Socioeconomic differences in the prevalence of common chronic diseases: an overview of eight European countries

BACKGROUND

Few studies have compared socioeconomic inequalities in the prevalence of both fatal and non-fatal diseases. This paper aims to give the first international overview for several common chronic diseases.

METHODS

Micro-level data were pooled from non-standardized national health surveys conducted in eight European countries in the 1990s. Surveys ranged in size from 3700 to 41 200 participants. The prevalence of 17 chronic disease groups were analysed in relation to education. Standardized prevalence rates and age-adjusted odds ratios (ORs) were calculated.

RESULTS

Most diseases showed higher prevalence among the lower education group. Stroke, diseases of the nervous system, diabetes, and arthritis displayed relatively large inequalities (OR > 1.50). No socioeconomic differences were evident for cancer, kidney diseases, and skin diseases. Allergy was more common in the higher education group. Relative socioeconomic differences were often smaller among the 60-79 age group as compared with the 25-59 age group. Cancer was more prevalent among the lower educated in the 25-59 age group, but among the higher educated in the 60-79 age group. For diabetes, hypertension, and heart disease, socioeconomic differences were larger among women as compared with men. Inequalities in heart disease were larger in northern European countries as compared with southern European countries.

CONCLUSION

There are large variations between chronic diseases in the size and pattern of socioeconomic differences in their prevalence. The large inequalities that are found for some specific fatal diseases (e.g. stroke) and non-fatal diseases (e.g. arthritis) require special attention in equity-oriented research and policies.

Biochemical characterization of Silene alba α4-fucosyltransferase and Lewis a products

alpha1,4-Fucosylation has been recently detected in Arabidopsis thaliana [Leonard et al. (2002), Glycobiology 12: 299-306], and corresponding enzymes have also been characterized in Beta vulgaris [Bakker et al. (2001), FEBS Lett, 507: 307-312], and Lycopersicum aesculentum [Wilson (2001), Glycoconjugate J., 18: 439-447]. Here we demonstrated fucosyltransferase activity (FucT) in Silene alba cells and tissues. The Fuc linkage to GlcNAc residues of the lactosamine moiety of the Type I acceptor was confirmed by mass spectrometry experiments. Le(a)-glycoconjugates are found in the Golgi apparatus and plasma membrane of plant cells. In planta, the highest levels of activity were detected in seedlings, young roots and male flowers. The enzyme was stable up to 45( composite function)C and the optimum pH of reaction was 8.0. The enzyme required Mg(2+) or Mn(2+) for activity and was inhibited by Zn(2+) and ethylenediaminetetraacetic acid. Chemical modification of the enzyme with group-selective reagents revealed that selective modifications of arginine and lysine residues had no effect on enzyme activity. However the enzyme contains histidine and tryptophan residues that are essential for its activity. In contrast to human FUT3, the S. alba alpha4-FucT was insensitive to N-ethylmaleimide (NEM) treatment. Measurement of enzyme activity in S. alba cell fractions indicated that the enzyme is bound to microsomal membranes, furthermore a soluble isoform of the protein may be present.

Biochemical characterization of Silene alba alpha4-fucosyltransferase and Lewis a products

alpha1,4-Fucosylation has been recently detected in Arabidopsis thaliana [Leonard et al. (2002), Glycobiology 12: 299-306], and corresponding enzymes have also been characterized in Beta vulgaris [Bakker et al. (2001), FEBS Lett, 507: 307-312], and Lycopersicum aesculentum [Wilson (2001), Glycoconjugate J., 18: 439-447]. Here we demonstrated fucosyltransferase activity (FucT) in Silene alba cells and tissues. The Fuc linkage to GlcNAc residues of the lactosamine moiety of the Type I acceptor was confirmed by mass spectrometry experiments. Le(a)-glycoconjugates are found in the Golgi apparatus and plasma membrane of plant cells. In planta, the highest levels of activity were detected in seedlings, young roots and male flowers. The enzyme was stable up to 45( composite function)C and the optimum pH of reaction was 8.0. The enzyme required Mg(2+) or Mn(2+) for activity and was inhibited by Zn(2+) and ethylenediaminetetraacetic acid. Chemical modification of the enzyme with group-selective reagents revealed that selective modifications of arginine and lysine residues had no effect on enzyme activity. However the enzyme contains histidine and tryptophan residues that are essential for its activity. In contrast to human FUT3, the S. alba alpha4-FucT was insensitive to N-ethylmaleimide (NEM) treatment. Measurement of enzyme activity in S. alba cell fractions indicated that the enzyme is bound to microsomal membranes, furthermore a soluble isoform of the protein may be present.

