Short-term effects of ambient particles on cardiovascular and respiratory mortality

BACKGROUND: Particulate air pollution is associated with increased mortality. There is a need for European results from multicountry databases concerning cause-specific mortality to obtain more accurate effect estimates. METHODS: We report the estimated effects of ambient particle concentrations (black smoke and particulate matter less than 10 mum [PM10]) on cardiovascular and respiratory mortality, from 29 European cities, within the Air Pollution and Health: a European Approach (APHEA2) project. We applied a 2-stage hierarchical modeling approach assessing city-specific effects first and then overall effects. City characteristics were considered as potential effect modifiers. RESULTS: An increase in PM10 by 10 microg/m (lag 0 + 1) was associated with increases of 0.76% (95% confidence interval = 0.47 to 1.05%) in cardiovascular deaths and 0.58% (0.21 to 0.95%) in respiratory deaths. The same increase in black smoke was associated with increases of 0.62% (0.35 to 0.90%) and 0.84% (0.11 to 1.57%), respectively. CONCLUSIONS: These effect estimates are appropriate for health impact assessment and standard-setting procedures.     

Patient pain in primary care: factors that influence physician diagnosis

BACKGROUND: The accurate recognition of patient pain is a crucial, but sometimes difficult, task in medical care. This study explored factors related to the physician's diagnosis of pain in primary care patients. METHODS: New adult patients were prospectively randomized to care by primary care providers at a university medical center clinic. Study participants were interviewed prior to the initial visit, and their level of self-reported pain was measured with the Visual Analog Pain Scale and the Medical Outcomes Study Short Form-36. The medical encounter was videotaped in its entirety and later analyzed using the Davis Observation Code to characterize physician practice style. Patient satisfaction was measured immediately after the visit. A review of the medical record was used to assess physician recognition of patient pain. RESULTS: For all patients (N = 509), as the amount of pain increased, the percentage of patients having pain diagnosed by the physician also increased. Female patients reported a greater amount of pain than male patients. When women were in severe pain, they were more likely than men to have their pain accurately recognized by their physician. The correct diagnosis of pain was not significantly related to patient satisfaction. Physician practice styles emphasizing technically oriented activities and health behavior discussions were strongly predictive of the physician diagnosing patient pain. CONCLUSIONS: The diagnosis of pain is influenced by the severity of patient pain, patient gender, and physician practice style. If the routine use of pain assessment tools is found to be effective in improving physician recognition and treatment of patients' pain, then application of these tools in patient care settings should be encouraged.     

Flavonoid intake in relation to lung cancer risk: case-control study among women in Greece

We have examined the role of three classes of flavonoids that are relatively common in the Greek diet (flavanones, flavan-3-ols, and flavonols) in the etiology of lung cancer using data from a case-control study among women, which was undertaken in Athens, Greece, in the late 1980s. Study subjects were 154 women with lung cancer and 145 control women with orthopedic conditions. Women reported their life-long smoking histories and average frequency of consumption, before onset of present disease, of 47 food items or beverages that collectively covered >80% of the intake of each of the energy-providing nutrients. Intakes of flavonoids were calculated using the recently published U.S. Department of Agriculture database. The data were modeled through logistic regression, controlling for energy intake and smoking. There was no indication that intake of any of the studied flavonoid categories reduces the risk of lung cancer; indeed, for flavonols there was an unexpected positive association. Thus, our study does not indicate a protective effect of flavanones, flavan-3-ols, or flavonols on lung cancer risk and indicates that the factors responsible for the protective effect of vegetables and fruits against the risk of this cancer are unlikely to belong to these flavonoid categories.     

