000 questionnaires had been completed and returned from medical institutions on in total 8589 disabled war victims in need of rehabilitation. People with severe disabilities comprised about 20% of all in need of rehabilitation. Those reported injured were 3.5 times more than those in need of physical rehabilitation. Most common types of injuries were fractures with a permanent disabling condition (3109 persons), peripheral nerve injuries (1213 persons) and amputations (956 persons). Traumatic brain injuries were registered for 594 and spinal cord injuries for 262 persons. Causes of injuries were explosive devices (such as mines, mortar shell shrapnel, etc.) in 37% of cases, bullets in 22%, accidents in 7%, other (such as fire, blast injuries, etc.) and unknown causes in 34%.

Increased blood lead and decreased calcium levels during pregnancy: a prospective study of Swedish women living near a smelter.

OBJECTIVES: The purpose of this study was to monitor blood lead in a northern Swedish cohort of mothers and children during pregnancy and at birth. METHODS: Blood lead was analyzed during pregnancy and in the umbilical cords of 290 women living near a smelter and in 194 control subjects. RESULTS: During pregnancy, there were statistically significant overall increases in blood lead concentrations by 20% and 15% in the smelter and reference areas, respectively. Mean maternal blood lead concentrations at delivery were 0.15 mumol/L (3.11 micrograms/dL) in the smelter area and 0.13 mumol/L (2.69 micrograms/dL) in the control area. Umbilical cord blood lead levels were 80% to 87% of the maternal levels. Blood lead levels were influenced by place of residence, employment at the smelter, smoking, and wine consumption. Maternal serum calcium levels decreased during pregnancy and were significantly lower than those of the newborns. CONCLUSIONS: An increase in blood lead concentrations was found during pregnancy, despite increased blood volume and unchanged or decreasing environmental lead levels. The mobilization of lead from bone during pregnancy may explain the increase.

Is placenta a good indicator of cadmium and lead exposure?

Distribution of lead and cadmium was studied in 25 placentas. Samples were taken from 6 different lobuli, and lead and cadmium concentrations were not determined by graphite furnace atomic absorption spectrometry. Lead and cadmium were not distributed uniformly, and the concentrations differed by a factor > or = 2 among different lobuli within the same placenta in 36% and 52% of the placentas, respectively. Placental lead and cadmium concentrations were also determined in homogenized samples from smelter (n = 49) and control (n = 53) areas in northern Sweden. Mean lead and cadmium concentrations were low, even in the smelter area (geometric means = 10 ng/g and 3 ng/g wet weight, respectively). The significant differences observed (i.e., higher blood lead concentrations in the smelter area during pregnancy and in umbilical cord blood) were not reflected in the placenta. We concluded, therefore, that the placenta is not a suitable organ to use for the monitoring of environmental exposure to lead. It could be used to monitor cadmium exposure, but if pregnancy outcome is to be studied, consideration should be given to the sampling procedure.

Total and inorganic mercury in breast milk in relation to fish consumption and amalgam in lactating women.

Total mercury concentrations (mean +/- standard deviation) in breast milk, blood, and hair samples collected 6 wk after delivery from 30 women who lived in the north of Sweden were 0.6 +/- 0.4 ng/g (3.0 +/- 2.0 nmol/kg), 2.3 +/- 1.0 ng/g (11.5 +/- 5.0 nmol/kg), and 0.28 +/- 0.16 microg/g (1.40 +/- 0.80 micromol/kg), respectively. In milk, an average of 51% of total mercury was in the form of inorganic mercury, whereas in blood an average of only 26% was present in the inorganic form. Total and inorganic mercury levels in blood (r = .55, p = .003; and r = .46, p = .01 6; respectively) and milk (r = .47, p = .01; and r = .45, p = .018; respectively) were correlated with the number of amalgam fillings. The concentrations of total mercury and organic mercury (calculated by subtraction of inorganic mercury from total mercury) in blood (r = .59, p = .0006, and r = .56, p = .001; respectively) and total mercury in hair (r = .52, p = .006) were correlated with the estimated recent exposure to methylmercury via intake of fish. There was no significant between the milk levels of mercury in any chemical form and the estimated methylmercury intake. A significant correlation was found between levels of total mercury in blood and in milk (r = .66, p = .0001), with milk levels being an average of 27% of the blood levels. There was an association between inorganic mercury in blood and milk (r = .96, p < .0001); the average level of inorganic mercury in milk was 55% of the level of inorganic mercury in blood. No significant correlations were found between the levels of any form of mercury in milk and the levels of organic mercury in blood. The results indicated that there was an efficient transfer of inorganic mercury from blood to milk and that, in this population, mercury from amalgam fillings was the main source of mercury in milk. Exposure of the infant to mercury from breast milk was calculated to range up to 0.3 microg/kg x d, of which approximately one-half was inorganic mercury. This exposure, however, corresponds to approximately one-half the tolerable daily intake for adults recommended by the World Health Organization. We concluded that efforts should be made to decrease mercury burden in fertile women.

