Age at natural menopause and breast cancer risk: the effect of errors in recall

Many case-control studies of breast cancer have reported estimates of relative risk of approximately 1.9 for menopause after 54 years of age when compared with menopause before 45 years of age. These estimates may be biased towards unity because of errors in recall of a woman's age at menopause. This paper investigates the magnitude of error associated with self-classification of women into categories of age at menopause by using personal interview and medical record data of 67 control women from a case-control study of breast cancer conducted in two retirement communities near Los Angeles in 1977-1978. These estimates of "misclassification" error are combined with various sets of "true" relative risks to yield "observable" relative risks. It is demonstrated that the relative risks associated with various age at menopause groups are likely to range from 1-3.4 rather than 1-1.9 as has been reported in the literature.     

Women and cosmetic breast surgery: weighing the medical, social, and lifestyle risks

In this article we provide a comparative analysis of qualitative, semistructured interviews with 24 women who had undergone different forms of cosmetic breast surgery (CBS). We argue that women must negotiate three types of risk: potential medical risks, lifestyle risks connected with choosing "frivolous" self-enhancements, and countervailing social risks affiliated with pressures to maximize one's feminine beauty. In addition, we highlight the challenges faced in negotiating these risks by examining the limits to traditional forms of medical informed consent provided to the women, who received little information on the medical risks associated with CBS, or who were given uncertain and contradictory risk information. Even respondents who felt that they were well informed expressed difficulties in making "wise" choices because the risks were distant or unlikely, and hence easily minimized. Given this, it is fairly understandable that the known social risks of "failed" beauty faced by the women often outweighed the ambiguous or understated risks outlined by medicine. We argue that traditional notions of informed consent and risk awareness might not be adequate for women choosing CBS.     

Toward less misleading comparisons of uncertain risks: the example of aflatoxin and alar.

Critics of comparative risk assessment (CRA), the increasingly common practice of juxtaposing disparate risks for the purpose of declaring which one is the "larger" or the "more important," have long focused their concern on the difficulties in accommodating the qualitative differences among risks. To be sure, people may disagree vehemently about whether "larger" necessarily implies "more serious," but the attention to this aspect of CRA presupposes that science can in fact discern which of two risks has the larger statistical magnitude. This assumption, encouraged by the indiscriminate calculation of risk ratios using arbitrary point estimates, is often incorrect: the fact that environmental and health risks differ in unknown quantitative respects is at least as important a caution to CRA as the fact that risks differ in known qualitative ways. To show how misleading CRA can be when uncertainty is ignored, this article revisits the claim that aflatoxin contamination of peanut butter was "18 times worse" than Alar contamination of apple juice. Using Monte Carlo simulation, the number 18 is shown to lie within a distribution of plausible risk ratios that ranges from nearly 400:1 in favor of aflatoxin to nearly 40:1 in the opposite direction. The analysis also shows that the "best estimates" of the relative risk of aflatoxin to Alar are much closer to 1:1 than to 18:1. The implications of these findings for risk communication and individual and societal decision-making are discussed, with an eye toward improving the general practice of CRA while acknowledging that its outputs are uncertain, rather than abandoning it for the wrong reasons.     

Post-marketing evaluation of the short term safety of COMVAX

We report an evaluation of the short-term safety of a pediatric bivalent combination vaccine containing RECOMBIVAXHB and Liquid PedvaxHIB, COMVAX. Safety was assessed through identification of medical utilization; potential adverse events were identified through computerized clinical databases for deaths, hospitalizations, emergency room visits, and outpatient clinic visits. We calculated relative risks whenever there was at least one diagnosis-specific event in the risk period following vaccination and compared the rates in specific time windows following vaccination with rates at 31-60 days following vaccination and also with rates in a historical cohort of children. A total of 27,802 doses of COMVAX were administered, with 127 separate adverse event codes with statistically significant elevated risks, and 66 codes with significantly decreased risks. Most potentially serious diagnoses appeared in four major categories: "Respiratory Events"; "Gastroenteritis"; "Adverse Effect of Medicinal and Biological Substance, NOS"; and "Fever". There was no consistent pattern to indicate increased risks for serious respiratory or gastrointestinal illness. For fever, most of the findings appeared to be explained by changes in data collection or by concomitant vaccination with M-M-R(-)II. There was an increased risk for fever hospitalizations following shot 1. The total number of children hospitalized with fever was seven out of 12,468 children; all recovered fully. In this study population of 27,802 vaccine recipients, COMVAX appeared to have a favorable safety profile.     

