Progress towards controlling the HIV epidemic in urban Ethiopia: Findings from the 2017-2018 Ethiopia population-based HIV impact assessment survey

INTRODUCTION

In 2014, the Joint United Nations Programme on HIV/AIDS set an 'ambitious' 90-90-90 target for 2020. By 2016, there were disparities observed among countries in their progress towards the targets and some believed the targets were not achievable. In this report, we present the results of data from the Ethiopia Population-based HIV Impact Assessment survey analyzed to assess progress with the targets and associated factors.

METHODS

We conducted a nationally representative survey in urban areas of Ethiopia. Socio-demographic and behavioural data were collected from consenting participants using a structured interview. HIV testing was done following the national HIV rapid testing algorithm and seropositivity confirmed using a supplemental laboratory assay. HIV viral suppression was considered if the viral load was <1,000 RNA copies/ml. Screening antiretroviral drugs was done for efavirenz, lopinavir, and tenofovir, which were in use during the survey period. In this analysis, we generated weighted descriptive statistics and used bivariate and logistic regression analysis to examine for associations. The 95% confidence interval was used to measure the precision of estimates and the significance level set at p<0.05.

RESULTS

Of 19,136 eligible participants aged 15-64 years, 614 (3% [95% CI: 0.8-3.3]) were HIV-positive, of which 79.0% (95% CI: 4.7-82.7) were aware of their HIV status, and 97.1% (95% CI: 95.0-98.3 were on antiretroviral therapy, of which 87.6% (95% CI: 83.9-90.5) achieved viral load suppression. Awareness about HIV-positive status was significantly higher among females (aOR = 2.8 [95% CI: 1.38-5.51]), significantly increased with age, the odds being highest for those aged 55-64 years (aOR = 11.4 [95% CI: 2.52-51.79]) compared to those 15-24 years, and was significantly higher among those who used condom at last sex in the past 12 months (aOR = 5.1 [95% CI: 1.68-15.25]). Individuals with secondary education and above were more likely to have achieved viral suppression (aOR = 8.2 [95% CI: 1.82-37.07]) compared with those with no education.

CONCLUSION

Ethiopia made encouraging progress towards the UNAIDS 90-90-90 targets. The country needs to intensify its efforts to achieve the targets. A particular focus is required to fill the gaps in knowledge of HIV-positive status to increase case identification among population groups such as males, the youth, and those with low education.

Neighborhood disadvantage, disorder, and health

We examine the question of whether living in a disadvantaged neighborhood damages health, over and above the impact of personal socioeconomic characteristics. We hypothesize that (1) health correlates negatively with neighborhood disadvantage adjusting for personal disadvantage, and that (2) neighborhood disorder mediates the association, (3) partly because disorder and the fear associated with it discourage walking and (4) partly because they directly impair health. Data are from the 1995 Community, Crime, and Health survey, a probability sample of 2,482 adults in Illinois, with linked information about the respondent's census tract. We find that residents of disadvantaged neighborhoods have worse health (worse self-reported health and physical functioning and more chronic conditions) than residents of more advantaged neighborhoods. The association is mediated entirely by perceived neighborhood disorder and the resulting fear. It is not mediated by limitation of outdoor physical activity. The daily stress associated with living in a neighborhood where danger, trouble, crime and incivility are common apparently damages health. We call for a bio-demography of stress that links chronic exposure to threatening conditions faced by disadvantaged individuals in disadvantaged neighborhoods with physiological responses that may impair health.

Relationships among postconcussional-type symptoms, depression, and anxiety in neurologically normal young adults and victims of mild brain injury

This study investigated the relationship between self-reports of postconcussional symptoms, depression, and anxiety in neurologically normal young adults and recovered victims of mild head injuries (MHI). The participants were 496 young adults with no history of MHI or depression, 56 neurologically normal individuals with clinical depression, and 40 people with history of MHI. All completed the Beaumont Postconcussional Index (BPCI), Beck Depression Inventory-II (BDI-II), and the Beck Anxiety Inventory (BAI). Groups were compared on frequency and severity of postconcussional symptoms, as well as general symptoms. Analysis revealed high correlations between scores on the Postconcussional Index (PCI) and the BDI-II (r=0.68) as well as between PCI and BAI (r=0.64). Correlations between BDI-II, BAI, and the General Symptom Index (GSI) were modest, but significant (r=0.44 and 0.48, respectively). MHI participants reported minimally higher scores on the PCI than the normative group. However, depressed individuals exhibited substantially higher endorsement of PCI symptoms and modestly higher endorsement of GSI symptoms than either the normative or MHI groups. The potential rule that depression can have in producing, exacerbating, and maintaining PCS-like symptoms must be considered when evaluating and treating victims of MHI.

Age and the effect of economic hardship on depression

The amount of depression associated with economic hardship among adults may depend on age. This study tests alternative hypotheses about the interaction. The first asserts that the amount of depression associated with economic hardship decreases with older age because of maturity and experience. The second, the opposite, asserts that the amount increases with older age because of increasingly limited future opportunities for recovery. The study analyzes data from 2,592 households in the 1995 and 1998 telephone survey of Aging, Status, and the Sense of Control (ASOC). Regression analyses find that the amount of depression associated with economic hardship decreases with older age, both cross-sectionally and over time. No model shows an increase with age in the depression associated with economic hardship. However, regressions do show that not having household wage income or having a disabling or life threatening chronic disease increases the depression associated with economic hardship. Those interactions somewhat suppress the moderating effect of older age on the association between economic hardship and depression.

Neighborhood disorder, fear, and mistrust: the buffering role of social ties with neighbors

This paper proposes that individuals who report that they live in neighborhoods characterized by disorder--by crime, vandalism, graffiti, danger, noise, dirt, and drugs--have high levels of fear and mistrust. It further proposes that an individual's alliances and connections with neighbors can buffer the negative effects of living in a neighborhood characterized by disorder on fear and mistrust. Results from a representative sample of 2482 Illinois residents collected by telephone in 1995 support the propositions. Living in a neighborhood with a lot of perceived disorder significantly affects mistrust and the fear of victimization, adjusting for sociodemographic characteristics. Perceived neighborhood disorder and social ties significantly interact: informal social ties with neighbors reduce the fear- and mistrust-producing effects of disorder. However, formal participation in neighborhood organizations shows little buffering effect.

Walking, exercising, and smoking: does neighborhood matter?