[Health inequalities among occupations: epidemiologic hints for labour and social protection policies]

BACKGROUND

Based on existing information systems in Italy, a program can be created for monitoring and surveillance of occupational differences in health. In recent years, a number of proposals were made for defining wearing-out jobs and for reforming the retirement age and/or required number of years of contributions: on these occasions the need to create a programme for monitoring occupational health was stressed. To this end, ISPESL (the National Institute of Occupational Safety and Prevention), in cooperation with the Epidemiology Unit of the Piedmont Region of Italy, assessed the validity of epidemiological indicators from existing sources and their use in creating a surveillance system of wearing-out jobs.

OBJECTIVES

The main results of the evaluations performed to date are presented herein. The results are discussed in relation to the information needs for developing both health policies and other types of policies addressing occupation.

MATERIALS AND METHODS

Each of the articles in this issue deals with a specific model (based on information sources available in Italy in the 1990's) for studying the relationship between health [general and cause-specific mortality; accidents and accident proneness; the main causes of chronic morbidity (cancer, diabetes, and vascular and respiratory diseases); self-reported health: perceived health, chronic illnesses; absenteeism, lifestyles, stress, working conditions] and occupation (most recent occupation or the main lifetime occupation recorded by the specific information source, using a 55-item classification created especially for this research). Here, the statistically significant associations are compared with data in the literature and discussed in light of the information needs for developing health policies and other pertinent policies.

RESULTS

For men, the data on health indicators taken from the available information sources were adequate for identifying occupational differences in health. Certain occupations were consistently disadvantaged: masons and construction vehicle operators, transport-vehicle operators, miners, quarry workers, and agricultural workers. Foundry workers and forgers showed less consistent excesses. A greater risk for the majority of health indicators considered was also observed for those manual jobs that require fewer specialised skills: cleaning staff refuse collectors, and waste-treatment workers; porters and unloaders; custodians and watchmen. Among women, the health indicators were much more dissociated: the gender differences seem to precede the occupational differences and require the planning of a more precise and sensitive system. The occupational differences in health represent the final outcome of exposure not only to occupational risk factors but also to psycho-social factors (e.g., nutritional, environmental, and relational problems in early childhood; lifestyles; difficult access to timely and effective healthcare), which must thus be taken into account when evaluating retirement age; to ensure that workers have equality of treatment. The synoptic and integrated use of diverse information sources was extremely complex. Whereas an occupation may show excess risk for health indicators derived from one source, the same occupation may not necessarily show the same excess when the indicators are derived from another source. This can be attributed to: the limited specificity of the classification system; low statistical power; the possibility that the presence of excesses (e.g., in mortality and morbidity) may simply be due to chance; the local or specific nature of the information source; the level of specificity or sensitivity of the health indicators to the risk factors.

CONCLUSIONS

The studies described in this issue demonstrate that if the existing information sources in Italy are integrated through proper record-linkage, they can be used to follow health outcomes over time in relation to occupational history or income, providing useful information for developing or revising retirement policies. If it were possible to progress from this phase of evaluation of predictive validity of the informative sources examined, to the implementation of their routine use in conducting studies and surveillance of health inequalities between occupations, Italy would gain a place in the forefront in Europe in this field.

[Workplace injuries and professional mobility correlated with health problems. The potential and limitations of the ISTAT Labour Force survey--July 1999]

BACKGROUND

Knowledge on the occupational and social factors that influence the relationship between illness, absence from work and occupational mobility is at present insufficient.

OBJECTIVES

To map out, by social class and occupational group, the impact of health problems on work and the distribution of accidents and morbidity associated with occupation.

METHODS

Using data from the National Survey of the Italian Labour Force (ISTAT, 1999), covering a sample of 200,384 subjects, prevalence odds ratios of morbidity, work injuries and change of occupation due to health problems were calculated by social class and occupation, adjusting for age and residence.

RESULTS

The working class showed a higher risk, due to health problems, of a reduction in time worked (OR = 3.70 in men and OR = 4.10 in women), of choosing to work part-time (OR = 2.04 in men and OR = 2.27 in women), or of withdrawing from the workforce (for artisans, skilled manual workers, farmers and agricultural labourers OR = 1.63 in men and OR = 1.47 in women). This class was also at a greater disadvantage not only with respect to accident rates (OR = 1.85 in men and OR = 1.88 in women), but also with respect to the time needed for post-trauma rehabilitation and return to work (for absences of one week to one month: OR = 1.67 and 1.83 for men and women, respectively; for absences of more than one month: OR = 1.29 and OR = 1.69). Moreover, the working class, when compared to other social classes, had a higher rate of suffering from illness, physical impairment or other physical and psychological problems caused or aggravated by working activity (25% in men and 32% in women).