Estimating the return-on-investment from changes in employee health risks on the Dow Chemical Company's health care costs

OBJECTIVE: We sought to estimate the impact of corporate health-management and risk-reduction programs for The Dow Chemical Company by using a prospective return-on-investment (ROI) model. METHODS: The risk and expenditure estimates were derived from multiple regression analyses showing relationships between worker demographics, health risks, and medical expenditures. RESULTS: A "break-even" scenario would require Dow to reduce each of 10 population health risks by 0.17% points per year over the course of 10 years. More successful efforts at reducing health risks in the population would produce a more significant ROI for the company. CONCLUSIONS: Findings from this study were incorporated into other components of a business case for health and productivity management, and these supported continued investments in health improvement programs designed to achieve risk reduction and cost savings.     

Status of the social inequality topic and health in the periodical "Das Gesundheitswesen"

People with social problems and risks very often also suffer from health problems and risks. This refers to at least 10% of the population. We were interested to learn how many articles in the leading German journal of Public Health "Das Gesundheitswesen" are dealing with this topic of social inequality and health. From 1990 to 1999 just 5.4% of the 1399 published articles deal with this topic. The authors mainly came from social epidemiology; practical research was rare. This also seems to be a consequence of a lack of research in the departments of social work education.     

Lipid and lipoprotein predictors of coronary heart disease in elderly men in the Honolulu Heart Program.

Data from the baseline and follow-up examinations of the Honolulu Heart Program (HHP) cohort of 8006 men of Japanese ancestry were used to examine several questions concerning the predictive role of lipids and lipoproteins for incident CHD. For the question "Do serum cholesterol levels measured in middle age predict incident CHD in elderly men 65 years old or older?" the answer was clearly yes. Multivariate relative risks and attributable risks for early and late onset of CHD were similar and statistically significant. For the question "Do serum cholesterol levels measured in the elderly predict subsequent CHD?" the answer again was clearly yes. Multivariate relative risks for elderly men were similar to those for middle-aged men, and attributable risks were consistently higher for elderly men. For the question "Do other lipid or lipoprotein levels measured in the elderly predict incident CHD better than serum cholesterol level?" the answer was no. Multivariate relative risks for low-density-lipoprotein (LDL) and non-high-density-lipoprotein cholesterol were similar to those for total cholesterol. HDL cholesterol was protective for incident CHD, but the patterns were not significant for the elderly. Serum triglyceride level was not a significant predictor of CHD for the elderly. The conclusion was that no matter at what age serum cholesterol was measured, it predicted subsequent CHD in the elderly men in this cohort.     

危险源风险体积法分析探索

[目的]以"风险体积"概括和展现危险源风险构成的整体性,探索破解危险源风险的理论途径。[方法]从经典风险理论,导出"风险体积"的概念,对危险源存在的事故风险进行三维分析,界定出危险源风险与隐患,体现从危险源到隐患再到风险的溯源关系。[结果]提出"一元隐患"、"二元隐患"和"三元风险"的观点。[结论]对于风险体积(三元风险),可通过降低(或消除)其中一种构成因素,使其缩小(或为零),事故风险下降(或消失)。     

An analysis of the risk in the French sea fishing industry. Example of the dockside accident risk