Neighborhood context could affect health behaviors because of structure or contagion. We expected that residents of US neighborhoods where a high percentage of residents are poor and do not have college degrees would be more likely to smoke and less likely to walk and exercise. We examined the hypotheses using multi-level data in which survey information from a representative sample of Illinois residents is linked to census-tract information about poverty and education in their neighborhood. Contrary to expectations we found that residents of poor neighborhoods were more likely to walk than those in less disadvantaged places, adjusting for individual poverty, household income, education, race, ethnicity, sex, age, and marital status. This was the case despite the fact that residents of poor neighborhoods were more afraid to leave the house and feared being victimized on the streets. Consistent with expectations we found that residents of neighborhoods where a high percentage of residents are college educated are more likely to walk. Thus, the two aspects of neighborhood socioeconomic status had opposite effects on walking. Neighborhood context had no effect on the likelihood of exercising strenuously. Men in poor neighborhoods were more likely to smoke than those in less disadvantaged places, but neighborhood context had no significant effect on women's likelihood of smoking.

Does medical insurance contribute to socioeconomic differentials in health?

Both access to insurance and health itself vary widely by socioeconomic status (SES). Are socioeconomic variations in health linked to insurance coverage or to factors that lie outside the medical care arena? Data from the Aging, Status, and the Sense of Control Survey were the basis of a representative U.S. national telephone survey conducted in 1995, and again in 1998. The results showed that persons with private insurance do not differ significantly from the uninsured in their self-reported health, physical functioning, or number of chronic conditions, whereas persons with public insurance report significantly worse health and more chronic conditions than the uninsured. These longitudinal results hold with adjustment for baseline health, SES, change in social status, and the hazard of attrition. Medical insurance does not mediate any associations between SES and health. Medical insurance of all kinds, however, does reduce difficulties in paying medical bills, and Medicaid is associated with more doctor visits and prescription drugs.

Refining the association between education and health: the effects of quantity, credential, and selectivity

We refine the established association between education and health by distinguishing three aspects of a person's education (quantity, credential, and selectivity) and by examining the mechanisms through which they may correlate with health. Data are from the 1995 Aging, Status, and the Sense of Control Survey, a representative U.S. national telephone survey of 2,593 respondents aged 18 to 95, with an oversample of elderly. Results show that physical functioning and perceived health increase significantly with years of formal education and with college selectivity for those with a bachelor's or higher degree, adjusting for age, sex, race, marital status, and parental education. The credential of a college degree has no net association with physical functioning and perceived health beyond the amount attributable to the additional years of schooling. Of the three aspects of education, years of schooling has the largest effect. Most of that association appears attributable to its correlation with work and economic conditions, social psychological resources, and health lifestyle. A large portion of the net association of college selectivity with physical functioning and perceived health appears attributable to health lifestyle.

Monograph: reassessment of human cancer risk of aldrin/dieldrin

In 1987, the US Environmental Protection Agency (EPA) classified aldrin and dieldrin as category B2 carcinogens, i.e. probable human carcinogens, based largely on the increase in liver tumors in mice fed either organochlorine insecticide. At that date, the relevant epidemiology was deemed inadequate to influence the cancer risk assessment. More time has now elapsed since early exposures of manufacturing workers to aldrin/dieldrin; therefore, updated epidemiological data possess more power to detect exposure-related differences in cancer risk and mortality. Also, recent experimental studies provide a plausible mode of action to explain the mouse specificity of dieldrin-induced hepatocarcinogenesis and call into question the relevance of this activity to human cancer risk. This monograph places this new information within the historic and current perspectives of human cancer risk assessment, including EPA's 1996 Proposed Guidelines for Carcinogen Risk Assessment. Updated epidemiological studies of manufacturing workers in which lifetime exposures to aldrin/dieldrin have been quantified do not indicate increased mortality or cancer risk. In fact, at the middle range of exposures, there is evidence of a decrease in both mortality from all causes and cancer. Recent experimental studies indicate that dieldrin-induced hepatocarcinogenesis in mice occurs through a nongenotoxic mode of action, in which the slow oxidative metabolism of dieldrin is accompanied by an increased production of reactive oxygen species, depletion of hepatic antioxidant defenses (particularly alpha-tocopherol), and peroxidation of liver lipids. Dieldrin-induced oxidative stress or its sequelae apparently result in modulation of gene expression that favors expansion of initiated mouse, but not rat, liver cells; thus, dieldrin acts as a nongenotoxic promoter/accelerator of background liver tumorigenesis in the mouse. Within the framework of EPA's Proposed Guidelines for Carcinogen Risk Assessment, it is proposed that the most appropriate cancer risk descriptor for aldrin/dieldrin, relating to the mouse liver tumor response, is 'not likely a human carcinogen', a descriptor consistent with the example of phenobarbital cited by EPA.

Consequences of retirement activities for distress and the sense of personal control

We compare retirement with full-time employment on four forms of engaging activity and examine the consequences of retirement activities for the sense of control and psychological distress. We use a 1995 U.S. national telephone probability sample of 2,592 respondents with an oversample of persons aged sixty and older. In comparison to the activities of full-time employees, those of retirees are more alienating on some aspects but more engaging on others. Retiree activities are more routine, provide less of a chance to learn new things, provide less positive social interaction with others, and they are especially unlikely to involve problem-solving. However, retirees' activities are also equally enjoyable and more autonomous compared to those of full-time workers. Autonomous activities, fulfilling activities which are enjoyable and provide the opportunity to learn new things, and integrated activities are all positively associated with a sense of control and negatively associated with psychological distress. However, solving problems is associated with both high levels of control and high levels of distress. Retirees have a significantly lower sense of control than do full-time employees, in large part because of the characteristics of their daily activities. At the same time, retirees do not have significantly higher levels of psychological distress.