CONCLUSIONS

The ISTAT National Survey provides an estimate of minor accidents with prognoses of less than three days, including those not reported to the National Institute for Insurance against Occupational Accidents and Diseases (INAIL). This allows a preliminary exploration of the relationship between health problems and occupational mobility; however, it seems necessary to collect more detailed information in order to more exhaustively explore the mechanisms which generate the inequalities observed.

[Risk of repeated injuries by economic activity in Italy in the 1990's]

BACKGROUND

Repetitive work injuries are a phenomenon that has not been sufficiently studied. Using data gathered by INAIL (National Institute for Insurance against Occupational Accidents and Diseases), it is possible to study the propensity of having a further injuries at the workplace after the first one.

OBJECTIVES

To identify the risk of experiencing multiple injuries according to occupation, with discussion of how useful the available information systems are.

METHODS

The data base includes workplace injuries, as classified by INAIL in Italy between 1994 and 2000 in the industrial and artisan sectors (2,162,702 subjects, ages 25-55). Selecting data on accidents occurring among 107,082 subjects who had experienced the first accident in 1996-99, in this cohort we assessed the occurrence of further accidents within two years in the same occupation, taking into account job mobility and factors eventually influencing underreporting (geographic area, age, severity of first accident and size of the enterprise). The risk for each occupation was computed stratifying by gender.

RESULTS

There were significant differences between the first and successive accidents when examined by type, age group, severity of physical consequences and company size. Among men, the occupations showing higher risk were those already known to be at high risk for accidents: cleaning staff and refuse workers, foundry workers, masons, pilots, woodworkers, carpenters, transport workers, sailors, farmers, and miners. Among women the occupations most at risk were postwomen and messengers, cleaning staff and refuse workers, waitresses, cooks, bartenders, machine tool operators, woodworkers, and weavers in the textile industry.

CONCLUSIONS

Among men, the risk of recurrent workplace accidents by occupation tends to reflect the frequency of the total accidents in each occupation. The results indicate that the study model employed is efficient and useful in providing risk profiles which allow identification of where to direct future studies, investigations, and preventive measures for each sex.

[Healthy life expectancy in the occupied segment of the Turin population]

BACKGROUND

The indicators of healthy life expectancy measure differences in health among various population subgroups more sensitively than do indicators of mortality.

OBJECTIVES

The aim of the study was to analyze some of the above indicators to evaluate the differences among occupational categories in Turin.

METHODS

Mortality tables by occupation were calculated on Turin residents, aged 18-64 years in 1991, using the Turin Longitudinal Study which combines personal, census, and health information for the residents of the city. Longitudinal assessments of health expectancy were obtained by means of record-linkage with the Cancer Registry, the Diabetes Registry, and hospital discharge records. In addition, prevalence estimates of good health, disability, and chronic illness, obtained from ISTAT (Central Statistics Institute) investigations in 1999-2000 were combined with mortality data using Sullivan's algorithm.

RESULTS

Among men there was a systematic disadvantage in almost all indicators of health expectancy for some manual occupations, while jobs requiring more qualifications were more advantaged. The health profile for women was more controversial, with an overall disadvantage among women who were professional consultants, although this group showed substantial variability: the legal professions had the lowest life and health expectancies, with approximately 3 years of life less than the health professions, which were among the most advantaged.

DISCUSSION

The various indicators gave results which were at times conflicting, especially because the information obtained from the available sources had major limitations. The development of indicators needs to aim for greater homogeneity between mortality and health data to ensure maximum comparability.

Trends in socioeconomic disparities in stroke mortality in six european countries between 1981-1985 and 1991-1995

This study assesses whether stroke mortality trends have been less favorable among lower than among higher socioeconomic groups. Longitudinal data on mortality by socioeconomic status were obtained for Finland, Norway, Denmark, Sweden, England/Wales, and Turin, Italy. Data covered the entire population or a representative sample. Stroke mortality rates were calculated for the period 1981-1995. Changes in stroke mortality rate ratios were analyzed using Poisson regression and compared with rate ratios in ischemic heat disease mortality. Trends in stroke mortality were generally as favorable among lower as among higher socioeconomic groups, such that socioeconomic disparities in stroke mortality persisted and remained of a similar magnitude in the 1990s as in the 1980s. In Norway, however, occupational disparities in stroke mortality significantly widened, and a nonsignificant increase was observed in some countries. In contrast, disparities in ischemic heart disease mortality widened throughout this period in most populations. Improvements in hypertension prevalence and treatment may have contributed to similar stroke mortality declines in all socioeconomic groups in most countries. Socioeconomic disparities in stroke mortality generally persisted and may have widened in some populations, which fact underlines the need to improve preventive and secondary care for stroke among the lower socioeconomic groups.

