Dust Exposures at U.S. Surface Coal Mines in 1982–1983

Exposures to British Mining Research Establishment corrected respirable dust and respirable quartz at U.S. surface coal mines during 1982–1983 were evaluated from coal mine operator and Mine Safety and Health Administration (MSHA) inspector samples. The average respirable quartz concentration from inspector samples ranged from .34-.49 mg/m³ for drilling jobs and .18 mg/m³ for bulldozer operators. For most other surface coal mine jobs, the average respirable quartz concentration was less than .1 mg/m³, and the average respirable dust concentration was less than 2 mg/m³. The results from the analysis of quartz exposures are consistent with epidemiological results for an increased silicosis risk among drillers. It is unclear, however, whether the MSHA samples provide a representative estimate of the average annual quartz concentration for drillers. Results suggest the need for a greater number of quartz samples to be taken on strip coal miners, particularly on drillers and bulldozer operators.     

2017年St.Gallen国际乳腺癌会议内外科热点问题解读

两年一度的St.Gallen国际乳腺癌会议与专家共识是对过去2年来乳腺癌领域所出现的新的治疗证据的盘点和总结.第15届St.Gallen国际乳腺癌会议就早期乳腺癌新辅助化疗、辅助化疗、辅助内分泌治疗、辅助靶向治疗的“加减法”进行了充分的讨论与表决,外科领域就保乳手术、前哨淋巴结活检术的适应证和禁忌证等问题以及新辅助化疗后的保乳术和前哨淋巴结活检进行了重点讨论;会议注重“对患者利益最大化,损害最小化”的原则,使乳腺癌综合治疗更加“精准”和“个体化”.本文对内外科的热点问题作一解读.     

A Medicare-Associated Spike in U.S. Cancer Rates at Age 65, 2000–2010

Age 65 represents a transition point where most U.S. residents begin Medicare coverage. We examined whether or not delays in medical care near this age extend to cancer diagnosis. We calculated single-year-of-age cancer incidence rates by site and stage for the most common cancer sites (i.e., prostate, female breast, lung, and colorectal) for the 2000–2010 period using data from the SEER 18 registries, and we used Poisson regression to identify a possible age-65 effect. The analysis was repeated on comparable Canadian data. Cancer rates at age 65 were found to be as much as 15% above expected in the U.S. data, with the age-65 effect strongly associated with site- and stage-specific survival. A smaller association was seen in the Canadian data. We found strong evidence that diagnosis of less severe cancers spikes at age 65. Delay of medical care prior to this age has complex policy implications.The 65th birthday is a major life milestone for many Americans. It corresponds to the age when nearly all become eligible for health-care coverage through Medicare, when many begin receiving Social Security benefits, and when many choose to retire. This age boundary has been shown to have profound effects on health and health-care utilization. For example, rates of medical screening, diagnosis, and treatment for conditions that are low urgency, asymptomatic, and reimbursable by Medicare are found at much higher levels among those aged 65 years than those aged 64 years.^1–3 It has been suggested that this phenomenon is driven by the low-cost “Welcome to Medicare” physical examination instituted in 2005, but too few people have taken advantage of this feature for it to explain much of the difference.⁴In contrast, rates of “nondeferrable admissions,” defined as conditions where hospital admission rates through emergency departments do not diminish on weekends, show no change at age 65 years.⁵ For those who are uninsured or underinsured, there are clear financial incentives to postpone nonurgent medical encounters until Medicare is available. The effect is too large, however, to be explained by the behavior of the uninsured and underinsured alone. Even some people who are fully insured postpone treatment until age 65 years, either because of the perception that Medicare is a more generous health-care plan than other insurance plans or because postponing is more convenient.⁵ Recovering from a hip replacement while retired, for example, may be more practical than attempting to do so while employed.None of the existing research on pent-up demand for Medicare has, to our knowledge, specifically considered cancer incidence. We hypothesized that cancer should follow the same pattern as seen for other medical conditions. Specifically, screen-detected, asymptomatic, nonlethal tumors should show an unusually high incidence rate at age 65 years relative to other ages, while advanced-stage, low-survival tumors should show no difference. If correct, this observation should inform the current discussion regarding the extent to which certain cancers are being overdiagnosed and overtreated as a consequence of aggressive screening,⁶ as the Medicare program may be unwittingly bearing an undue share of the cost of such treatment. Conversely, underdiagnosis and undertreatment of those approaching 65 years of age may also be unduly shortening life spans among this group.We measured the elevation in cancer rates at age 65 years above what would be expected based on the otherwise smooth trend between ages 55 and 75 years. We considered prostate, female breast, lung, and colorectal cancers—the four most common cancer sites—which accounted for approximately 54% of all incident cases in the United States during the 2000–2010 period. Each of these cancers is detectable through screening, although at the time of writing only colorectal cancer screening for those aged 50–75 years was unequivocally endorsed by the U.S. Preventive Services Task Force (USPSTF).⁷ Breast cancer screening for women aged 50–74 years is generally recommended, but the guidelines for women older than 40 years of age are currently under review.^8,9 Lung cancer screening is recommended only for current or recent heavy smokers aged 55–80 years,¹⁰ and prostate cancer screening is not recommended at all.¹¹ We further investigated the relationship between the age-65 effect and the severity of the cancer, as measured by five-year survival. Finally, we compared the results from the United States with equivalent results from Canada, where no change in health-care insurance status occurs at age 65, but where 65 is also a popular retirement age.     

Gestational age shortening in single births at term. Italy 1990–1998

The increasing incidence of moderate preterm births (32–36 gestation weeks) might reflect a more general tendency toward a shortening of the gestational length occurring also in the term births (37 + gestation weeks). We examined all Italian 1st live born singletons (n = 2,356,365) and found that from 1990 to 1998 the births of 40 + gestation weeks decreased from 60.7 to 51.7% and among term births the average gestation weeks decreased from 39.74 to 39.55. In term pregnancies the effect of low education and advanced age of the mother in decreasing the gestational length persisted over time, but, independently of the maternal factors, the pregnancies experienced a progressive shortening. The finding, if confirmed for other countries, should deserve further investigations on possible determinants, as improved estimates of gestational age through the widespread use of prenatal ultrasound or diffusion of hazardous and stressing working and living conditions.     

Cutting costs: it can be done. But at what price?

Through tough negotiating, an in-house doctor, and strict plan limits, Tamar Inns spent $745 per covered life on health care last year. Is it too low?     

Dialogue. Industry consolidation: what's at stake for consumers and purchasers?

The behavioral healthcare field has undergone massive consolidation, especially in the last year. Health plans, hospital systems, and community-based organizations have all been affected. Economists argue that consolidation is a logical consequence of the current, competitive healthcare market. But consumers and purchasers wonder if the mergers and acquisitions will benefit them. Efficient markets are supposed to stimulate competition in ways that reward purchasers and consumers of services. When prices go down and quality improves as a result of competitive market forces, then the market has functioned properly and has served its purpose. Behavioral healthcare, however, is an essential human service, not a commodity. And the consumers and purchasers of healthcare are typically not the same person or entity, which also makes the healthcare market different from the markets for cars, computers, food, or any other type of consumer product. More than 100 million Americans now receive managed behavioral health benefits from only three companies. With such intense power concentrated in the hands of such a small number of providers, the time has come to evaluate the impact of the consolidation trend. In the following dialogue article, leaders, representing different interest groups review the benefits and risks of massive industry consolidation, and propose solutions to the critical challenges that it raises.