Medical surveillance for hematological disorders among active and retired oil refinery workers

Ten-year (1985-1995) results of an expanded medical surveillance program of 2475 active employees and retirees of an oil refinery and petrochemical complex in Illinois are presented. At the end of the program, 116 participants with persistent abnormalities of complete blood cell count had been referred for hematologic evaluation, and most were found to have benign conditions. Fifteen of the 116 were referred for bone marrow and cytogenetic studies. All of the referred active employees (seven) were found to have completely normal bone marrows with no evidence of any myelopathic process. Among the eight retirees, two had normal bone marrows, one was diagnosed with Philadelphia chromosome-positive chronic myelogenous leukemia, one declined to participate, and four were diagnosed to have myelodysplastic syndrome (MDS) of various subtypes. A total of eight cases of MDS were identified, including six cases among program participants and two cases among nonparticipants. The MDS standardized incidence ratio of 1.26 (95% confidence interval = 0.54-2.47) was not statistically significant, and there was virtually no increase of MDS in persons less than 80 years of age (4 observed and 3.8 expected). This MDS increase was entirely from program participants, probably because of intensive follow-up and diagnostic screening. Routine surveillance of complete blood cell count information did not identify any new cases of leukemia or MDS in active employees. These findings suggest that the utility of expanded medical surveillance program in this population is very limited.

Education and the subjective quality of life

We examine whether education influences subjective quality of life. If it does, what are the mechanisms by which education affects well-being? We propose that education improves well-being because it increases access to nonalienated paid work and economic resources that increase the sense of control over life, as well as access to stable social relationships, especially marriage, that increase social support. We examine the relationship between education and a variety of indicators of subjective quality of life-depression, anxiety, anger, aches and pains, malaise, and dissatisfaction. Using two representative national samples collected in 1990 and 1995, we find that the well educated have lower levels of emotional distress (including depression, anxiety, and anger) and physical distress (including aches and pains and malaise), but they do not have lower levels of dissatisfaction. Education reduces distress largely by way of paid work, nonalienated work, and economic resources, which are associated with high personal control; but the extent to which it reduces distress by way of marriage and social support is much more modest. We contrast distress and dissatisfaction as indicators of the subjective quality of life.

Illness absence at an oil refinery and petrochemical plant

Results from a prospective illness-absence surveillance of refinery and petrochemical workers from 1986 through 1994 are presented. Illness absence data for this study were extracted from the morbidity section of the Shell Oil Company's Health Surveillance System, which includes records of all illness absences in excess of 5 days. The majority of employees (59%) had no illness absence during the 9-year period studied. The 13% of the population who had three or more absences accounted for 63% of the total illness absence episodes and 62% of the total work days lost. Frequency rate and duration of absence increased with increasing age. The increased illness absence was associated with the presence of known health risk factors, such as smoking, elevated blood pressure, high cholesterol, and obesity. For example, obese women had a twofold increased illness absence rate compared with nonobese women and the rate for male smokers doubled that of nonsmoking men. These health risk factors are also more common among employees with three or more absences than those with fewer or no absences. The goal of this analysis is to quantify the impact of illness absence to develop disease prevention strategies to maximize good health in employees and to minimize both the frequency and duration of illness absence.

A mortality study of oil refinery and petrochemical employees

Results from a prospective mortality surveillance of 3803 refinery and petrochemical workers at a Shell Oil Company facility in Louisiana are presented. This report includes employees who worked more than 6 months before January 1, 1994 and pensioners who were alive as of January 1, 1973. Vital status was ascertained through 1993. Regardless of the comparison population used to calculate expected numbers (United States, Louisiana, or the surrounding tri-parish area), significantly fewer deaths were observed for all causes combined, all malignant neoplasms, heart disease, nonmalignant respiratory disease, and cirrhosis of the liver among male employees after 10 or more years' latency. With the United States as comparison, the all causes combined standardized mortality ratio (SMR) was 0.72 (95% confidence interval [CI] = 0.65 to 0.79), and the SMR for all cancer was 0.75 (95% CI = 0.61 to 0.92). The brain cancer rate for this group was nonsignificantly increased, with five observed deaths and three expected deaths, whereas mortality from leukemia was consistently lower than expected. The overall favorable mortality experienced by employees at this refinery and chemical plant is probably a result of a combination of factors, such as the healthy worker effect, relatively low risks related to the workplace, and the beneficial effects of continuing employment.

Fundamental analysis in research on well-being: distress and the sense of control

Fundamental analysis defines the basic terms of social and behavioral research. It usually follows the rule "one concept to a measure." However, some responses inherently reflect more than one underlying attribute, as when a test score reflects both knowledge of the subject and practice with taking tests. The standard methods of fundamental analysis break down in the presence of such cross-cutting factors. In this article, we discuss two instances of confusion and disagreement among social and behavioral scientists generated by the effects of cross-cutting factors on critical measures. In the first instance, a tendency to agree with the statements of others can make beliefs about personal control over events and outcomes seem unrelated to beliefs about control by chance, fate, or powerful others. The tendency to agree correlates positively with age. In the second instance, emotional expressiveness can make the frequency or intensity of sadness seem unrelated to the frequency or intensity of happiness. Women, who make up the large majority of older Americans, express themselves more freely than men. The apparent disjointedness of internal and external attributions of control, or of positive and negative emotions, results from methods assuming that the response to each question reflects one and only one underlying factor. Cross-cutting factor models eliminate the bias and confusion produced by response tendencies and help isolate and define the essential dimensions of response.

A novel DNA repair response is induced in human cells exposed to ionizing radiation at the G1/S-phase border

We have discovered a novel DNA repair response which is induced in cells irradiated with gamma rays at the G1/S-phase border. The induction of this repair response occurs at a stage in the cell cycle when overall levels of excision repair are reduced compared to cells irradiated in either S phase, G2/M phase or exponential growth. The induced repair is characterized by the formation of very long excision repair patches (VLERP) containing at least 150 nucleotides compared to the constitutive repair patches that are 3-5 nucleotides. These VLERP appear to be produced in response to a DNA lesion specific to ionizing radiation since they were not observed in cells irradiated with UV radiation at G1/S phase. The formation of VLERP requires both the nucleotide excision repair pathway, since they are absent in irradiated xeroderma pigmentosum group A cells, and the synthesis of new protein and mRNA. The time course for the induction of the VLERP shows an initial delay of 2 h, followed by a steady increase for up to 12 h after irradiation. By comparison, the production of the constitutive short repair patches shows an initial rapid production which levels out after 4 h.

Identification of a potential role for the adventitia in vascular lesion formation after balloon overstretch injury of porcine coronary arteries

BACKGROUND

In the present series of experiments, we examined the onset of cell proliferation and growth factor expression after balloon overstretch injury to porcine coronary arteries.

