Undocumented migrants in Switzerland: geographical origin versus legal status as risk factor for tuberculosis.

Undocumented migrants, meaning migrants without a legal residency permit, come to Geneva from countries with high tuberculosis (TB) incidence. We estimate here whether being undocumented is a determinant of TB, independently of origin. Cross-sectional study including undocumented migrants in a TB screening program in 2002; results were compared to 12,904 age and frequency matched participants in a general TB screening program conducted at various workplaces in Geneva, Switzerland from 1992 to 2002. A total of 206 undocumented migrants (36% male, 64% female, mean age 37.8 years (SD 11.8), 82.5% from Latin America) participated in the TB screening program. Compared to legal residents, undocumented migrants had an adjusted OR for TB-related fibrotic signs of 1.7 (95% CI 0.8;3.7). The OR of TB-related fibrotic signs for Latin American (vs. other) origin was 2.7 (95% CI 1.6;4.7) among legal residents and 5.5 (95% CI 2.8;10.8) among undocumented migrants. Chest X-ray screening identified a higher proportion of TB-related fibrotic signs among Latin Americans, independently of their residency status.

Epidemic and population patterns in the Chinese Empire (243 B.C.E. to 1911 C.E.): quantitative analysis of a unique but neglected epidemic catalogue.

A catalogue of dates and places of major outbreaks of epidemic diseases, that occurred in the Chinese Empire between 243 B.C.E. and 1911 C.E., combined with corresponding demographic data, provides a unique opportunity to explore how the pressure of epidemics grew in an agrarian society over 2000 years. This quantitative analysis reveals that: (1) the frequency of outbreaks increased slowly before the 12th century and rapidly thereafter, until 1872; (2) in the first millennium of our era, the people of China lived for decades free of major epidemics; in the second millennium, major outbreaks occurred every couple of years, but were localized; (3) in the more recent centuries, these outbreaks were as common, but disseminated to more places. This evolution, closely matching the demographic growth, was similar in the north and south of China, and therefore may have been similar in other regions of the world.

Twelve-year trends and correlates of dietary salt intakes for the general adult population of Geneva, Switzerland.

BACKGROUND/OBJECTIVES: Investigate dietary salt intake trends by gender, and their associations with risk factors for cardiovascular diseases in Geneva, Switzerland. SUBJECTS/METHODS: Continuous surveillance of the Geneva general adult (35-74 years) population for 12 years (1993-2004) using a validated, semi-quantitative food frequency questionnaire (FFQ) in random, cross-sectional, representative samples (6688 men, 6647 women). Dietary salt intake assessment by FFQ excluded discretionary salt, but was calibrated on total salt intake using an independent validation substudy of 100 volunteers who additionally provided 24-h urine collections. RESULTS: Quartiles (mean) of calibrated dietary salt intake (g per day) were 9.9, 10.5, 11.2 (10.6) in men, and 7.0, 7.8, 8.9 (8.1) in women and were above current recommendations. Quartiles (mean) of salt density (g MJ(-1)) were 0.99, 1.16, 1.39 (1.23) in men, and 0.98, 1.12, 1.30 (1.17) in women. Both measures were stable during the 12-year surveillance period, regardless of hypertension treatment. Salt-density differences between cardiovascular disease risk factor subgroups were moderate. Salt density increased with age and body mass index. The main dietary non-discretionary salt food sources (men/women: 47/48%) were breads (17/17%), cheeses (11/10%), meat and meat products (8/7%), soups (6/9%) and ready-to-eat foods (5/5%). CONCLUSIONS: Salt intakes from all sources for the Geneva, and perhaps the Swiss adult population are above current recommendations. The quantitative and qualitative data provided in this paper could be used to develop and implement strategies for salt-intake reduction in Switzerland.

The James Lind Library: explaining and illustrating the evolution of fair tests of medical treatments.

The James Lind Library (www.jameslindlibrary.org) has been established to improve public and professional general knowledge about fair tests of treatments in healthcare and their history. Its foundation was laid ten years ago at the Royal College of Physicians of Edinburgh, and its administrative centre is in the College's Sibbald Library, one of the most important collections of historic medical manuscripts, papers and books in the world. The James Lind Library is a website that introduces visitors to the principles of fair tests of treatments, with a series of short, illustrated essays, which are currently available in English, Arabic, Chinese, French, Portuguese, Russian and Spanish. A 100-page book-- Testing Treatments--is now available free through the website, both in English and in Arabic and Spanish translations. To illustrate the evolution of ideas related to fair tests of treatments from 2000 BC to the present, the James Lind Library contains key passages and images from manuscripts, books and journal articles, many of them accompanied by commentaries, biographies, portraits and other relevant documents and images, including audio and video files. New material is being added to the website continuously, as relevant new records are identified and as methods for testing treatments evolve. A multinational, multilingual editorial team oversees the development of the website, which currently receives tens of thousands of visitors every month.