Obesity and the use of health care services

OBJECTIVE: This study investigated differences in the use of health care services and associated costs between obese and nonobese patients. RESEARCH METHODS AND PROCEDURES: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of medical services and related charges was monitored for 1 year. Data collected included sociodemographics, self-reported health status using the Medical Outcomes Study Short Form-36, evaluation for depression using the Beck Depression Index, and measured height and weight to calculate BMI. RESULTS: Obese patients included a significantly higher percentage of women and had higher mean age, lower mean education, lower mean health status, and higher mean Beck Depression Index scores. Obese patients had a significantly higher mean number of visits to both primary care (p = 0.0005) and specialty care clinics (p = 0.0006), and a higher mean number of diagnostic services (p < 0.0001). Obese patients also had significantly higher primary care (p = 0.0058), specialty clinic (p = 0.0062), emergency department (p = 0.0484), hospitalization (p = 0.0485), diagnostic services (p = 0.0021), and total charges (p = 0.0033). Controlling for health status, depression, age, education, income, and sex, obesity was significantly related to the use of primary care (p = 0.0364) and diagnostic services (p = 0.0075). There was no statistically significant relationship between obesity and medical expenditures in any of the five categories or for total charges. DISCUSSION: Obesity is a chronic condition requiring long-term management, with an emphasis on prevention. If this critical health issue is not appropriately addressed, the prevalence of obesity and obesity-related diseases will continue to grow, resulting in escalating use of health care services.     

Clinical faculty tracks and academic success at the University of California Medical Schools.

PURPOSE: To describe the five faculty series for medical school faculty in the University of California (UC) system, their criteria for advancement, associated challenges, and the different ways they are used by each school. METHOD: During 2001-02, the associate dean for academic affairs at each UC medical school was interviewed for information on the number of faculty in each academic series, the role of each series, and problematic issues associated with them. The averaged merit and promotion results for each series for 1999-2002 at the University of California, Davis, School of Medicine, were examined. RESULTS: The two clinical faculty series showed the most variability among the UC campuses for number of faculty, and strategy for appointment and advancement. The percentage of faculty in the Clinical X series varied from 8% to 39% at the five campuses. All campuses agreed that faculty in the Clinical X series must participate in applied or translational clinical investigation or educational investigation, and disseminate their work. All campuses required that the Ladder-Rank and In-Residence faculty devote the majority of their time to hypothesis-driven research. At University of California, Davis, the two clinical series had the highest approval rates for merits and promotion actions. The Ladder-Rank series had the highest denial rate for merits and promotion. CONCLUSIONS: Clinical series in the UC system are used differently at the five medical schools. Appointing junior faculty in series with minimal expectations as a "safe starting place" is favored for building long-term faculty. Faculty in all series tend to do well in the academic review process, indicating that these series define distinct expectations. Clinical faculty's accomplishments are increasingly understood, valued, and rewarded.     

The temporal pattern of respiratory and heart disease mortality in response to air pollution

Short-term changes in ambient particulate matter with aerodynamic diameters < 10 micro m (PM10) have been associated with short-term fluctuations in mortality or morbidity in many studies. In this study, we tested whether those deaths are just advanced by a few days or weeks using a multicity hierarchical modeling approach for all-cause, respiratory, and cardiovascular deaths, for all ages and stratifying by age groups, within the APHEA-2 (Air Pollution and Health: A European Approach) project. We fit a Poisson regression and used an unconstrained distributed lag to model the effect of PM10 exposure on deaths up to 40 days after the exposure. In baseline models using PM10 the day of and day before the death, we found that the overall PM10 effect (per 10 micro g/m3) was 0.74% [95% confidence interval (95% CI), -0.17 to 1.66] for respiratory deaths and 0.69% (95% CI, 0.31-1.08) for cardiovascular deaths. In unrestricted distributed lag models, the effect estimates increased to 4.2% (95% CI, 1.08-7.42) for respiratory deaths and to 1.97% (95% CI, 1.38-2.55) for cardiovascular deaths. Our study confirms that most of the effect of air pollution is not simply advanced by a few weeks and that effects persist for more than a month after exposure. The effect size estimate for PM10 doubles when we considered longer-term effects for all deaths and for cardiovascular deaths and becomes five times higher for respiratory deaths. We found similar effects when stratifying by age groups. These larger effects are important for risk assessment.