METHODS AND RESULTS

Domestic juvenile swine underwent balloon overstretch injury to the left anterior descending and circumflex coronary arteries with standard percutaneous transluminal coronary angioplasty balloon catheters. To identify proliferating cells, 5-bromo-2-deoxyuridine (BrDU) was administered over a period of 24 hours before the animals were killed at either 1, 3, 7, or 14 days after injury. Immunohistochemistry was performed with monoclonal antibodies to BrDU and smooth muscle cell markers. Three days after injury, a large number of proliferating cells were located in the adventitia, with significantly fewer positive cells found in the media and lumen. Seven days after injury, proliferating cells were found primarily in the neointima, extending along the luminal surface. In situ hybridization for PDGF A-chain and beta-receptor mRNAs revealed that the expression of these two genes was closely correlated with the sites of proliferation at each time point. Studies in which BrDU was injected between days 2 and 3 and the animals were killed on day 14 suggested that the proliferating adventitial cells may migrate into the neointima.

CONCLUSIONS

These data suggest that adventitial myofibroblasts contribute to the process of vascular lesion formation by proliferating, synthesizing growth factors, and possibly migrating into the neointima. Increased synthesis of alpha-smooth muscle actin observed in the adventitial cells after arterial injury may constrict the injured vessel and contribute to the process of arterial remodeling and late lumen loss after angioplasty.

Mortality study of employees with potential exposure to epichlorohydrin: a 10 year update

OBJECTIVES

A 10 year extension of follow up (up to 1993) of 863 employees who had potential exposure to epichlorohydrin at two chemical plants between May 1948 and December 1965 was conducted to further evaluate the previously reported potential association between exposure to epichlorohydrin and heart disease.

METHODS

The mortality observed was compared with that expected from the death rates from the local male population where these chemical plants are located. Workers were assigned to one of five exposure categories based on their job with the highest level of potential exposure. Vital status was ascertained to the end of 1993.

RESULTS

Among diseases of particular interest, there were no excess deaths from heart disease (standardised mortality ratio (SMR) 63.3), lung cancer (SMR 63.8), or non-malignant respiratory disease (SMR 37.7) for employees with 20 or more years after first exposure. Based on the level of potential exposure to epichlorohydrin, mortality for heart disease was slightly higher (SMR 75.7, 95% confidence interval (95% CI) 51.8-106.7) in the moderate to heavy exposure group than in the none to light exposure group (SMR 59.5, 95% CI 37.7-89.3); this difference is well within the range of random variation. The SMR for heart disease was 90.4 among employees who had both probable exposure to allyl chloride and moderate to heavy exposure to epichlorohydrin, although it was 88.1 among employees who had moderate to heavy potential exposure to epichlorohydrin but no exposure to allyl chloride.

CONCLUSIONS

This study does not support an association between exposure to epichlorohydrin and heart disease or lung cancer. There were no additional deaths from leukaemia in this update; the raised SMR for leukaemia noted in the previous study has substantially decreased from 500.0 to 161.3 (95% CI 33.2-471.0) and is not significant. The overall mortality and cancer mortality of employees potentially exposed to epichlorohydrin continued to be lower than that of the local population.

Education, age, and the cumulative advantage in health

The positive association between educational attainment and health is well established, but the way in which the education-based gap in health varies with age is not. Do the health advantages of high educational attainment and disadvantages of low educational attainment diverge or converge with age? The cumulative advantage perspective predicts a diverging SES gap in health with age, but past evidence does not allow us to accept or reject the hypothesis. We address this issue in two samples, cross-sectionally and over time, with three health measures. The first data set consists of a 1990 telephone interview of a national probability sample of U.S. households. There are 2,031 respondents, aged 18 to 90. The second is a national probability sample of U.S. households in which 2,436 respondents aged 20 to 64 were interviewed by telephone in 1979 and reinterviewed in 1980. We find that the gap in self-reported health, in physical functioning, and in physical well-being among people with high and low educational attainment increases with age. The health advantage of the well educated is larger in older age groups than in younger. Health advantages of high income and disadvantages of low income also diverge with age, but household income does not explain education's positive effect.

Mortality among maintenance employees potentially exposed to asbestos in a refinery and petrochemical plant

This paper reports the mortality experience from 1948 to 1989 of 2,504 maintenance employees who had a minimum of one year of employment in jobs with potential exposure to asbestos at a Texas refinery and petrochemical plant. For the purposes of this study, "potential exposure" is equated with those jobs or crafts having the greatest direct potential proximity to, or which worked directly with, asbestos-containing materials, especially asbestos-containing thermal insulation. Approximately one-half of the study population had 10 years or longer potential exposure, and 80% had their first potential exposure before 1970. The total population exhibited significantly lower mortality for all causes, the standardized mortality ratio (SMR = 77); and for all cancer (SMR = 85), as compared to residents in the surrounding communities. Statistically significant deficits in mortality were also observed in a number of noncancerous diseases such as heart disease (SMR = 78; 95% CI = 69-88), nonmalignant respiratory disease (SMR = 70; 95% CI = 50-95), and cirrhosis of the liver (SMR = 44; 95% CI = 22-79). Mortality among employees who had 20 years or longer since their first potential exposure was also examined; the pattern of mortality was similar to that exhibited by the total cohort, with a slight increase in the SMR for most of the causes. The only statistically significant excess of mortality found was a fourfold increase in mesothelioma (5 observed and 1.2 expected deaths) the SMR was 428 (95% CI = 139-996) for the total cohort and was 469 (95% CI = 152-1093) for those who had 20 years or more since first potential exposure. In contrast to asbestos industry worker studies, mortality for lung cancer was substantially lower than the general population (SMR = 81; 95% CI = 63-103). The observed number of deaths for cancer of the larynx was virtually the same as expected (3 observed vs. 2.8 expected). This study also showed decreased mortality for cancers of gastrointestinal organs such as the esophagus (SMR = 78), stomach (SMR = 63), large intestine (SMR = 91), rectum (SMR = 55), or pancreas (SMR = 90)--cancers that have been reported to be elevated in studies of various industry workers directly exposed to asbestos.