Nordic children with myelomeningocele: the utilization of and satisfaction with health care and medical services.

A study was conducted on utilization of and satisfaction with the health care and medical services among 527 Scandinavian children (aged 4-18) with myelomeningocele (MMC). Data were collected from two sources: a questionnaire distributed to parents in 1984, and patients' medical records. Comparisons were made with a control group comprised of 7,792 children. Over a period of one year, 52% of the MMC group and 6% of the controls were hospitalized. Over 3 months, children with MMC had more contact with specialist care services than had the controls, while contact with primary health care was the same for both groups. Continuity of care and satisfaction with time spent with the physician were both greater among children with MMC than in the control group. Dissatisfaction with medical services was expressed by approximately 10% of the parents of both categories. Such dissatisfaction was found significantly more frequently among Danish parents and well educated mothers. Dissatisfaction with care was not related to either the child's age or the severity of its disability. Danish children with MMC received treatment relatively more frequently from primary care physicians than from specialists. In Sweden, where satisfaction was the greatest, families with children with MMC were supported by local habilitation teams.

Lead and cadmium levels in human milk and blood.

Lead and cadmium levels were determined (with AAS) in blood and milk obtained at 6 weeks after delivery from women living in the vicinity of a copper and lead metal smelter and in a control area. Analysis of lead and cadmium were also performed in blood samples obtained at delivery. Accuracy of the analysis was confirmed by the analysis of quality control samples. In general, blood and milk levels of lead and cadmium were low in both areas. At 6 weeks after delivery the lead levels in blood and milk were 32 +/- 8 and 0.7 +/- 0.4 micrograms Pb/l, respectively (total mean +/- S.D., n = 75). Cadmium levels in blood and milk were 0.9 +/- 0.3 and 0.06 +/- 0.04 microgram Cd/l, respectively (n = 75). At delivery the lead levels in blood of women in the smelter area were higher, 38.7 micrograms Pb/l, than the blood lead levels in women from the control area, 32.3 micrograms Pb/l, (P < 0.001). At 6 weeks after delivery there was no difference in blood lead levels between the two groups. In contrast, the lead levels in milk were higher in women from the smelter area, 0.9 microgram Pb/l, than in women from the control area, 0.5 microgram Pb/l, (P < 0.001). No differences in blood cadmium levels were found between the two groups. Milk cadmium levels in women from the control area, 0.07 microgram Cd/l, were somewhat higher (P < 0.01) than in women from the smelter area, 0.05 microgram Cd/l.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurological dysfunction above cele level in children with spina bifida cystica: a prospective study to three years.

The aim of this study was to characterize the neurological dysfunction above the cele level in children with spina bifida cystica. 22 neonates were investigated prospectively to a median age of three years. Before primary closure of the spinal malformation and at three and 18 months of age, MRI and inspection of vocal cord function were performed. The children were also assessed by a physical therapist at 12 and 24 months, 19 children had a Chiari malformation, 18 children developed neurological dysfunction above the cele level. Children with signs of isolated motor impairment stabilized or improved during the second year. Six children developed severe functional impairment of respiration, feeding and motor performance within the first three months of life. Severe neurological signs/symptoms were associated with myeloschisis, clinical signs of a tethered cord and recurrent periods of shunt dysfunction.