[Determinants of hypercholesterolemia in Geneva: should the focus be on genes or environment?]. / Déterminants de l'hypercholestérolémie a Genève: doit-on se concentrer sur res gènes ou l'environnement?

Do genetic (G), or environmental (E), factors primarily determine blood lipid concentrations in the Geneva population? On-going research on the causes of hypercholesterolemia in populations based on data collected by the Bus Santé Survey is summarized. About 2/3 of the HDL-cholesterol variance could not be explained by the most important 5 of 10 environmental factors and 9 of 275 common genetic variants identified in the analyses. The remaining 1/3 of the variance was explained mainly by obesity, smoking, alcohol intake, age, and gender. The common polymorphisms played a much smaller role. GxG, GxE, and ExE interactions were the weakest determinants. Environmental factors appear to be the main determinants of hypercholesterolemia in populations. Measurement of genetic traits for clinical or public health purposes is currently not useful.

History of medical screening: from concepts to action.

The objective of medical screening is to identify disease in its preclinical, and therefore hopefully still curable, phase. This may have been an old quest in medicine but it became historically possible when at least four conditions were met: the availability of simple, valid and acceptable forms of tests, the discovery of effective treatments, the establishment of a theory of screening, and the wide access to health care. Five selected examples that illustrate the history of medical screening are reviewed: screening for psychiatric disorders in the United States army as it is one of the oldest screening programmes; screening for syphilis as it used one of the earliest screening tests; screening for diabetes as one of the first modern forms of mass screening; screening for cervical cancer using the Pap test as one of the greatest successes of screening; and screening for breast cancer by mammography as this offers a good opportunity to discuss the development of modern evaluation of screening programmes. The evaluation of the impact of screening on human health slowly progressed, from obvious changes in the vital statistics such as the decline in incidence of syphilis, to less obvious changes such as the decline in mortality of cancer of the uterus, to finally more subtle changes, such as the impact of mammographic screening on breast cancer mortality. Methods of evaluation had therefore to adapt, evolving from simple surveys to case-control studies and randomised trials. The history of screening is short, but very rich and mostly still to be written.

Are there reliable predictors of postoperative pain?

BACKGROUND: The purpose of this study was to identify the preoperative determinants of severe postoperative pain. METHODS: Potential predictors were assessed using a questionnaire submitted on the day before surgery. Pain at rest, and pain during coughing/mobilization, were measured using visual analog scales on the day of surgery and on the following 2 days. The type of postoperative pain management was not standardized and was prescribed by the anesthesiologist in charge. Multivariate logistic regression models explaining postoperative pain were developed in Group I, comprising 304 consecutive patients undergoing orthopedic or intraperitoneal surgery, and validated in Group II, comprising 145 independent patients. RESULTS: Of the 62 variables examined by univariate analysis, only five were found to increase the risk of severe postoperative pain in Group I at rest and six factors during cough/mobilization. In the multivariate model for pain at rest, general anesthesia, expectation of postoperative pain, and chronic sleeping difficulties increased the risk of severe postoperative pain. In Group II, only chronic sleeping difficulties remained (OR: 3.97, 95% Cl: 1.69-9.29). In the multivariate model during cough/mobilization, intraperitoneal surgery, fear of postoperative pain, and having a relative with a history of pain increased the risk of severe postoperative pain in Group I. Intraperitoneal surgery OR 2.45 (95% Cl = 1.01-4.50) and having a relative with a history of pain OR 2.06 (95% Cl = 1.005-4.50) remained in Group II. CONCLUSION: Of the many factors that may influence postoperative pain, chronic sleeping difficulties emerge in this population of patients as the strongest determinant of pain at rest. Intraperitoneal surgery and having a relative with a history of pain are the strongest determinants of pain during cough/mobilization. These findings make physiological sense and deserve more attention by anesthesiologists.

Measuring the habitat as an indicator of socioeconomic position: methodology and its association with hypertension.