In many maritime countries, the work of sea fishermen is one of the most hazardous of occupations. The number of accidents is much greater than in other occupations on land or at sea, and the accidents themselves are often more serious. When considering the risks and hazards of fishing, one initially thinks of major risks like collisions or vessels running aground, as well as the work related injuries which are mainly caused by the fishing equipment (otter boards, ropes) and by the motions of the vessel. These accidents and, in a more general sense, the dangers met by fishermen at sea have already been studied. But little research has been undertaken on the problem of accidents of fishermen while the vessel is in port; and in France, these accidents account for about 30 % of all registered injuries for the sea fishing industry. The presented report takes a look at this category of accidents, on the basis of data on 5074 accidents registered between 1996 and 2005. An examination of statistics therefore points to certain types of risks and dangerous situations, but it also leaves a number of questions pending. One of these is the number of "unknown" causes. Falls, in particular, are usually linked to an outside factor which is not listed on the form the sailors must fill out. To compensate for the limitations of the epidemiological analysis, on-site observation seemed to be the best way of understanding the risks of the activities of fishermen in the port.     

In-flight radiation: counseling patients about risk.

BACKGROUND: At the high altitudes, which are the domain of commercial airliners, cosmic-ray exposure rates are hundreds of times greater than at ground level. If this radiation originated at a regulated industrial or medical facility, many frequent flyers would receive annual exposures in excess of the present legal limit applicable to members of the public. For pregnant travelers, the fetus is also at risk, with a sensitivity that varies during the course of pregnancy. METHODS: Health risks from in-flight radiation exposure are analyzed specifically to calculate the likelihood of cancer, birth defects, and genetic damage. A literature review was conducted from 1985 to 1998, using the key words "cosmic radiation," "aviation medicine," "radiation risk," and "in-flight radiation." RESULTS AND CONCLUSIONS: The analysis shows that for the passenger who travels only occasionally, the risks are extremely small. For business frequent flyers the risks are still small, but not negligible.     

Occult-blood screening for colorectal carcinoma: the yield and the costs

The potential benefits and risks associated with Hemoccult screening have been reviewed in two companion papers. This final article assesses two major determinants of the overall "disease yield" of occult-blood screening, as well as the economic costs entailed by the maneuver. First, asymptomatic polyps detected and treated by such screening are more properly considered "false" positives than "true" positives--the benefits of their aggressive diagnosis and extirpation in the general population being much less established than the risks. Secondly, the ongoing detection rate for colorectal carcinoma on subsequent (e.g., annual) screenings of a population already screened will be substantially less than the initial screening yield; yet, the risks of confirmatory diagnostic procedures remain high. Lastly, there are many hidden costs to occult-blood screening that have generally not been recognized. Therefore, the use of Hemoccult screening as a routine health maintenance maneuver cannot yet be justified for any age-group.     

Cancer risks near nuclear facilities: the importance of research design and explicit study hypotheses

Background

In April 2010, the U.S. Nuclear Regulatory Commission asked the National Academy of Sciences to update a 1990 study of cancer risks near nuclear facilities. Prior research on this topic has suffered from problems in hypothesis formulation and research design.

Objectives

We review epidemiologic principles used in studies of generic exposure–response associations and in studies of specific sources of exposure. We then describe logical problems with assumptions, formation of testable hypotheses, and interpretation of evidence in previous research on cancer risks near nuclear facilities.

Discussion

Advancement of knowledge about cancer risks near nuclear facilities depends on testing specific hypotheses grounded in physical and biological mechanisms of exposure and susceptibility while considering sample size and ability to adequately quantify exposure, ascertain cancer cases, and evaluate plausible confounders.

Conclusions

Next steps in advancing knowledge about cancer risks near nuclear facilities require studies of childhood cancer incidence, focus on in utero and early childhood exposures, use of specific geographic information, and consideration of pathways for transport and uptake of radionuclides. Studies of cancer mortality among adults, cancers with long latencies, large geographic zones, and populations that reside at large distances from nuclear facilities are better suited for public relations than for scientific purposes.     

