Estimating the mortality impacts of particulate matter: what can be learned from between-study variability?

Epidemiologic studies of the link between particulate matter (PM) concentrations and mortality rates have yielded a range of estimates, leading to disagreement about the magnitude of the relationship and the strength of the causal connection. Previous meta-analyses of this literature have provided pooled effect estimates, but have not addressed between-study variability that may be associated with analytical models, pollution patterns, and exposed populations. To determine whether study-specific factors can explain some of the variability in the time-series studies on mortality from particulate matter [less than/equal to] 10 microm in aerodynamic diameter (PM(10)), we applied an empirical Bayes meta-analysis. We estimate that mortality rates increase on average by 0.7% per 10 microg/m(3) increase in PM(10) concentrations, with greater effects at sites with higher ratios of particulate matter [less than/equal to] 2.5 microm in aerodynamic diameter (PM(2.5))/PM(10). This finding did not change with the inclusion of a number of potential confounders and effect modifiers, although there is some evidence that PM effects are influenced by climate, housing characteristics, demographics, and the presence of sulfur dioxide and ozone. Although further analysis would be needed to determine which factors causally influence the relationship between PM(10) and mortality, these findings can help guide future epidemiologic investigations and policy decisions.     

Weight of the evidence or wait for the evidence? Protecting underground miners from diesel particulate matter

A coalition of mine operators has used a variety of tactics to obstruct scientific inquiry and impede public health action designed to protect underground miners from diesel particulate matter. These workers are exposed to the highest level of diesel particulate matter compared with any other occupational group.This case study profiles a decade-long saga of the Methane Awareness Resource Group Diesel Coalition to impede epidemiological studies on diesel exhaust undertaken by the National Institute for Occupational Safety and Health and the National Cancer Institute, and to derail a health standard promulgated by the Mine Safety and Health Administration. The case study highlights the coalition's mastery of legislative, judicial, and executive branch operations and the reaction of policymakers.     

Potential Effects of California’s New Vaccine Exemption Law on the Prevalence and Clustering of Exemptions

Exemptions from childhood immunizations required for school entry have continued to increase among California kindergartners, and exemptions show spatial clustering within the state. A 2014 change in California’s school-entry vaccine exemption law requires parents filing for an exemption to submit signed documents from a health care provider. However, the evidence presented here suggests that the policy change will probably not be sufficient to reverse the growing trend in vaccine refusals.State-mandated immunization requirements for school entry have been instrumental in achieving high immunization coverage rates and ensuring herd immunity against infectious disease outbreaks.1 However, in most states parents can obtain a personal beliefs exemption (PBE) from school-entry requirements.2 A growing trend of parental vaccine hesitancy has led to an increase in PBE rates, and such increases are associated with higher risks of disease outbreaks.3 In California, for example, rates of PBEs among children entering kindergarten increased by 380% from 1996 to 2010 (from 0.5% to 2.3%).4,5In response to rising PBE rates, California passed Assembly Bill 2109 (AB2109) in September 2012.6 California’s previous law allowed a parent to obtain a PBE by signing an affidavit stating that immunization is contrary to the parent’s beliefs.7 This affidavit was preprinted on the California School Immunization Record, making exemptions readily accessible. Previous research demonstrates an association between easier state exemption procedures and higher exemption rates.8,9 Authored by state assembly member and pediatrician Richard Pan, AB2109 requires parents filing an exemption to submit an attestation signed by a health care provider stating that they have been provided information about the risks and responsibilities of refusing vaccination and an attestation signed by parents indicating receipt of this information.6 AB2109 went into effect in January 2014.It is not yet known whether this policy change will reverse or slow the trend of increasing PBE rates in California, although a similar regulatory change in Washington appears to have reduced PBEs.10 Here we present the most recent data on PBEs in California and demonstrate continued spatial variation in PBE rates statewide. These data represent the last kindergarten cohort before AB2109 was passed, so they will provide a useful baseline as the new law takes effect. We also discuss the implications of spatial clustering for the potential effectiveness of AB2109.     

New impacts of Grossman’s health investment model and the Russian demand for medical care

Aim

By analyzing the Russian demand for medical care, we aim to highlight the practical relevance of Grossman’s health investment model, one of the most important developments in health economic theory.

Subjects and methods

We refer to the often-criticized inconsistencies between the health investment model’s theoretical implications and its empirical results. While the theoretical model implies, inter alia, that the demand for medical care increases with improving health, empirical tests show conflicting results. In order to solve this inconsistency, we specify the model’s inherent health investment production function to be of decreasing rather than constant returns to scale. Afterwards, we employ our derived structural demand function for medical care in an empirical panel analysis using data from the Russia Longitudinal Monitoring Survey for 1996–2008.