[Use of pension records for occupational health surveillance: example of record-linkage with hospital discharge records to study the association between work and the incidence of leukaemias, lung and bladder cancer, and miscarriage]

BACKGROUND

Epidemiologic surveillance of occupational health based on routinely collected data allows groups of workers to be studied, whose type of work (e.g. small enterprises, self-employed workers, artisans) makes it difficult to use a traditional cohort study design.

OBJECTIVE

To evaluate the validity of a study design based on the record-linkage between hospital discharge records and INPS social security records (National Institute for Social Security), in order to investigate the association between past employment in an economic sector and occurrence of diseases with a low fraction attributable to occupation and a high frequency in the population, where it is too costly to perform retrospective interviews to gather data from each recruited subject.

METHODS

A case-control study design was used in which hospital discharge records from 1995 in the Piedmont Region represented the source of subjects enrolled. Four series of cases were identified: males aged 40-75 years, with first hospital admission for leukaemia, lung or bladder cancer; and women aged 18-39 years, admitted for miscarriage. The controls were a random sample of patients admitted in the same year and matched by sex and age. The exposure variable was the prevalent economic sector in the occupational history of the subjects enrolled, as inferred from INPS social security records.

RESULTS

No economic sector examined showed a significant excess of incidence of bladder cancer or leukaemia. There was a significant excess of lung cancer in subjects with longest employment in the building industry, in metal working, and in the "foundries, heat pressing, forging, and rolling mills" sector. A significant excess of miscarriages was present only in women working in commerce.

DISCUSSION

The results demonstrated overall a low consistency compared with those obtained via other surveillance systems of occupational morbidity and mortality, as well as by means of analytical studies. The results appear more plausible for the sectors characterized by a low number of job tasks, or by a more homogenous exposure to risk factors among workers in different jobs. Among the limitations of this study the lack of a complete occupational history, the absence of information on potential confounders like smoking and alcohol consumption, and the probable non-differential misclassification of the longest held job need to be stressed

[Study of the relationship among work and demographic characteristics, sickness absence and occupational mobility]

BACKGROUND

The problem of sick absences from work is correlated to a series of organizational, social and psychological factors which interact with risk factors typical of the work performed, and thus determine how frequently absences occur. The correlation between morbidity and work is of interest in itself for studying the processes of occupational mobility.

OBJECTIVES

To examine, using data from administrative sources, the association of sick absence with individual and workplace factors, as well as the relationship between illness and career mobility.

METHODS

Employee sick absence data registered at INPS (National Institute of Social Insurance) in the period 1992-95 were studied using a sample of 124,686 subjects.

RESULTS

The probability of being absent from work due to illness did not appear to be affected by sex or age. The sectors more at risk for sick absences were the service sector, business and commerce. Inequalities were noted in illness rates to the disadvantage of those who had received redundancy payments in the previous years. New hirings and upward mobility were associated with a lower occurrence of illness. A higher probability of illness was observed in those who had lost their jobs and in those who had changed from full-time to part-time work.

CONCLUSIONS

It is likely that formal regulations and practices in use within INPS vary according to the different economic activities. Therefore this source allows investigation of illness only in activities with homogeneous regulatory aspects. The results confirm a link between unstable work situations and illness and between illness and career advancement.

[Differences of perceived health and lifestyle by occupational groups in the Italian ISTAT (Central Statistic Institute) health survey]

BACKGROUND

Little is known about the distribution by occupation of chronic illness, disability, morbidity, and lifestyles which put health at risk.

OBJECTIVES

To provide a map of the social inequalities in various dimensions of health and lifestyle by social class and for specific occupational groups. To formulate a hypothesis about the mechanisms which generate these inequalities.

METHODS

Prevalence rate ratios and prevalence odds ratios of perceived health, chronic illness, disability, absenteeism, trauma, smoking, and obesity calculated with data from the 1999-2000 Italian ISTAT (Central Statistics Institute) health survey; the study population includes adults (aged over 18 years) employed, or searching for a job, or withdrawn from the workforce.