Mind the Gap

Background

Recent analysis has demonstrated a remarkably consistent, nonlinear relationship between estimated inhaled dose of combustion particles measured as PM_2.5 (particulate matter with aerodynamic diameter ≤ 2.5 μm) and cardiovascular disease mortality over several orders of magnitude of dose—from cigarette smoking, environmental tobacco smoke (ETS) exposure, and ambient air pollution exposure.

Objectives

Here we discuss the implications of this relationship and point out the gaps in our knowledge that it reveals.

Discussion

The nonlinear exposure–response relationship that is revealed—much steeper at lower than at higher doses—explains the seemingly inconsistent risks observed from ambient air pollution and cigarette smoking but also raises important questions about the relative benefits of control at different points along the curve. This analysis also reveals a gap in the evidence base along the dose–response curve between ETS and active smoking, which is the dose range experienced by half the world’s population from indoor biomass and coal burning for cooking and heating.

Conclusions

The shape of the exposure–response relationship implies much larger public health benefits of reductions at the lower end of the dose spectrum (e.g., from reductions in outdoor air pollution) than from reducing the rate of active smoking, which seems counterintuitive and deserving of further study because of its importance for control policies. In addition, given the potential risks and consequent global disease burden, epidemiologic studies are urgently needed to quantify the cardiovascular risks of particulate matter exposures from indoor biomass burning in developing countries, which lie in the dose gap of current evidence.     

The effects of prenatal care upon the health of the newborn.

Data upon all births and infant deaths in New York City in 1968 are analyzed using methods for the analysis of multidimensional contingency tables. These methods provide estimates of the effect of variations in prenatal care upon the relative risks of low birth weight and neonatal and postneonatal mortality, controlling for a wide variety of factors which tend to "select" women into a program of prenatal care. Significant relationships between lack of prenatal care and infant mortality are estimated, but these occur mainly via the relationship of inadequate prenatal care to low birth weight. Furthermore, among white mothers who delivered on a private service, those receiving inadequate levels of prenatal care experienced only slightly increased risks of a low birth weight infant. In contrast, white mothers who delivered on a general service, and all black mothers, experienced substantially increased risks when receiving inadequate prenatal care. A variety of behavioral characteristics of mothers were not controlled in these analyses, and thus clear causal inferences concerning the efficacy of prenatal care cannot be drawn. These analyses do, however, identify a significant population of women at substantial risk.     

Risk assessment and risk communication in chemical exposure

The Directorate-General V at the European Commission has published a report called "Guidance on risk assessment at work". Several industrial enterprises and associations also have issued corresponding guidelines. The field presents quite a diverse variety on how risks should be assessed and managed at work, who should do it and in which form reports should be presented and to whom. The understanding of different directives and guidelines is further aggravated by confusing subtleties in definitions and terminology. Traditionally Occupational Health Professionals have had their natural consultative role in Risk Assessment and Risk Management, but growing changes in attitudes tend more and more to ignore the importance of health expertise while dealing with risks threatening health. Terminology in terms of "Hazard", "Risk", "Risk Assessment", "Risk Management" will be addresses and explained. Examples of guiding will be presented.     

Health promotion versus health protection? Employees' perceptions and concerns

The "second public health revolution" targets factors in the environment, together with lifestyle, to prevent illness and untimely death. Yet the growth of the "wellness movement" has driven a wedge between public health advocates who argue for environmental solutions and those whose major focus is individual behavior. This tension is nowhere more evident than in the workplace, where the new wellness professionals are at odds with specialists in occupational health and industrial hygiene. This paper reports findings from a cross-sectional survey of a sizeable sample of workers at six New England facilities of a very large American manufacturing firm, assessing their perceptions of risk in the two domains: environmental exposures and lifestyle risks. Multiple regression analyses reveal that both job risks and life risks are associated with a variety of potentially costly and disruptive health problems, even after controlling for demographic and occupational factors. This analysis suggests that wellness programs in the workplace will be more effective if they integrate environmental protection with efforts to reduce lifestyle risk.     