Characteristics of cancer cell death after exposure to cytotoxic drugs in vitro

The characteristics of cell death were investigated after exposure of CCRF-CEM.f2 cells to five drugs over a broad concentration range; these were the glucocorticoid dexamethasone (DXM), the mitotic inhibitor vincristine (VIN) and three antimetabolites, methotrexate (MTX), 5'-fluoro-2'-deoxyuridine (FUdR) and 5'-fluorouracil (5-FU). Drug-treated cells were monitored for cell death mechanisms at different times by examining the pattern of DNA degradation, cell morphology and flow cytometric profile, together with effects on cell growth over 72 h. At growth-inhibitory drug concentrations, the first changes were cell cycle perturbations detectable after 4-6 h of drug exposure. The appearance of features characteristic of apoptotic cell death was noted after all drug treatments in the CCRF-CEM.f2 cell line, but the pattern and kinetics varied considerably. VIN induced apoptotic changes by 12 h, while DXM treatment caused apoptosis only after 48 h. Both MTX and FUdR induced morphological changes characteristic of apoptosis at least 24 h before internucleosomal DNA cleavage, which was detectable only after 48 h. In contrast, 5-FU did not cause internucleosomal DNA cleavage by 48 h at any concentration, despite the presence of morphologically apoptotic cells 24 h earlier. These data suggest that disruption of the cell cycle caused by drug treatment may be the common trigger initiating the drug-specific apoptotic sequence of dying cells.

Long-term follow-up mortality study of petroleum refinery and chemical plant employees

A previous report presented the 1948-1983 mortality patterns of the Shell Deer Park Manufacturing Complex employees who were employed for at least 3 months from 1948 through 1972. The present study updates the earlier investigation by extending the vital status follow-up through 1989 and by expanding the cohort to include employees hired after 1972. As in the previous study, the overall mortality and cancer mortality for both refinery and chemical employees were quite favorable compared to residents in the local population. Among refinery workers, cancers for which a suspicion of work-relatedness was raised in the previous study, i.e. leukemia and cancers of the central nervous system and biliary passage/liver, no supportive evidence was found in this update. For both refinery and chemical plant employees, the mortality rate due to cancers of all lymphopoietic tissue increased with increasing duration of employment; this finding was also noted by the original study. This was also evident for lymphoreticulosarcoma in refinery employees and for leukemia in chemical plant employees. However, elevations of cancers of all lymphatic and hematopoietic tissue are primarily confined to employees who started work at the complex before 1946. By contrast, deaths from cancer of all lymphatic and hematopoietic tissue for employees hired after 1945 were 22% lower than the comparison population. Seven deaths with mesothelioma mentioned on the death certificates were identified, with 3.2 deaths expected, resulting in a statistically nonsignificant SMR of 219.

Does employment affect health?

Employment correlates positively with health, but is employment cause or consequence? The social causation hypothesis says that employment improves the health of men and women. The selection hypothesis says that healthy people get and keep jobs more than unhealthy people do. We test both hypotheses using longitudinal data from a national probability sample (N = 2,436 interviewed in both years). In the equations representing social causation, full-time employment predicts slower declines in perceived health and in physical functioning for both men and women. Full-time employment has the same effect for both sexes. Among women, it also has the same effect for White and non-White, and for married and nonmarried. In the equations representing social selection, physical functioning increases the odds of getting or keeping a full-time job for both sexes. Perceived health increases the odds for women but not for men. In regard to homemaking among women, homemaking predicts significantly greater declines in health, but health has no effect on the odds of becoming or staying a homemaker.

Have sperm counts been reduced 50 percent in 50 years? A statistical model revisited

OBJECTIVE

To reanalyze data that were used in a linear model to predict that mean sperm counts have been reduced globally by approximately 50% in the last 50 years.

DESIGN

The mean sperm counts and their temporal distribution were reanalyzed via several different statistical models (quadratic, spline fit, and stairstep).

CONCLUSION

There are several reasons why a published linear regression model is inappropriate to infer a 50% reduction in mean sperm counts in the last 50 years. These include [1] the potential selection biases that may have occurred with the 61 assembled studies such that they are not representative of their underlying populations; [2] the likely variability in collection methods, in particular, the lack of adherence to a minimum prescribed abstinence period, as has been stated for the largest study, which contained 29.7% of all the subjects included in the analysis; [3] the paucity of data in the first 30 years of the 50-year trend analysis; [4] the fact that if the last 20 years of data are examined, which contains 78.7% of all the studies and 88.1% of the total number of subjects, there is no decrease in sperm counts, in fact, sperm counts were observed to have increased; [5] the conflicting data from a large individual laboratory, which was not prone to the collection variability that likely occurred between the 61 studies, that did not suggest a decline in mean sperm count or seminal volume during a comparable time period, even though this laboratory published the data that were largely responsible for the high historical values in the linear model; and, most importantly, [6] the variety of other mathematical models that perform statistically better at describing the recent data than the linear model and thus offer substantially different hypotheses. The data are only robust during the last 20 years of the analysis, in which all the models, except the linear model, suggest constant or slightly increasing sperm counts.

Mortality among employees at a plastics and resins research and development facility

OBJECTIVES

The study was undertaken to update a previous study of employees from a resins and plastics research and development facility and to further examine the mortality of these employees with particular emphasis on deaths due to pancreatic cancer.

METHODS

This retrospective cohort study examined mortality from 1962 to 1992 for 257 men who were employed for at least one year during a 14 year period from 1962 to 1975 at a plastics and resins research and development facility. During the operative period, the primary activities involved applications and process development for polypropylene, polystyrene, epoxy resins, and to a lesser extent high density polyethylene.

RESULTS

The cohort was young and was followed up for an average of 26 years. Although mortality for all causes among employees who worked at least one year at this facility was low (standardised mortality ratio (SMR) 0.74), the death rate from cancer was moderately higher than that of the general population (14 observed and 9.4 expected deaths). There were four observed and 0.5 expected deaths from pancreatic cancer among men who worked at this facility for at least one year, which resulted in a statistically increased SMR of 8.88 (95% confidence interval 2.42-22.74). All cases of pancreatic cancer had "laboratory" jobs, and their ages at death were relatively young compared with deaths in the general population from pancreatic cancer. Lung cancer mortality was high but not significant with seven observed and 3.5 expected deaths. There were no deaths due to non-malignant respiratory disease (1.9 expected).

CONCLUSIONS

The increased cancer mortality was entirely due to excess deaths from pancreatic and lung cancers. No causative agent or process for these cases of pancreatic cancer has been identified. This study shows no increased colorectal cancer mortality as was found among another group of workers involved in the manufacture of polypropylene.