RESULTS

Among workers in manual unskilled labour, construction and agriculture are noted for worse health and more unhealthy lifestyles than average. For example, perceived bad health is more widespread among agricultural labourers (OR = 1.63), masons and construction machine operators (OR = 1.75), transport drivers (OR = 1.40), male caretakers, custodians, janitors and domestic help (OR = 1.46), electro-technicians (OR = 1.44), leatherworkers and shoemakers (OR = 3.58), miners and quarrymen (OR = 2.60), earthenware and stone workers (OR = 2.14), garment and furnishings workers (OR = 1.86); in female workers excess risk for perceived bad health was present among agricultural labourers (OR = 2.08), caretakers, custodians, janitors and domestic helpers (OR = 1.49), waitresses, cooks and bartenders, (OR = 1.44), and textile workers (OR = 1.67). Smoking was more widespread among chemical workers (OR = 1.41), and in miners and quarrymen (OR = 1.30). An excess risk of smoking of 20-25% was evident in spinners, weavers and finishers; masons, (and) builders; waiters, cooks and bartenders; garment and furnishings workers; porters and warehouse workers. The risk was 10% higher among foundry workers and forgers, plumbers, carpenters and welders, and transport drivers. Among women the propensity to smoke was higher among waitresses, cooks and bartenders (OR = 1.37), cleaners, commerce and service workers (OR = 1.22). Other occupational groups with an increased smoking prevalence, where women were less represented, included: chemical workers (OR = 2.25), butchers (OR = 1.97), postwomen (OR = 1.58), plastics workers (OR = 1.56), shippers (OR = 1.37).

CONCLUSIONS

It can be hypothesized on the one hand that there are factors and mechanisms common to the various occupational groups belonging to the same social class; on the other, there are factors and mechanisms specific to certain occupational categories. The latter can generate specific health subcultures. A greater integration between qualitative and quantitative research is recommended, which would yield better explanations of the observed inequalities.

[Occupational mortality in Italy during 1992, assessed through record-linkage between pension records and death certificates]

BACKGROUND

The creation of a surveillance system of occupational mortality in Italy is limited by the low quality of information on occupation in death certificates, since the information is often incomplete or lacking and because only the occupation at the time of death is registered.

OBJECTIVE

To evaluate the possible use of INPS (National Institute of Social Security) records for the purpose of surveillance of occupational mortality, in terms of feasibility of setting up a system and of validity of the results obtained.

METHODS

Death records of 218,510 subjects aged 18-74, deceased in the 12 months following the 1991 census, were obtained from ISTAT (Central Statistics Institute). These were combined through record-linkage with the INPS social security archives, which contain the employment records by economic sector going back to 1974, in order to assign these deaths the sector in which they had worked the longest. Mortality by specific causes was evaluated by industry by means of a proportional mortality analysis stratified by sex and occupational status, and adjusted for age, education, marital status, geographical area of birth, drawing a disability pension, employment status at the time of death and work instability.

RESULTS

Record-linkage allowed attribution of the longest held job to 70% of the deaths recorded. Results are presented and discussed only on mortality in men due to asbestosis and silicosis, and causes of death with a substantial proportion attributable to occupation: chronic obstructive pulmonary disease (COPD); cancers of the bladder, nasal cavity, larynx, lung and pleura; leukaemia and lymphoma; accidental causes. Among the economic sectors with a significant excess mortality, the following are well documented in the literature: mortality due to COPD in the coal and peat-bog sectors; due to leukaemia among farmers; due to sino-nasal tumours in wood-working and furniture production; due to cancer of the larynx, lung, and pleura in occupations where there was probable exposure to asbestos (fishing and maritime transport, non-metal mining, building industry, and naval, train and aircraft construction); due to silicosis in industries with potential exposure to crystalline silica; due to accidental causes in the building industry and farming. Other mortality excesses and deficits, especially those due to bladder and lympho-haemopoietic cancers, appear to be only partly consistent with those described by other authors.

DISCUSSION

The feasibility of developing a surveillance system of occupational mortality based on the INPS source was found to be good, and, at least among males, for 75% of the deceased subjects historical information existed concerning the economic sectors registered in the INPS records. The results obtained would appear to indicate that the system is capable of highlighting risk excesses due to widespread exposure in the industries examined, regarding diseases for which there is a strong association with exposure. On the other hand, due to the inherent limits of the study's design (lack of a complete work history and of precise information on the jobs held) its use is not recommended in the surveillance of diseases with a low proportion attributable to a risk factor, or with wide exposure variability in a given sector among the various jobs.

[Occupational differences in exposure to hazardous work conditions]

BACKGROUND

Few studies have been aimed at describing organizational and psychosocial conditions of the Italian workforce by occupational group, and they have been mainly conducted within specific occupations.

OBJECTIVES

The present study aimed at identifying specific groups of occupations which have unfavourable profiles from the point of view of exposure to specific organizational factors and psychosocial risks, and to physical, chemical and ergonomic risks, and analyzing their distribution by worker age.

