Antonio Ivan Lazzarino

Systematic review of epidemiological studies on health effects associated with management of solid waste

BackgroundManagement of solid waste (mainly landfills and incineration) releases a number of toxic substances, most in small quantities and at extremely low levels. Because of the wide range of pollutants, the different pathways of exposure, long-term low-level exposure, and the potential for synergism among the pollutants, concerns remain about potential health effects but there are many uncertainties involved in the assessment. Our aim was to systematically review the available epidemiological literature on the health effects in the vicinity of landfills and incinerators and among workers at waste processing plants to derive usable excess risk estimates for health impact assessment.MethodsWe examined the published, peer-reviewed literature addressing health effects of waste management between 1983 and 2008. For each paper, we examined the study design and assessed potential biases in the effect estimates. We evaluated the overall evidence and graded the associated uncertainties.ResultsIn most cases the overall evidence was inadequate to establish a relationship between a specific waste process and health effects; the evidence from occupational studies was not sufficient to make an overall assessment. For community studies, at least for some processes, there was limited evidence of a causal relationship and a few studies were selected for a quantitative evaluation. In particular, for populations living within two kilometres of landfills there was limited evidence of congenital anomalies and low birth weight with excess risk of 2 percent and 6 percent, respectively. The excess risk tended to be higher when sites dealing with toxic wastes were considered. For populations living within three kilometres of old incinerators, there was limited evidence of an increased risk of cancer, with an estimated excess risk of 3.5 percent. The confidence in the evaluation and in the estimated excess risk tended to be higher for specific cancer forms such as non-Hodgkins lymphoma and soft tissue sarcoma than for other cancers.ConclusionsThe studies we have reviewed suffer from many limitations due to poor exposure assessment, ecological level of analysis, and lack of information on relevant confounders. With a moderate level confidence, however, we have derived some effect estimates that could be used for health impact assessment of old landfill and incineration plants. The uncertainties surrounding these numbers should be considered carefully when health effects are estimated. It is clear that future research into the health risks of waste management needs to overcome current limitations.

Introduction of laparoscopic bariatric surgery in England: observational population cohort study

Objectives To describe national trends in bariatric surgery and examine the factors influencing outcome in bariatric surgery in England. Design Observational population cohort study. Setting Hospital Episode Statistics database. Participants All patients who had primary gastric bypass, gastric banding, or sleeve gastrectomy procedures between April 2000 and March 2008. Main outcome measures 30 day mortality, mortality at one year after surgery, unplanned readmission to hospitalwithin 28 days, and duration of stay in hospital. Results 6953 primary bariatric procedures were carried out during the study period, of which 3649 were gastric band procedures, 3191 were gastric bypass procedures, and 113 were sleeve gastrectomy procedures. A marked increase occurred in the numbers of bariatric procedures done, from 238 in 2000 to 2543 in 2007, with an increase in the percentage of laparoscopic procedures over the study period (28% (66/238) laparoscopic procedures in 2000 compared with 74.5% (1894/2543) in 2007). Overall, 0.3% (19/6953) patients died within 30 days of surgery. The median length of stay in hospital was 3 (interquartile range 2-6) days. An unplanned readmission to hospital within 28 days of surgery occurred in 8% (556/6953) of procedures. No significant increase in mortality or unplanned readmission was seen over the study period, despite the exponential increase in minimal access surgery and consequently bariatric surgery. Conclusions Bariatric surgery has increased exponentially in England. Although postoperative weight loss and reoperation rates were not evaluated in this observational population cohort study, patients selected for gastric banding had lower postoperative mortality and readmission rates and a shorter length of stay than did those selected for gastric bypass.

Open versus minimally invasive esophagectomy: trends of utilization and associated outcomes in England.