Results

In contrast to other studies, we show that even Grossman’s standard model setting generates a structural demand function for medical care that implies sick people use more medical care, provided that the functional form of the health investment production function is properly specified. Further, our empirical analysis affirms our theoretically derived implications and provides important new insights into the Russian demand for medical care.

Conclusions

Grossman’s health investment model is of practical relevance to health economists.

     

Life Events and the Onset of Celiac Disease from a Patient’s Perspective

Stressful events have been investigated in various immune-mediated diseases but not in celiac disease. Our aim was to examine the relationship of stressful events assessed by the standardized interview of Paykel with the diagnosis of celiac disease in comparison to patients, with a diagnosis of gastroesophageal reflux disease used as the control group. Adults with celiac disease (n = 186) reported more frequent and more severe life events in the years prior to the diagnosis than control patients (n = 96) (67.2% vs. 37.5%, p < 0.001, mean Paykel score 11.5 vs. 13.4, p = 0.001, respectively). Findings were not significantly different between celiac disease and control patients for the time lapse between the event and the diagnosis (mean 5.5 vs. 5.7 months). Pregnancy was defined as a negative event by 20.3% of celiac women, but never by control women. Findings were confirmed when analyses were repeated in the subgroup of patients of both groups with diagnosis made within one year of onset of symptoms. Data indicate that, before diagnosis, the number of stressful events in celiac disease was more frequent although less severe than in the control group suggesting that life events may favor the clinical appearance of celiac disease or accelerate its diagnosis.     

Evaluation of biodiesel’s impact on real-world occupational and environmental particulate matter exposures at a municipal facility in Keene, NH

Many organizations are interested in biodiesel as a renewable, domestic energy source for use in transportation and heavy-duty equipment. Although numerous biodiesel emission studies exist, biodiesel exposure studies are nearly absent from the literature. This study compared the impact of petroleum diesel fuel and a B20 blend (20% soy-based biodiesel/80% petroleum diesel) on occupational and environmental exposures at a rural municipal facility in Keene, NH. For each fuel type, we measured concentrations of fine particulate matter (PM_2.5), elemental carbon (EC), and organic carbon (OC) at multiple locations (in-cabin, work area, and near-field) at a materials recovery facility utilizing non-road equipment. B20 fuel use resulted in significant reductions in PM_2.5 mass (56–76%), reductions in EC (5–29%), and increases in OC (294–467%). Concentrations of PM_2.5 measured during petroleum diesel use were up to four times higher than PM_2.5 concentrations during B20 use. Further analysis of the EC and OC fractions of total carbon also indicated substantial differences between fuels. Our results demonstrate that biodiesel blends significantly reduced PM_2.5 exposure compared to petroleum diesel fuel in a workplace utilizing non-road construction-type equipment. While this suggests that biodiesel may reduce health risks associated with exposure to fine particulate matter mass, more exposure research is needed to better understand biodiesel-related changes in particulate matter composition and other exposure metrics.     

Economic (in)equality and sustainability: preschool children’s views of the economic situation of other children in the world

This study explored preschool children’s knowledge and views of other children’s economic situation worldwide, and their self-reported sources of such knowledge. A total of 53 final-year preschool children, aged 5–6, from 12 preschools in Sweden were interviewed. Children’s responses were analysed using content analysis and the Structure of the Observed Learning Outcomes Taxonomy. Most of them seemed to have knowledge about the lives and the economic situation of other children in the world. Many of the preschool children could justify their views with one or more relevant ideas or thoughts, and a few of them were also able to logically connect their arguments. Parents, media and observations of real-life situations were reported as major sources of knowledge, while preschool was mentioned by a few. Further research is needed to enhance our knowledge about how to integrate social and economic sustainability in preschool’s pedagogical activities and to engage children meaningfully in such learning.     

A re-evaluation of the modern psychiatric hospital from the standpoint of the Kyoto school’s critique of modernity

Medicine, Health Care and Philosophy - Michel Foucault defines the modern psychiatric hospital as an institution of power that excludes and disciplines those who are deemed immoral, perverse, or...     

EPA’s proposed Worker Protection Standard and the burdens of the past

Background:

An Environmental Protection Agency (EPA) recommendation for extensive changes to the Agency’s 40-year-old Worker Protection Standard is currently stalled in the “proposed rule” stage. The proposal, which was available for public comment until 18 August, would improve safety, training, and hazard communication policies for agricultural pesticides. Exposure to hazards, including high heat, heavy machinery, stoop labor, and pesticides, makes occupational illness uncommonly common among the USA’s estimated 2.5 million farm workers.