METHODS

The analysis was conducted on a sample of 4,195 workers in the Piedmont Region who were members of the CGIL Trade Union (Italian General Confederation of Labour), who answered a self-administered questionnaire in 2000, aimed at assessing chemical, physical, and ergonomic risks, accidents, and psychosocial factors connected with work organization and work tasks. Psychosocial risks were assessed via three scales aimed at measuring the degree of control, psychophysical demands, and worker satisfaction. The proportion of workers exposed to the above mentioned risks was analysed according to occupational group. This group was then compared with all other groups taken together, according to prevalence of high strain condition (combination of high demand and low control) and HSUR condition (High Strain Unfairly Rewarded; combination of high strain and low satisfaction).

RESULTS

Among males aged 25-44 years, restricted to the occupation groups with more than ten workers in high strain condition, significantly higher proportions of stress were observed in leather workers and shoemakers, paper factory workers, rubber workers, crane and bridge crane operators, plastic workers, painters, transport drivers and carpenters. For many of these groups, excesses were confirmed for the HSUR condition. Among subjects aged over 44 years, a higher risk for high strain was confirmed in rubber workers, transport drivers and carpenters. In addition, machine tool operators, assembly line and mechanical workers in this age group were exposed to higher risk of stress. In younger women there was a significantly higher risk of both high strain and HSUR conditions in workers employed in the rubber, plastic and the food industries, and in machine tool workers. Such excess risk was confirmed in the latter three categories also among older women. In general, the proportion of male workers classified as working in high strain conditions decreased as age increased, while in women it remained stable.

CONCLUSIONS

The study allowed evaluation of the differential impact of exposure to physical, chemical, and psychosocial risk factors among occupational groups, thus contributing to the identification and classification of exhausting jobs. The results further showed, particularly among men, a smaller proportion of older workers, compared to younger ones, exposed to harmful physical, chemical, ergonomic and psychosocial conditions, indicating a possible propensity of companies to adapt workplace conditions, organization and internal mobility to worker age.

[Risk of workplace injuries by occupation in Italy in the 1990's]

BACKGROUND

In Italy it is not possible to assess the incidence of workplace injuries by occupation due to the absence of denominator data.

OBJECTIVES

To evaluate severe workplace injuries by occupation, age and gender, via discussion of the validity of the available methods and informative systems.

METHODS

The database included injuries in the industrial and artisan sectors in Italy during the period 1995-1999, as classified by INAIL (National Institute for the Insurance against Occupational Accidents and Diseases). A proportional case-control study was used. Three types of severe injuries were analyzed: fatal (3,685), permanently disabling (88,254) and injuries resulting in temporary disability for more than 40 days (238,609). Controls were represented by minor injuries with temporary disability lasting between 8 and 13 days (512,643). The relative risks were calculated by occupation and stratified by age and sex. The control group was chosen in order to minimize distortions and represented a balance between empirical criteria based on the experience of safety technicians and the quality and limits of INAIL archives.

RESULTS

Among men in some construction occupations (operators of construction equipment, crane operators and masons), and in truck drivers, farm workers, messengers, and miners there were elevated risks in all age groups and for all levels of injuries severity. The model was more problematic to apply to women because the control group was less representative of the work population at risk.

CONCLUSIONS

The case-control study model produced results consistent with those in the international literature, even if the use of minor injuries as the control group gives partly distorted risk estimates. The results supply information for decision making and for allocating resources for prevention and safety.

[Severity of workplace injuries by occupation in Italy in the 1990's]

BACKGROUND

The indicators of severity commonly used for studying workplace injuries are somewhat limited. It is possible to use RIDIT Analysis (Relative to an Identified Distribution) as an alternative method

OBJECTIVES

To order occupations in Italy by severity of workplace injuries and discuss the methodological problems and the outcomes from available administrative data.

METHODS

The database included injuries defined by INAIL (National Institute for Insurance against Occupational Accidents and Diseases) in Italy in the period 1995-99 in the industrial and artisan sectors (1,647,220 events). RIDIT Analysis was applied using Bross analysis of ordinal data. A distribution of injuries in Italy for the same period on a six-level scale of severity was used as a reference. The RIDIT value for each occupation was calculated and stratified by age, sex, and occupational sector.

RESULTS

Among men, the occupations in which injuries were more severe than the average in Italy were construction, transport, woodworking, and mining. Above-average injury severity among women was found in transport drivers, postwomen, messengers, and workers in performing arts, the food industry, and tourism. A positive relationship between age and severity of injury was observed in all occupations in both sexes. Average severity was higher among artisans.

CONCLUSIONS

The method used allows ranking of occupations according to injury severity and should be systematically introduced into existing systems of surveillance so that data can be used to foster prevention and workplace safety.

Trends in educational inequalities in smoking in northern, mid and southern Italy, 1980-2000

BACKGROUND

We aimed to determine the direction and magnitude of socioeconomic inequality in smoking in Italy over the last two decades, focusing on both national and macro-regional patterns.