What's more dangerous, your aspirin or your car? Thinking rationally about drug risks (and benefits)

We compare mortality risks of several common drugs with risks related to work, transportation, and recreation. Comparing risks can provide a more intuitive sense of the magnitude of drug risks than stand-alone estimates can, to help inform policy discussions. The drug risks we quantify generally exceed the magnitude of risks for other domains (although aspirin and cars are similarly "risky" under the definition of risk used here). Nonetheless, these comparisons underscore a crucial point: that risks should not be evaluated without considering attendant benefits. We discuss the need for the Food and Drug Administration to compare risks and benefits quantitatively, consistently, and explicitly.     

公立医院收支管理风险量化评价的两种方法比较分析

目的:构建科学合理的收支管理风险量化评价指标体系,为识别公立医院收支管理环节存在的风险提供依据。方法:分别采用传统描述性统计方法和熵值法对收支风险指标进行赋权。结果:"备用金年底是否及时收回""支出申请与内部审批是否分离"等风险点在两种方法下其权重排序差异较大。结论:在传统医院收支风险管理领域,实务界关注收入支出的数量真实性、合法合规性,而以差异化为导向的熵值法更关注的是不同被试之间的差异性,即易被忽视的风险点,这与近几年审计实务中发现的问题基本吻合,医院财务管理人员应予以重点关注。     

Carpal tunnel syndrome and manual work: a longitudinal study

OBJECTIVE: To assess risks associated with work-related biomechanical overloads in onset/course of carpal tunnel syndrome. METHODS: Work-groups with job tasks spanning different biomechanical exposures were evaluated at baseline in terms of American Conference of Governmental Industrial Hygienists hand-activity/peak force action limit and threshold limit values (TLV). Exposures of interest were "unacceptable" (hand-activity above TLV) and "borderline" (between action limit and TLV) overloads. Clinical/individual data were collected at baseline and 12 months. RESULTS: One-year incidence of "classic/possible" carpal tunnel syndrome symptoms as defined by consensus criteria was 7.3% (153 of 2092). "Unacceptable" overload was associated with a 3-fold increased risk of onset with respect to "acceptable" load. At ordered logistic regression analysis of symptom-status variations, increased risks were recorded for "unacceptable" and "borderline" overloads. CONCLUSIONS: Effectiveness of encouraging workplace adherence to the American Conference of Governmental Industrial Hygienists recommendations deserves investigation as a possible key to wide-scale prevention.     

Maternal occupational exposure to electromagnetic fields before, during, and after pregnancy in relation to risks of childhood cancers: findings from the Oxford Survey of Childhood Cancers, 1953-1981 deaths

BACKGROUND: The concern that maternal exposure to electromagnetic fields (EMF) might be related to childhood cancer risks, particularly leukemia risks. METHODS: Maternal occupational data already collected as part of the Oxford Survey of Childhood Cancers have been reviewed. Information on occupations held before, during, and after the pregnancy was sought for 15,041 children dying of cancer in Great Britain in the period 1953-1981, and for an equal number of matched controls. Each period of working was classified under one of five headings: (1) sewing machinist; (2) textile industry workers (other than sewing machinists) with likely exposures to EMF; (3) other machinists and other jobs with likely "higher" EMF exposure; (4) other jobs with likely exposure to some EMF, and (5) jobs with little potential for EMF exposure. RESULTS: Relative to risks in the children of mothers who held occupations with little potential for EMF exposure during pregnancy (a category that included housewives), risks of all childhood cancers were close to unity both for the children of sewing machinists (22 case and 31 control mothers, RR 0.72, 95% CI 0.42 to 1.25) and for the children of other machinists with likely "higher" EMF exposures (44 case and 47 control mothers, RR 0.93, 95% CI 0.61 to 1.41). Corresponding risks for all childhood leukemias and for all childhood brain cancers were similarly unexceptional. Simultaneous adjustment for social class, maternal age at birth of child, and sibship position had little effect. CONCLUSIONS: The study findings did not indicate that maternal occupational exposure to EMF during pregnancy is a risk factor for childhood leukemias, childhood brain cancers, or the generality of all childhood cancers.