Objective:To assess the trends in uptake of minimal invasive esophagectomy in England over the last 12 years (1996/1997–2007/2008) and to compare their clinical outcomes with those after open esophagectomy. Summary of Background Data:Around 7400 people are affected each year in the United Kingdom. Prognosis following esophageal resection is, however, poor. Even after “curative” surgery, 5-year survival rates do not exceed 25%. The minimally invasive approach to esophagectomy has attracted attention as a potentially less invasive alternative to conventional surgery. Methods:Data on patients undergoing esophagectomy for esophageal cancer were extracted from a national administrative database. The outcomes of interest were in-hospital mortality, 30-day in-hospital mortality, 30-day total (ie, in and out of hospital) mortality, 365-day total mortality, 28-day emergency readmission rates, and length of hospital stay. Hierarchical logistic regression was used to identify the effect of minimal invasive esophagectomy (MIE) on the outcomes after adjustment for age, gender, socioeconomic deprivation, and comorbidity. Results:A total of 18,673 esophagectomies were performed over the 12-year study period. The use of minimal access surgery increased exponentially over time (from 0.6% in 1996/1997 to 16.0% in 2007/2008). There was a suggestion that patients undergoing MIE had better 1-year survival rates than patients receiving open esophagectomy (OR = 0.68, 95% CI = 0.46–1.01, P = 0.058). Conclusion:The uptake of MIE in England is increasing exponentially. With the possible exception of 1-year survival, patients selected for MIE demonstrated similar mortality and length of stay outcomes when compared with those undergoing conventional surgery. These results need to be confirmed in large-scale randomized controlled trials.

Rapid Maxillary Expansion for the Treatment of Nasal Obstruction in Children Younger Than 12 Years

OBJECTIVE To assess short- and long-term effects of rapid maxillary expansion (RME) on nasal flow in young children. Since RME has been reported to positively influence nasal obstruction in subjects with respiratory problems by reducing nasal resistance, a similar efficacy of RME could be expected in children with deciduous and/or mixed dentition who are affected by maxillary constriction and nasal obstruction from a different cause. DESIGN Prospective study of children younger than 12 years, with different grades of malocclusion and oral breathing. Data included active anterior rhinomanometry in both the supine and orthostatic positions, as well as radiographic cephalometric measurements. SETTING Tertiary care university hospital. Data were prospectively collected from 2005 to 2007. PATIENTS Nasal flow and resistance were measured in 65 children younger than 12 years, with mixed or deciduous dentition and different grades of malocclusion and oral breathing. MAIN OUTCOME MEASURE Efficacy of RME for resolution of maxillary constriction. RESULTS After RME, an improvement of nasal flow and resistance has been recorded in patients, in the supine position, who presented both anterior and posterior obstruction. Less notable changes were shown in isolated forms of obstruction and in the orthostatic position. CONCLUSION In cases of maxillary constriction and nasal airway obstruction, RME has proved to be efficient for the improvement of nasal respiration in children via a widening effect on the nasopharyngeal cavity.

Disruption of multisystem responses to stress in type 2 diabetes: Investigating the dynamics of allostatic load

Significance Our observations provide evidence to link epidemiological studies implicating stress-related processes with biological dysfunction in type 2 diabetes. The patterns of cardiovascular, inflammatory, neuroendocrine, and cholesterol responses exemplify the disturbances of reactivity and recovery predicted by the allostatic load model, including prolonged responses to stress due to delayed shutdown of physiological reactivity, and inadequate (blunted) responses resulting in compensatory hyperactivity in other mediating pathways. Chronic allostatic load may be a mechanism through which stress exposures contribute to diabetes risk, while also being implicated in the adverse health consequences of diabetes such as coronary heart disease and cognitive decline. Psychological stress-related processes are thought to contribute to the development and progression of type 2 diabetes, but the biological mechanisms involved are poorly understood. Here, we tested the notion that people with type 2 diabetes experience chronic allostatic load, manifest as dynamic disturbances in reactivity to and recovery from stress across multiple (cardiovascular, neuroendocrine, inflammatory, metabolic) biological systems, coupled with heightened experience of chronic life stress. We carried out an experimental comparison of 140 men and women aged 50–75 y with type 2 diabetes and 280 nondiabetic individuals matched on age, sex, and income. We monitored blood pressure (BP) and heart rate, salivary cortisol, plasma interleukin (IL)-6, and total cholesterol in response to standardized mental stress, and assessed salivary cortisol over the day. People with type 2 diabetes showed impaired poststress recovery in systolic and diastolic BP, heart rate and cholesterol, and blunted stress reactivity in systolic BP, cortisol, cholesterol, and IL-6. Cortisol and IL-6 concentrations were elevated, and cortisol measured over the day was higher in the type 2 diabetes group. Diabetic persons reported greater depressive and hostile symptoms and greater stress experience than did healthy controls. Type 2 diabetes is characterized by disruption of stress-related processes across multiple biological systems and increased exposure to life stress. Chronic allostatic load provides a unifying perspective with implications for etiology and patient management.