STUDY OBJECTIVES: (1) to develop an indicator of socioeconomic position based on the social standing of the habitat (SSH), that is, the residential building, its immediate surroundings, and local neighbourhood; (2) to assess the relation of SSH to two usual markers of socioeconomic position (education and occupation) and a known, socially determined health outcome (hypertension). DESIGN: Population survey measuring SSH, detailed educational and occupational histories, and blood pressure. The SSH is a standardised assessment of the external and internal aspects of someone's building (or house), and of the characteristics of its immediate surroundings and local neighbourhood. SETTING: A sample of participants to the Bus Santé survey between 1993 and 1998, in Geneva, Switzerland. PARTICIPANTS: 588 men and women, aged 35 to 74. MAIN RESULTS: The SSH index was highly reproducible (kappa=0.8). Concordance of SSH with education or occupation was good for people of either high or low socioeconomic position, but not for those with medium education and/or occupation. There was a higher prevalence of hypertension in the lowest compared with the highest groups, defined on the basis of education or occupation, but the SSH was the only indicator that showed a higher prevalence of hypertension among people in the middle of the social spectrum. CONCLUSIONS: People of medium education or occupation are heterogeneous with respect to their habitat. Those living in habitats of medium social standing may be most affected by hypertension but this association could not be revealed on the basis of education and occupation alone. The habitat seems to capture different aspects of the socioeconomic position compared with the usual indicators of social class.

Impact of 'Mad Cow Disease' publicity on trends in meat and total vitamin A consumption in Geneva between 1993 and 2000.

BACKGROUND: In March 1996, revelations about the possible risk for humans of the 'mad cow disease' epidemic had a sudden impact on the diets of European populations. OBJECTIVE: To assess changes in meat and nutrient intakes in adults living in Geneva, Switzerland from 1993 to 2000. DESIGN: Independent annual cross-sectional surveys (4047 women and 4092 men total). MAIN OUTCOME MEASURE: Dietary habits assessed and compared to baseline (January 1993-April 1996) via validated semi-quantitative food-frequency questionnaire. RESULTS: Women beef abstainers increased from 8.9 to 14.9% in late 1996 (P<0.001) and 13.3% in 1997 (P<0.05); among meat consumers, in late 1996 meat/beef intakes declined -10/-12% (both P<0.05). From 1997 to 2000 most intake levels drifted back toward those at baseline, but chicken intakes were significantly (all P<0.05) greater each year (+19% in 2000 (P<0.001). Consistent but less dramatic changes were observed among men. From late 1996 until 2000, liver abstention was significantly (all P<0.05) greater (women from 60 to 78%; men from 61 to 73% in 2000; (both P<0.001). The only nutrient intakes that decreased significantly (all P<0.05) each year from 1997 through 2000 were retinol and total vitamin A women: -22% (P<0.001); -11% (P<0.05) respectively; men: -16% (P<0.001); -10% (P<0.05) respectively, in 2000). Total vitamin A intakes exceeded the dietary reference intake (DRI) for liver eaters (women 185%, men 153%), but were below the DRI for liver abstainers (women 83%; men 66%) in 2000. CONCLUSION: The decreases in beef and liver consumption since late 1996 led to the discovery of a long-term disparity in the retinol and total vitamin A intakes of liver eaters vs abstainers.

Evaluation of do not resuscitate orders (DNR) in a Swiss community hospital.

OBJECTIVE: To evaluate the effect of an intervention on the understanding and use of DNR orders by physicians; to assess the impact of understanding the importance of involving competent patients in DNR decisions. DESIGN: Prospective clinical interventional study. SETTING: Internal medicine department (70 beds) of the hospital of La Chaux-de-Fonds, Switzerland. PARTICIPANTS: Nine junior physicians in postgraduate training. INTERVENTION: Information on the ethics of DNR and implementation of new DNR orders. MEASUREMENTS AND MAIN RESULTS: Accurate understanding, interpretation, and use of DNR orders, especially with respect to the patients' involvement in the decision were measured. Junior doctors writing DNR orders had an extremely poor understanding of what DNR orders mean. The correct understanding of the definition of a DNR order increased from 31 to 93% (p<0.01) after the intervention and the patients' involvement went from 17% to 48% (p<0.01). Physicians estimated that 75% of their DNR patients were mentally competent at the time of the decision. CONCLUSION: An intervention aimed at explaining the ethical principles and the definition of DNR orders improves understanding of them, and their implementation, as well as patient participation. Specific efforts are needed to increase the involvement of mentally competent patients in the decision.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease.

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Contribution of body composition to nutritional assessment at hospital admission in 995 patients: a controlled population study.