METHODS

We used data from six National Health Interview Surveys from 1980 to 2000, whose sample size ranged between 60,000 and 140,000. We calculated age-adjusted prevalence rates of current smoking and estimated odds ratios (OR) and relative indexes of inequality (with 95% confidence intervals) using logistic regression analysis.

RESULTS

In men aged 25-49, the OR of current smoking of low compared to high educated was 1.26 (95% CI: 1.16, 1.37) in 1980 and 1.71 (95% CI: 1.62, 1.80) in 2000. A reversal of the association between education and tobacco use from positive (OR = 0.43) to negative (OR = 1.12) was found for women of the same age group. Changes in educational inequalities in smoking were similar between different macro-regions for men, whereas among women, smaller differentials over all the study period were found in southern regions compared to central and northern regions, despite similar direction in trends.

CONCLUSIONS

The gap between high- and low-educated groups has widened, especially in the youngest generations. Southern regions lag behind central and northern Italy in the progression of the smoking epidemic.

Bias in parental transmission of the HLA-DR3 allele in Sardinian multiple sclerosis

The authors analyzed the female: male (F:M) ratio according to the HLA-DRB1-DQB1 genotype in a cohort of multiple sclerosis (MS) patients from Sardinia, where the disease is associated with DR3 and DR4. In the whole cohort of 1,097 patients, F:M ratio was 2.24; however, it was 2.88 in DR3/DR3 and 2.52 in DR3/DRX (X#DR3 and DR4) individuals. Parental transmission of DR3 and DR4, assessed in a set of 565 case-parent triads, showed evidence of paternal inheritance of DR3 in affected women, thus explaining the excess of females in the DR3 category.

Socioeconomic inequalities in mortality among elderly people in 11 European populations

STUDY OBJECTIVE

To describe mortality inequalities related to education and housing tenure in 11 European populations and to describe the age pattern of relative and absolute socioeconomic inequalities in mortality in the elderly European population.

DESIGN AND METHODS

Data from mortality registries linked with population census data of 11 countries and regions of Europe were acquired for the beginning of the 1990s. Indicators of socioeconomic status were educational level and housing tenure. The study determined mortality rate ratios, relative indices of inequality (RII), and mortality rate differences. The age range was 30 to 90+ years. Analyses were performed on the pooled European data, including all populations, and on the data of populations separately. Data were included from Finland, Norway, Denmark, England and Wales, Belgium, France, Austria, Switzerland, Barcelona, Madrid, and Turin.

MAIN RESULTS

In Europe (populations pooled) relative inequalities in mortality decreased with increasing age, but persisted. Absolute educational mortality differences increased until the ages 90+. In some of the populations, relative inequalities among older women were as large as those among middle aged women. The decline of relative educational inequalities was largest in Norway (men and women) and Austria (men). Relative educational inequalities did not decrease, or hardly decreased with age in England and Wales (men), Belgium, Switzerland, Austria, and Turin (women).

CONCLUSIONS

Socioeconomic inequalities in mortality among older men and women were found to persist in each country, sometimes of similar magnitude as those among the middle aged. Mortality inequalities among older populations are an important public health problem in Europe.

The role of individual and contextual socioeconomic circumstances on mortality: analysis of time variations in a city of north west Italy

STUDY OBJECTIVE

To evaluate the independent and mutual effects of neighbourhood deprivation and of individual socioeconomic conditions on mortality and to assess the trends over the past 30 years and the residual neighbourhood heterogeneity.

DESIGN

General and cause specific mortality was analysed as a function of time period, highest educational level achieved, housing conditions, and neighbourhood deprivation, using multilevel Poisson models stratified by gender and age class.

SETTING

The study was conducted in Turin, a city in north west Italy with nearly one million inhabitants and consisting of 23 neighbourhoods.

PARTICIPANTS

The study population included three cohorts of persons aged 15 years or older, recorded in the censuses of 1971, 1981, and 1991 and followed up for 10 years after each census.

MAIN RESULTS

Individual and contextual socioeconomic conditions showed an independent and significant impact on mortality, both among men and women, with significantly higher risks for coronary heart and respiratory diseases among people, aged less than 65 years, residing in deprived neighbourhoods (9% and 15% excess for coronary heart diseases, 20% and 24% for respiratory diseases, respectively for men and women living in deprived neighbourhoods compared with rich). The decreasing time trend in general mortality was less pronounced among men with lower education and poorer housing conditions, compared with their more advantaged counterparts; the same was found in less educated women aged less than 65 years.

CONCLUSIONS

These results and further developments in the evaluation of impact and mechanisms of other contextual effects can provide information for both health and non-health oriented urban policies.