The combined association of psychological distress and socioeconomic status with all-cause mortality: a national cohort study.

BACKGROUND Psychological distress and low socioeconomic status (SES) are recognized risk factors for mortality. The aim of this study was to test whether lower SES amplifies the effect of psychological distress on all-cause mortality. METHODS We selected 66 518 participants from the Health Survey for England who were 35 years or older, free of cancer and cardiovascular disease at baseline, and living in private households in England from 1994 to 2004. Selection used stratified random sampling, and participants were linked prospectively to mortality records from the Office of National Statistics (mean follow-up, 8.2 years). Psychological distress was measured using the 12-item General Health Questionnaire, and SES was indexed by occupational class. RESULTS The crude incidence rate of death was 14.49 (95% CI, 14.17-14.81) per 1000 person-years. After adjustment for age and sex, psychological distress and low SES category were associated with increased mortality rates. In a stratified analysis, the association of psychological distress with mortality differed with SES (likelihood ratio test-adjusted P < .001), with the strongest associations being observed in the lowest SES categories. CONCLUSIONS The detrimental effect of psychological distress on mortality is amplified by low SES category. People in higher SES categories have lower mortality rates even when they report high levels of psychological distress.

Low socioeconomic status and psychological distress as synergistic predictors of mortality from stroke and coronary heart disease.

Background The purpose of this study was to test whether lower socioeconomic status (SES) augments the effect of psychological distress on mortality from stroke or coronary heart disease (CHD). Methods We prospectively linked data from 66,500 participants 35 years or older in the Health Survey for England, selected using stratified random sampling from 1994 to 2004, and free of cardiovascular disease and cancer at baseline, with mortality records. The median follow-up time was 7.9 years. SES was indexed by occupational class, and psychological distress was assessed using the 12-item General Health Questionnaire (GHQ-12). Results After adjustment for demographic and clinical variables, both psychological distress and low SES were associated with increased mortality: the hazard ratios (HR) for one-category increase in low SES (three categories in total) were 1.15 for stroke-death (95% confidence interval [CI] = 1.00–1.31, p = .043) and 1.24 for CHD-death (95% CI = 1.09–1.41, p = .001); the HR for one-category increase in GHQ-12 (three categories in total) was 1.18 for stroke-death (95% CI = 1.07–1.30, p = .001) and 1.24 for CHD-death (95% CI = 1.13–1.36, p < .001). In stratified analyses, the strongest associations were found in the lowest SES categories: the HR for GHQ-12 toward stroke-death was 1.15 in high-SES participants (95% CI = 0.97–1.37, p = .107) and 1.31 in low-SES ones (95% CI = 1.13–1.51, p < .001); the HR for GHQ-12 toward CHD-death was 1.10 in high-SES participants (95% CI = 0.97–1.25, p = .129) and 1.33 in low-SES ones (95% CI = 1.19–1.48, p < .001). Conclusions People in low socioeconomic circumstances are more vulnerable to the adverse effect of psychological distress. This pattern should be taken into account when evaluating the association between psychosocial variables and health outcomes.