Building strategic partnerships between employers and managed care firms to enhance quality of care

The challenges of integrating behavioral healthcare delivery and the demand for better management of behavioral healthcare benefits require corporate risk managers to focus on issues of quality and outcomes. A strategic partnership between the employer and a managed care organization is one tool for reducing risk and improving the quality of services for beneficiaries, using the techniques of total quality management. The following article describes a six-step process for launching such a strategic partnership, along with some potential pitfalls.

Sex stratification and health lifestyle: consequences for men's and women's perceived health

A representative national sample of 2,031 adults aged 18 to 90 was interviewed by telephone in 1990. Results showed that men report better health than women, but that the gap closes with age. We argue that a gender difference in labor and lifestyles explains sex differences in perceived health across the life course: gender inequality in paid and unpaid work and the subjective experience of inequality disadvantage women, whereas lifestyle disadvantages men. Women are less likely to be employed, and are more likely to work part-time, have lower incomes and more economic hardship, and to do more unpaid domestic labor than men, all of which except domestic labor are associated with poor health. Domestic labor improves health, up to doing 60 percent of the housework. Women also have more distress and fewer subjective work rewards, both of which are associated with poor health. If women had the same levels of paid work, household income, economic hardship, work rewards, and distress as men, their health would equal that of men's and surpass it by age 59. Although we expected to find an overwhelming male disadvantage in lifestyle, we did not. Men are more likely than women to walk and to exercise strenuously, both of which are associated with good health. If women's labor and leisure-time physical activity equalled men's, women over the age of 54 would experience better health than men. Men's lifestyle disadvantage comes from their greater tendency to smoke and to be overweight, both of which are associated with poor health.

Mortality, morbidity, and haematological results from a cohort of long-term workers involved in 1,3-butadiene monomer production

A retrospective mortality analysis and prospective morbidity and haematological analyses were performed for Shell Deer Park Manufacturing Complex (DPMC) male employees who worked in jobs with potential exposure to 1,3-butadiene from 1948 to 1989. 614 employees qualified for the mortality study (1948-89), 438 of those were still employed during the period of the morbidity study (1982-9), and 429 of those had haematological data available for analysis. Industrial hygiene data from 1979 to 1992 showed that most butadiene exposures did not exceed 10 ppm (eight-hour time weighted average (8 hour TWA)), and most were below 1 ppm, with an arithmetic mean of 3.5 ppm. 24 deaths occurred during the mortality study period. For all causes of death, the standardised mortality ratio (SMR) was 48 (95% confidence interval (95% CI) = 31-72), and the all cancer SMR was 34 (95% CI = 9-87). There were only two deaths due to lung cancer (SMR 42, 95% CI = 5-151) and none due to lymphohaematopoietic cancer (expected = 1.2). Morbidity (illness absence) events of six days or more for the 438 butadiene employees were compared with the rest of the complex. No cause of morbidity was in excess for this group; the all cause standardised morbidity ratio (SMbR) was 85 (95% CI = 77-93) and the all neoplasms SMbR was 51 (95% CI = 22-100). Haematological results for the 429 with laboratory data were compared with results for the rest of the complex. No significant differences occurred between the two groups and the distributions of results between butadiene and non-butadiene groups were virtually identical. These results suggest that butadiene exposures at concentrations common at DPMC in the past 10-20 years do not pose a health hazard to employees.

Overweight and depression

Is being overweight distressing? If it is, is the distress due to negative appraisals by others, to the stresses of trying to fit norms of thinness by dieting, or to the health consequences of being overweight? If being overweight is stigmatizing, negative evaluations by others may be internalized as high levels of depression. This perspective predicts that being overweight has a direct effect on depression, and that the effect is greater in social groups where being overweight is less common, especially among women, Whites, younger people, the well-educated, and the well-to-do. Alternatively, overweight may not be distressing per se. Instead, attempting to fit norms of appearance that equate thinness with attractiveness by dieting is distressing. According to this perspective, the association between being overweight and depression is explained by dieting. Finally, this association may be due to the health consequences of being overweight. A random sample of 2,020 U.S. adults aged 18-90 were interviewed by telephone in 1990. Results showed that being overweight has no direct effect on depression in any social group except among the well-educated. Overweight persons are more likely to diet and to experience worse physical health, both of which are associated with depression. Combined, these explain the negative effects of being overweight on depression.

A cohort mortality study of two California refinery and petrochemical plants

This study examined the 1973 to 1989 mortality experience of Shell's two California manufacturing locations' employees who worked more than 6 months before December 31, 1989 and pensioners who were alive as of January 1, 1973. Vital status of each employee as of December 31, 1989 was determined from various sources including company records, the National Death Index, and the Social Security Administration's Master Beneficiary Record file. The study included many long-term employees, with more than half (57%) of the total population working 20 years or longer. The total population exhibited 11% lower all causes mortality and 20% lower cancer mortality, as compared with the California general population. There were no significant excesses of any cause-specific mortality including cancer. Among total employees, mortality for several cancer sites showed a statistically nonsignificant increase, for example, cancer of the kidney (8 observed deaths and 6.02 expected), cancer of the bladder (11 observed deaths and 9.17 expected), and Hodgkin's disease (2 observed deaths and 1.01 expected). A review of these work histories revealed no predominant work area or job assignment. In contrast to the ecologic studies based on local county rates, lung cancer mortality in this study was significantly lower (Standardized Mortality ratio [SMR] = 0.73). In addition, statistically significant deficits in mortality were found for cirrhosis of the liver (SMR = 0.63) and all external causes of death (SMR = 0.74). This study also failed to show an increased mortality rate for cancers of the brain, stomach, and prostate--causes which have been reported to be elevated in other refinery and petrochemical employee studies.

Age and depression

In this study, the relationship between age and depression is analyzed, looking for effects of maturity, decline, life-cycle stage, survival, and historical trend. The data are from a 1990 sample of 2,031 U.S. adults and a 1985 sample of 809 Illinois adults. The results show that depression reaches its lowest level in the middle aged, at about age 45. The fall of depression in early adulthood and rise in late life mostly reflects life-cycle gains and losses in marriage, employment, and economic well-being. Depression reaches its highest level in adults 80 years old or older, because physical dysfunction and low personal control add to personal and status losses. Malaise from poor health does not create a spurious rise of measured depression in late adulthood. However, some of the differences among age groups in depression reflect higher education in younger generations, and some reflect different rates of survival across demographic groups that also vary in their levels of depression.