Body weight, weight changes and BMI are easily obtainable indicators of nutritional status, but they do not provide information on the amount of fat-free and fat masses. The purpose of the present study was to determine if fat-free mass (FFM) and fat mass were depleted in patients with normal BMI or serum albumin at hospital admission. A group of 995 consecutive patients were evaluated for malnutrition by BMI, serum albumin, and 50 kHz bioelectrical impedance analysis and compared with 995 healthy adults, matched for age and height, and then compared with FFM and fat mass percentiles previously determined in 5225 healthy adults. A BMI of

Influence of occupational exposure to latex on the prevalence of sensitization and allergy to latex in a Swiss hospital.

BACKGROUND: Replacement of powdered latex gloves has been recommended in order to prevent the development of latex allergy in health care workers. The conclusion that occupational exposure to latex gloves represents a risk factor for latex allergy is mainly based on studies without exposure controls. Atopy is also thought to be a risk factor for the development of latex allergy. OBJECTIVE: To determine the prevalence of atopy, sensitization to latex, and symptoms following latex exposure in professionally exposed and nonexposed hospital personnel by means of a cross-sectional study. METHODS: Six hundred randomly sampled individuals working in medicine and surgery departments and in surgery theaters and 300 sex- and age-matched individuals classified as administrative personnel were selected from the employee data base of the Geneva University Hospital. A questionnaire about exposure to latex and symptoms following this exposure was sent to all individuals. Skin prick test reactions and serum IgE to latex as well as standard environmental allergens were determined in both groups. RESULTS: Respiratory and skin (local) symptoms but not objective tests of latex sensitization (positive skin prick test and specific IgE to latex) were significantly associated with occupational exposure to latex (p < 0.001). Only among atopics subjects was 15 years or more of occupational exposure associated with a significantly higher prevalence of local symptoms than among those who were exposed from 1 to 9 years (odds ratio: 3.2; 95% confidence interval: 1.6-6.5). Atopy was significantly associated with sensitization to latex (odds ratio: 10.3; 95% confidence interval: 4.0-26.6) but not with local symptoms. Tests of latex sensitization were both frequently positive, less frequently negative, resulting in low kappa values. CONCLUSION: These results support the current preventive health care recommendation to replace powdered latex gloves. In atopics, increasing years of occupational exposure increase the risk of developing latex allergy. In contrast to questionnaires about local symptoms, skin prick tests and specific serum IgE to latex are of limited value in epidemiologic studies of latex allergy.

Can the declining prevalence of left-handedness with age be due to smoking?

The objective of this study was to assess whether smoking habits can explain the decline in left-handedness prevalence with age. Subjects participating in a population-based survey (n = 3,071) in Geneva, Switzerland, completed a questionnaire on innate hand preference, current hand preference for writing and smoking habits. The prevalence of innate left-handedness in the Geneva population was 9.4% in men and 7.4% in women. There was no association between smoking and left-handedness. It is concluded that smoking is not associated with hand preference and is an unlikely cause of overmortality in left-handed subjects.

Role of nasopharyngeal culture in antibiotic prescription for patients with common cold or acute sinusitis.

The aim of the present study was to assess the hypothesis that, when present in nasopharyngeal secretions, Streptococcus pneumoniae. Haemophilus influenzae, and Moraxella catarrhalis play a pathogenic role early in the course of an upper respiratory tract infection. Adults with a clinical diagnosis of acute sinusitis or common cold were enrolled. Participants were randomly assigned in a double-blind manner to receive azithromycin 500 mg daily or placebo for 3 days. The effect of treatment on symptom evolution in the predefined subset of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis in their nasopharyngeal secretions was assessed. Of 265 patients enrolled, 132 received placebo and 133 azithromycin. Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis was identified in nasopharyngeal secretions of 77 patients (29%). In this predefined subgroup of patients with Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 occurred in 73% of those treated with azithromycin compared with 47% of those who received placebo (P=0.007). The median time before resolution of symptoms was 5 days in the azithromycin group compared to 7 days in the placebo group. Respiratory complications requiring antibiotic treatment occurred in 19% of patients in the placebo group and in 3% of the azithromycin group (P=0.025). In the remaining 188 patients without Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, resolution of symptoms by day 7 was similar in both groups (69% in the placebo group vs. 64% in the azithromycin group [P=0.75]). Antibiotic treatment is of clinical benefit for patients with acute sinusitis or common cold when Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis is present in nasopharyngeal secretions. This observation provides new insights into the pathogenic role of these bacteria in the early stage of the common cold.