Objectives:

To consider the proposed revisions’ likelihood of addressing historical gaps in farmworker protection.Methods: The proposal was compared to the existing Worker Protection Standard, and key aspects were analyzed in relation to existing science on farm labor hazards, as well as historic occupational health, labor and immigration policy.

Results:

US law historically has left farm workers largely unprotected. These exclusions and delays have been tolerated in part thanks to the myth of the independent family farmer, but more significant is the stingy nativism that presumes to benefit from immigrant labor without assuming any responsibility to protect the humans who provide it. In the first half of the 1970s, workers lobbied for robust protections, but rule making was impeded by lack of data and by the disproportionate influence of agricultural employers who sought minimal regulation. In 1974, the EPA passed the first Worker Protection Standard for farm workers. Key aspects of the proposed revision include stronger protections against drift and re-entry exposures, better information provision and training, and increased protections for workers under 16 years.

Conclusions:

The proposed changes represent an improvement over existing legislation, but do not go far enough. The revision should be strengthened along lines suggested by farm workers themselves, and other labor laws must also be amended to give the men, women, and children who work in the fields of this country full rights and protections.     

The smoker’s paradox and the real risk of smoking

No satisfactory explanations have been offered for the smokers paradox, the greater short-term survival of smokers after a myocardial infarction nor for the large variations in the coronary risk rate for smoking ranging between 1 and 5.9. These discrepancies as well as the smokers paradox may be caused by different baseline characteristics of smokers and nonsmokers, whereas the usually quoted coronary risk of 2 is derived from studies based on the assumption of equal baseline characteristics. As neither this assumption nor the possibility of unequal starting conditions have been tested, we examined the main cardiovascular risk factors in smoking and nonsmoking boys as near as possible to baseline, at the age of fourteen. This age appeared to be best suited, because boys starting to smoke early are most likely to become regular and heavy smokers. Of 336 boys, 39 had smoked 8.3 ± 6.0 cigarettes/day for 15.5 ± 11.2 months. Compared to nonsmokers, boys who started to smoke early had lower LDL cholesterol and ₂-antiplasmin, greater handgrip strength, vital capacity and forced expiratory volume, better perfomance on bicycle ergometry and higher testosterone. The differences in total cholesterol, LDL cholesterol, vital capacity, handgrip strength, testosterone and ₂-antiplasmin persisted after adjustment for age, body mass, and testosterone. In addition, the differences in perfomance on bicycle ergometry and forced expiratory volume persisted after adjustment for age. These favourable baseline characteristics of those starting to smoke early can explain the smokers paradox. In addition, they suggest that the individual coronary risk in smokers is considerably higher than 2, because the assumption of equal baseline characteristics of smokers and nonsmokers cannot be upheld.This revised was published online in April 2005. In the previous version the article category was missing.     

‘It’s one of those “It’ll never happen to me” things’: young women’s constructions of smoking and risk

In this article, we examine how young women make sense of the risks associated with smoking cigarettes. We recruited young women smokers and ex-smokers living in Australia in 2014 and 2015 to participate in semi-structured interviews and a participant-produced photography activity on young women’s experiences of smoking and smoking-related risk. We analysed the data using discourse analysis to examine how young women positioned themselves in relation to smoking-related risk, and how this was shaped by discourses of health, risk and femininity. We identified four dominant interpretative repertoires: ‘the risks of smoking are self-evident’, ‘it’s not going to happen to me’, ‘smoking as a lesser evil’ and ‘smoking to cope with stress and emotion’. Through our analysis, we found that by drawing on these repertoires, participants were able to position the risks of smoking as both acceptable and unacceptable. Participants also made use of several of these repertoires to position anti-smoking messages as ineffective. We place these findings in the context of broader health and risk discourses surrounding young women’s use of smoking to reinforce and subvert representations of ‘respectable’ femininity. We identify ways in which public health approaches could and should be developed to recognise the complexity and contradiction inherent in young women’s lay accounts of smoking-related risk and situate smoking risks in the context of young women’s everyday lives.     

Who’s afraid of EBM? Medical professionalism from the perspective of evidence-based medicine

Evidence-based medicine (EBM) and medical professionalism are two prominent notions in current medical debates. However, proponents of professionalism fear a restriction in doctors’ freedom to make their best decisions for individual patients caused by the influence of EBM and highly standardised decision procedures. The challenge which EBM allegedly poses to physicians’ discretion forms the starting point for an analysis of the relationship between professionalism, as an inherent value system of medical practice, and EBM, as an approach to optimise the decision-making for individual patients. The analysis starts with a brief conceptual clarification of the ambiguous term “professionalism”. It then focuses on three key aspects of medical professionalism which may come into conflict with the basic tenets of EBM. The potential tensions between (a) professional autonomy and clinical practice guidelines, (b) individualised care and standardisation, and (c) esoteric authority and public accountability are analysed and a suggestion for reconcilement regarding each point is made. The article closes with a summary on how a better reflection on medical professionalism may help towards a fuller understanding of EBM and vice versa.     