Personal and job characteristics of musculoskeletal injuries in an industrial population

A cross-sectional study was conducted of 10,350 full-time regular employees who worked at Shell Oil Company's manufacturing facilities between 1987 and 1989. Two hundred seventy-five employees with low-back and 456 with nonlow-back musculoskeletal injuries were compared with 8295 employees who did not have musculoskeletal injuries during this period. Based on morbidity data collected from a prospective health surveillance system, this study shows that estimated relative risks (RRs) for low-back injuries are significantly higher among smokers (RR = 1.54, P less than .01) and overweight persons (RR = 1.42, P less than .01). This observation is also true for nonlow-back musculoskeletal injury (RR = 1.23, P = .05 for smokers and RR = 1.53, P less than .01 for overweight persons). In addition, persons in potentially more physically demanding jobs (primarily maintenance job titles) had an increased RR for both low-back and nonlow-back musculoskeletal injuries (RR = 1.57, P less than .01 and RR = 1.35, P = .02, respectively). The findings of this study suggest that it may be possible to reduce the impact of musculoskeletal injury through implementation of an integrated injury prevention program. Such programs would include not only the traditional elements of job factors evaluation and modifications, employee education and training, and an overall increased attention to ergonomics but also medical counseling and support for personal fitness programs, workplace smoking cessation programs, and weight-reduction programs.

Morbidity patterns among employees at a petroleum refinery

This study examined the morbidity experience of a prospective cohort of 2132 male employees who worked at a petroleum refinery from 1981 through 1988. The morbidity data included all illness-absence episodes in excess of 5 days during the study period. Standardized morbidity ratios (SMRs) of disease prevalence were calculated using data from all manufacturing employees of the Shell Oil Company as an internal comparison group. As such, there is no potential bias associated with the "healthy worker effect" in this type of study design. Morbidity for all causes combined was virtually the same as that for the comparison group with 2,311 observed and 2,318 expected disease prevalence events. However, there were statistically increased prevalence of musculoskeletal system disorders (SMR = 136) and injuries (SMR = 125) among staff employees and skin and subcutaneous tissue disorders (SMR = 138) among production employees. A review of the original morbidity reports for these skin conditions revealed that none were due to exposure to chemical products or solvents. The SMR for neoplasms of the lymphatic and hematopoietic tissue among production employees was slightly elevated but was based on only three cases (2.4 expected). Of the three cases, none was due to leukemia.

Medical surveillance for leukemia at a petrochemical manufacturing complex: four-year summary

Four-year results are presented on 2086 participants of a medical surveillance program of current and retired employees at a manufacturing complex in Illinois. Annual complete blood cell count testing and intensive follow-up of all out-of-normal-range results began in 1985 on a voluntary basis. The program to date has not identified any evidence for an unusual distribution of out-of-range complete blood cell count results. Active employees with out-of-range complete blood cell count values had no increase in adverse health outcomes compared with those with in-range values. Retired employees with out-of-range values were more likely to have a serious underlying medical condition, but this appeared to be more a function of age than of occupational exposure. Four cases of myelodysplastic syndrome were brought to our attention as a result of the program, but there is no similarly followed population available for comparison to determine whether this represents an increase over expected cases. The lack of correlation of out-of-range complete blood cell count results in active employees with serious hematologic disease raises significant questions about the utility of such surveillance for chemically exposed groups (eg, benzene-exposed workers) when exposure levels are low and well controlled.

Prospective morbidity surveillance of Shell refinery and petrochemical employees

Results for a prospective morbidity study of 14,170 refinery and chemical workers from 1981 through 1988 are presented. Illness/absence data for this study were extracted from the morbidity section of the Shell Health Surveillance System which includes records of all illness/absences in excess of five days. Age adjusted annual morbidity frequency rates and annual durations of absence are presented by age, sex, job, and work status. Generally, rates and durations of absence were highest for older age groups, women, and production workers. Increased risk was associated with the presence of known disease risk factors. Overall, 48% of the employees had at least one illness/absence in excess of five days during the eight year period. Twelve per cent of the employees had four or more absences, which accounted for 54% of the total number of absences and 52% of the total work days lost. Among men, the five most common conditions accounted for 72% of all illness/absences. In descending order they were injuries (25%), respiratory illnesses (17%), musculoskeletal disorders (14%), digestive illnesses (9%), and heart disease (7%). Similar patterns were noted among women. These findings may be useful in setting priorities and directing efforts such as health education programmes and other strategies for the prevention of disease.

Morbidity prevalence study of workers with potential exposure to epichlorohydrin

This study examined the morbidity experience from 1981 to 1988 of two cohorts (Shell cohort and Enterline cohort) of workers who had potential exposure to epichlorohydrin (ECH). The morbidity prevalence data for this study were extracted from the morbidity section of the Shell health surveillance system which included all illness and absence records in excess of five days. For both cohorts, the standardised morbidity ratios (SMRs) for all causes and all neoplasms were similar to an internal comparison group. There were no increases in heart disease morbidity for the Shell cohort (SMR = 97) or the Enterline cohort (SMR = 90). The SMRs for heart disease in the lower exposure group of the Shell cohort were 101 and 93 for the corresponding Enterline cohort. They were 92 and 87, respectively, in the higher exposure group. The increased risk of heart disease mortality reported by Enterline et al in workers more heavily exposed to ECH was not confirmed in this morbidity study. Morbidity from skin and subcutaneous tissue disorders, however, was found to be increased significantly in the Shell cohort. The SMR was 98 for the lower exposure group and 195 for the higher exposure group. A review of the original morbidity reports for each case suggested that factors unrelated to exposure to ECH such as the physical demands of a particular job, amount of time outside--for example, exposure to poison ivy--and other underlying medical conditions may be of greater importance than exposure to ECH.

Smoking and morbidity frequency in a working population

As part of Shell's health surveillance program, morbidity frequency and severity by smoking status (current smoker, exsmoker, nonsmoker) were compared for the 3-year period 1985 through 1987. Morbidity data for this study were extracted from the morbidity section of the Shell Health Surveillance System, which included all illness and absence events in excess of 5 days. Statistically significant positive associations were seen between smoking habits and overall morbidity, diseases of the circulatory system, and diseases of the respiratory system for both male and female employees. In addition, a significantly increased association between smoking and both non-motor vehicle accidents and motor vehicle accidents among current smokers was noted. Current smokers had a greater than 60% higher frequency rate (P less than .05) for non-motor vehicle accidents than nonsmokers for both men and women. Male smokers also had a 75% increased (P less than .05) motor vehicle accident rate. These results suggest that it may be possible to reduce overall illness and injury morbidity through implementation of successful smoking cessation programs.