[Cardiopathy and stress-inducing factors]

BACKGROUND

There is wide consensus on the association between work stress and cardiovascular disease, ischaemic heart disease and hypertension in particular, both from the clinical and epidemiological point of view.

OBJECTIVES

The aim of this article was to review the most recent data on these topics found in the international literature on occupational health and cardiology.

METHODS

A literature review was performed.

RESULTS AND CONCLUSION

The relationship between stress and cardiovascular diseases is mediated by several direct and indirect mechanisms and is related not only to high cognitive and emotional stress but especially to poor coping strategies, which are strongly influenced by lack of control over working conditions and lack of social support. This entails high costs both for the individual and society, not only in terms of workers' health and well-being, but also as regards work ability and performance efficiency, with negative consequences on production and services. Some working activities, where public health is also at stake (such as train, bus and lorry drivers, air pilots and traffic controllers), deserve special attention, due to the well-documented prevalence of job-related cardiovascular disease.

[Descompresive craniectomy in head injury. Intractable I.C.P. ]

Decompressive craniotomy is a neurosurical technique known since the origin of neurosurgery, but its use as a routine started at the end of the 19th century. In last decades, the use of decompressive craniotomy decreased, mainly because of poor results obtained and the advances in medical treatment of refractory intracranial hypertension in the Intensive Care Units. Nevertheless, in recent years there has been a renewed interest with the use of this surgical techique in young patients with head injuries and severe intracranial hypertensio'n, but no surgical mass lesion, as well as in patients with ischemic stroke causing life threatening mass effect. The authors present a series of four young patients with head injuries and "malignant" intracranial hypertension on whom wide craniotomies were performed with an excellent outcome. The literature is reviewed.

Larval trypanorhynchs (Platyhelminthes: Eucestoda: Trypanorhyncha) from black-scabbard fish, Aphanopus carbo and oceanic horse mackerel, Trachurus picturatus in Madeira (Portugal)

Four different types of trypanorhynch postlarvae were found attached to the stomach mucosa, external stomach wall or free in the body cavity of two marine fishes from Madeira, namely blackscabbard fish, Aphanopus carbo and oceanic horse mackerel, Trachurus picturatus. Morphological features shown by SEM indicated that the postlarvae belonged to the species Tentacularia coryphaenae, Sphyriocephalus tergestinus, Nybelinia lingualis and possibly N. yamaguitii. Prevalence [mean intensity (range)] of T. coryphaenae, S. tergestinus and Nybelinia spp. in A. carbo (n = 135) was 12.6% [1.65 +/- 1.27(1-6)], 5.9% [1.57 +/- 0.79 (1-3)] and 2.2% [1.33 +/- 0.58 (1-2)] respectively. The prevalence of T. coryphaenae and S. tergestinus showed some seasonality, with a rise in prevalence of T. coryphaenae corresponding to a decrease in prevalence of S. tergestinus. However these differences were not significant. In T. picturatus (n = 304) only N. lingualis was found at a prevalence of 9.6%. Both S. tergestinus and N. lingualis were recovered only from the stomach mucosa or external stomach wall, while T. coryphaenae was observed either attached to the stomach mucosa or free in the visceral cavity of the fish. The paper presents the first scanning electron micrographs (SEM) of Sphyriocephalus tergestinus and a new geographical record of N. lingualis in T. picturatus.

Expressed sequence tags from poplar wood tissues--a comparative analysis from multiple libraries

Xylogenesis involves successive developmental processes--cambial division, cell expansion and differentiation, cell death--each occurring along a gradient from the cambium to the pith of the stem. Taking advantage of the high level of organisation of wood tissues, we isolated cambial zone (CZ), differentiating xylem (DX) and mature xylem (MX) from both tension wood (TW) and opposite wood (OW) of bent poplars. Four different cDNA libraries were then constructed and used to generate 10,062 EST, reflecting the genes expressed in the different wood tissues. For the most abundant clusters, the EST distributions were compared between libraries in order to identify genes specific or over-represented at some specific developmental stages. They clearly showed a developmental shift between CZ and DX, whereas there is a continuity of development between DX and MX. CZ was mainly characterized by clusters of genes involved in cell cycle, protein synthesis and fate. Interestingly, two clusters with no assigned function were found specific to the cambial zone. In DX and MX, clusters were mostly involved in methylation of lignin precursors and microtubule cytoskeleton. In addition, in DX, EST from TW and OW were compared: five clusters of arabinogalactan proteins, one for sucrose synthase and one for fructokinase were specific or over-represented in TW. Moreover, a putative transcription factor and a cluster of unknown function were also identified in DX-TW. The informative comparison of multiple libraries prepared from wood tissues led to the identification of genes--some with still unknown functions--putatively involved in xylogenesis and tension wood formation.