To be held and to hold one’s own: narratives of embodied transformation in the treatment of long lasting musculoskeletal problems

This study elaborates on narrative resources emerging in the treatment of longlasting musculoskeletal and psychosomatic disorders in Norwegian psychomotor physiotherapy (NPMP). Patients’ experiences produced in focus group interviews were analyzed from a narrative perspective, combining common themes across groups with in depth analysis of selected particular stories. NPMP theory expanded by Løgstrup’s and Ricoeur’s philosophy, and Mattingly’s and Frank’s narrative approach provided the theoretical perspective. Patients had discovered meaning imbued in muscular tension. Control shifted from inhibiting discipline and cognitive strategies, towards more contingence with gravity and sensation, and increased freedom to be what and who they were. Trust, time, open speech, and being respectfully listened to were described as therapeutic pre-conditions. The body was experienced as the source of their voice as their own. As tension patterns transformed, novel experience in sensation appeared to feed narrative imagination, reshaping past plots, embodied identity and future prospects. NPMP was disclosed as a treatment integrating detection, battle and repair as narrative subplots, but the core narrative was the journey of transformation. Novel embodied narrative resources nourished the quest for a life and identity in tune with the body as one’s own.     

Women’s Quality of Life in the Premenopausal and Postmenopausal Periods

Purpose The purpose of this research was to determine the relationship between menopausal symptoms and quality of life in women in the pre and postmenopausal periods.Methods and instruments All 171 women in the climacteric period who registered at the Pamukkale University Education and Research Hospital Obstetrics and Gynecology Clinic between January and July 2001 were included in the study. A questionnaire asking for sociodemographic information, complaints related to the climacteric period, and HRT use, as well as the WHOQOL brief, were used in order to obtain data.Findings One hundred of the women who participated in the study were premenopausal and 71 were postmenopausal and the mean age was 47.39 (SD=6.65). No significant difference was found in pre and postmenopausal women in the comparison of their quality of physical life, psychological, social relationships and environment scores (p>0.05). The physical quality of life scores for those without vasomotor complaints in the pre and postmenopausal periods were significantly higher in those with a high educational level and women who had been menopausal between 1–5 years and more than 10 years (p<0.05). Age and HRT use in postmenopausal women were not found to affect quality of life scores (p>0.05).Result We did not find any significant difference in the quality of life of pre and postmenopausal women.     

Multiple Antioxidants in the Prevention and Treatment of Parkinson’s Disease

Parkinson’s disease (PD) is one of the major progressive neurological disorders for which no preventative or long-term effective treatment strategies are available. Epidemiologic studies have failed to identify specific environmental, dietary or lifestyle risk factors for PD except for toxic exposure to manganese, meperidine (Demerol®, the “designer drug” version of which often contains a toxic byproduct of the synthesis, 1-methyl-4-phenyl 1,2,3,6 tetrahydropyridine [MPTP]), and some herbicides and pesticides. The search for genetic risk factors such as mutation, overexpression or underexpression of nuclear genes in DA neurons in idiopathic PD has not been successful as yet. Polymorphism in certain genes appears to be a risk factor, but there is no direct evidence for the causal relationship between polymorphism and increased risk of PD. In familial PD, mutation in the α-synuclein gene is associated with the disease, but a direct role of this gene in degeneration of DA neurons remains to be established. Although mutations in the Parkin gene has been associated with autosomal recessive juvenile Parkinson’s disease, the role of this gene mutation in causing degeneration of DA neurons has not been defined. We have reported that in hereditary PD, a mutation in the α-synuclein gene may increase the sensitivity of DA neurons to neurotoxins. We hypothesize that, in idiopathic PD, epigenetic (mitochondria, membranes, protein modifications) rather than genetic events are primary targets which, when impaired, initiate degeneration in DA neurons, eventually leading to cell death. Although the nature of neurotoxins that cause degeneration in DA neurons in PD is not well understood, oxidative stress is one of the intermediary risk factors that could initiate and/or promote degeneration of DA neurons. Therefore, supplementation with antioxidants may prevent or reduce the rate of progression of this disease. Supplementation with multiple antioxidants at appropriate doses is essential because various types of free radicals are produced, antioxidants vary in their ability to quench different free radicals and cellular environments vary with respect to their lipid and aqueous phases. L-dihydroxyphenylalanine (L-dopa) is one of the agents used in the treatment of PD. Since L-dopa is known to produce free radicals during its normal metabolism, the combination of L-dopa with high levels of multiple antioxidants may improve the efficacy of L-dopa therapy.