An assessment of the effects of impaired renal function and haemodialysis on the pharmacokinetics of fluconazole

1. The oral pharmacokinetics of fluconazole were studied in three groups of volunteers (n = 5) with various degrees of renal function (GFR greater than 70 ml min-1; 20-70 ml min-1; less than 20 ml min-1) and in a group of patients with chronic end-stage renal failure requiring regular haemodialysis. 2. The pharmacokinetics of fluconazole were markedly affected by impaired renal function with the elimination of half-life in Group III (GFR less than 20 ml min-1) being approximately three times that observed in normal volunteers (Group I). 3. Fluconazole renal clearance was positively correlated with GFR. 4. Non-renal clearance of fluconazole decreased with decreasing renal function. 5. Approximately 38% of the 50 mg dose of fluconazole was removed by haemodialysis extending over a 3 h period.

The perceived burden of children

We expect that mothers vary in the degree to which they perceive their children as burdensome, and that this variation may help explain why past research on the effect of children on mothers' psychological distress often finds insignificant or inconsistent effects: mothers who feel their children are a burden may have high distress levels compared with mothers who do not feel burdened. We find that mothers experience their children as differentially burdensome at different stages in the life cycle: younger mothers' perceived burden increases with each additional child, but older mothers are less affected by increasing numbers of children. Preschool children increase all mothers' perceived burden because they tend to make mothers feel that they cannot be alone when they want to. Employed mothers feel less burdened by their children than the nonemployed. Social context - the density of people in the home, integration into the neighborhood, and the presence of relatives in the area - had a number of unexpected effects. Crowding in the home increased the perception that children are burdensome by way of subjective crowding - the perception that there is too much activity in the home, the perceived inability to be alone, and dissatisfaction with living space. However, controlling for subjective crowding, the more adults in the home, the less the burden of children, presumably because these other adults can help care for the children. Integration into the neighborhood increased the likelihood of sharing child care with friends and neighbors, but this shared child care increased the perception of burden. We had expected the opposite. Possibly it increases perceived burden because it increases the obligation to care for one's neighbors' children in return for their help. Having relatives in the area increased the likelihood that these family members would care for one's children, but this child care had no significant effect on reducing burden. Instead, relatives in the area increased a mother's perception that she could not be alone when she wanted to, which increased burden. Thus, we find a number of costs of social integration for mothers.

A study to assess the anticholinergic activity of rolipram in healthy elderly volunteers

Rolipram is an antidepressant with a novel mechanism of action: enhanced noradrenaline (first messenger) synthesis and release, and inhibition of cAMP (second messenger) breakdown. This study was aimed at objectively assessing potential anticholinergic effects of rolipram in healthy elderly volunteers by measurement of saliva production and pupil size. Eight male volunteers between 67 and 77 years of age first received in a randomized manner either a single dose of 50 mg amitriptyline or a placebo control. After a minimum washout period of seven days, they then received a multiple dosing regimen of a) 0.75 mg and b) 1.5 mg rolipram given every eight hours over a 5-day period with a two day washout between a) and b). Whereas no changes at all in pupil size could be observed, amitripyline significantly reduced salivary flow. Rolipram however had no effect on saliva production after either single or repeated administration of 0.75 or 1.5 mg. The results are discussed in connection with pharmacokinetic parameters obtained in the study.

Bkm sequences from the human X chromosome contain large clusters of GATA/GACA repeats

In order to determine whether the regional localizations of Bkm repeats detected on the human X chromosome consisted of typical GATA/GACA repeats, clones were isolated, mapped, and sequenced. Nine Bkm-hybridizing clones from Kunkel's fluorescent-activated, cell-sorted X-chromosome library were all unique. Five were mapped in detail with restriction enzymes and the Bkm-hybridizing segments were localized. Confirmation of X chromosomal homology was obtained for 2 of the clones and Bkm segments from these 2 clones were sequenced. Seventeen contiguous GATA repeats were found in each clone and the overall repeat arrangement showed relatively few differences from previously sequenced Bkm sequences. These are the first sequences of human Bkm repeats. The results, when compared with previously published results, suggest that there may be significant differences between the organization of Bkm repeats on the human X and on the human Y chromosome.

Exercise and psychologic well-being in the community

In a representative sample of 401 adults in Illinois in 1984, the authors found that increased participation in exercise, sports, and physical activities is associated with improved psychologic well-being. Part of this association is through improved subjective physical health. The authors controlled for potentially confounding factors, including sociodemographic characteristics, instrumentalism, and overweight. They concluded that exercise is associated with decreased symptoms of depression (feelings that life is not worthwhile, low spirits, etc.), anxiety (restlessness, tension, etc.), and malaise (rundown feeling, trouble sleeping, etc.) in the general population, most of which is not severely depressed, and in which many persons are engaged in moderate, nonaerobic exercise.

Intramuscular hemangiosarcoma with pulmonary metastasis in a horse

Intramuscular hemangiosarcoma resulting in severe anemia and thrombocytopenia was diagnosed in a 3-year-old Thoroughbred filly. Necropsy revealed multiple tumors within skeletal muscles and multiple pulmonary metastases.

Megaesophagus in a cow

Megaesophagus developed subsequent to presumed pharyngeal trauma in a cow. Signs resolved after prolonged antibiotic treatment and supportive care.

Herd problem of abortions and malformed calves attributed to bovine viral diarrhea

A herd problem of abortions and the birth of malformed calves developed subsequent to a transient febrile illness in adult cows. The herd was not vaccinated against bovine viral diarrhea (BVD). Bovine viral diarrhea virus was isolated from blood of one calf. The problem continued for 8 months. The entire herd was vaccinated with a killed BVD virus product. No further problems developed. This herd problem illustrates one of the many recognized clinical manifestations of BVD.

Public opinion about doctors' pay

Public opinion about doctors' incomes was examined in a national random sample of 843 respondents; 70.1 per cent of those questioned felt physicians are overpaid. There was a high degree of agreement among various groups that physicians are overpaid, but older people and Whites were more likely to think so than younger people and other ethnic groups. People who believe that the United States is characterized by unequal educational opportunity, unfair income distribution, and limited resources were also more likely to think physicians are overpaid.