The Association Between Cortisol Response to Mental Stress and High-Sensitivity Cardiac Troponin T Plasma Concentration in Healthy Adults

Objectives The objective of this study was to examine the association between cortisol response to mental stress and high-sensitivity cardiac troponin T (hs-cTnT) in healthy older individuals without history of cardiovascular disease (CVD). Background Mental stress is a recognized risk factor for CVD, although the mechanisms remain unclear. Cortisol, a key stress hormone, is associated with coronary atherosclerosis and may accentuate structural and functional cardiac disease. Methods This cross-sectional study involved 508 disease-free men and women aged 53 to 76 years drawn from the Whitehall II epidemiological cohort. We evaluated salivary cortisol response to standardized mental stress tests (exposure) and hs-cTnT plasma concentration using a high-sensitivity assay (outcome). We measured coronary calcification using electron-beam dual-source computed tomography and Agatston scores. Results After adjustment for demographic and clinical variables associated with CVD as well as for inflammatory factors, we found a robust association between cortisol response and detectable hs-cTnT (odds ratio [OR]: 3.98; 95% confidence interval [CI]: 1.60 to 9.92; p = 0.003). The association remained when we restricted the analysis to participants without coronary calcification (n = 222; OR: 4.77; 95% CI: 1.22 to 18.72; p = 0.025) or when we further adjusted for coronary calcification in participants with positive Agatston scores (n = 286; OR: 7.39; 95% CI: 2.22 to 26.24; p = 0.001). Conclusions We found that heightened cortisol response to mental stress was associated with detectable plasma levels of cTnT using high-sensitivity assays in healthy participants, independently of coronary atherosclerosis. Further research is needed to understand the role of psychosocial stress in the pathophysiology of cardiac cell damage.

Hearing and quality of life in a south European BAHA population

Abstract Conclusion: The overall results show a high ratio of satisfaction in the sample population, which is in accordance with a successful BAHA counselling and rehabilitation of their hearing impairment. Objectives: The acceptance of a bone anchored hearing aid (BAHA) device by a south European population, which could be expected to have some reticence for wearing this device, has been investigated. Methods: The outcome of BAHA implantation was assessed in 24 patients with bilateral and unilateral hearing loss by administration of several questionnaires, such as the Handicap Hearing Inventory (HHI), Client Oriented Scale of Improvement (COSI), Open and General Glasgow Benefit Inventory and Entific Medical System QoL, along with a complete audiological test battery. Results: Speech reception threshold (SRT) in bilateral cases improved both in quiet and in noise. In unilateral cases, word perception and accuracy of sound localization improved when sound was presented from the back. COSI scores, at both the intermediate and the final evaluations, showed a fair adaptation level of the patients and their satisfaction for prefixed targets.

Combined protocol for treatment of secondary effects from facial nerve palsy

Abstract Conclusion: Rehabilitation was significantly efficient in both groups of patients with synkinesis, especially in those in whom treatment with botulinum toxin type A (BTX-A) preceded physical rehabilitation. Objective: To determine the influence of preventive treatment with BTX-A on synkinesis when physical rehabilitation is planned. Methods: Twenty patients, who recovered from facial palsy with final House-Brackmann (HB) grade II and III, were randomized to assess the efficacy of preventive BTX-A treatment on final synkinesis score after physical rehabilitation. Synkinesis was graded according to the four-point scale derived from the SunnyBrook Facial Grading System (FGS). Physical rehabilitation was carried out using NeuroMuscular Retraining Therapy (NMRT). In the randomized groups, NMRT was administered with (group a) or without pre-BTX-A treatment (group b). Results: Patients who were preliminarily treated with BTX-A in the affected area showed a 2.1 improvement of score on the SunnyBrook scale (p < 0.001), with significantly better results in comparison to the non-BTX-A group.