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Hospitalization Costs Associated with Homelessness in New York City.
S.A. Salit, et al. New England Journal of Medicine 338 (June 11, 1998): 1734-40.

Homelessness is associated with substantial excess costs for hospital stays; housing and supportive services for the homeless may improve their health and reduce the need for costly hospitalizations.

This study compared hospital discharge data on 18,864 hospital admissions of homeless adults in New York City for 2 years (1992 and 1993) with 383,986 admissions of otherlow-income adults who were not homeless. Admissions related to childbirth were excluded from the study.

The results revealed significant differences between the two populations. Treatment for substance abuse and mental health problems accounted for 51.5 percent of the admissions of homeless people compared with 27.8 percent of the other low-income populations; 80.6 percent of the admissions involved a principal or secondary diagnosis of substance abuse or mental illness, roughly twice the rate of other patients. Potentially preventable conditions such as trauma, respiratory disorders, skin disorders, and infections (excluding AIDS) and parasitic diseases were responsible for almost 20 percent of the admissions among the homeless. This rate was significantly higher than that found in the comparison population. In addition, homeless patients had longer and costlier hospitalizations than those in the comparison groups.

Physical Activity and Fitness

Is School Sports Participation a Protective Factor Against Adolescent Health Risk Behaviors?
R.M. Page, et al. Journal of Health Education 29(May/June 1998): 186-92.

Participation in school sports may act as a protective factor against risk behaviors such as cigarette smoking, illegal drug use, and weapon carrying.

This study used the national, school-based Youth Risk Behavior Survey (YRBS). The sample included 12,272 students in grades 9 through 12. School sports participation was assessed by the following question: "During the past 12 months, on how many sports teams run by your school did you play?" This did not include physical education classes. The relationship was calculated between school sports participation and health risk behaviors.

Among both males and females, those participating on one or two teams and three or more teams were significantly more likely to have not ever tried cigarette smoking; ever smoked cigarettes regularly; smoked cigarettes in the past 30 days; ever used cocaine; ever used marijuana; and ever used an illegal drug other than cocaine and marijuana. Sports involvement, however, appeared to increase the risk for males of using smokeless tobacco products. Only 12.5 percent of students not participating on sports teams used smokeless tobacco products, compared to 17.5 percent of those involved in one or two teams and 20.1 percent involved in three or more teams. Compared to non-participants, females participating on one or two teams were found to be 1.7 times more likely to have not ever had a sexually transmitted disease and 1.5 times more likely to have not been pregnant. Students participating on one or two teams were significantly less likely to have carried a weapon during the past 30 days and to have attempted suicide in the past 12 months.

Alcohol and Other Drugs

Alcohol Screening Questionnaires in Women. A Critical Review.
K.A. Bradley, et al. Journal of the American Medical Association 280 (July 8, 1998): 166-71.

Routine screening programs that identify patients with alcohol abuse or dependence increase the proportion of women with alcohol-related problems who are counseled.

This review summarizes the published, peer-reviewed literature regarding the performance of screening questionnaires for heavy drinking and/or alcohol abuse or dependence in general clinical populations of women in the United States. The review was limited to questionnaires with 10 or fewer items.

The review indicated that the CAGE (Cut Down, Annoyed, Guilty, Eye Opener), AUDIT (Alcohol Use Disorders Identification Test), and TWEAK (Tolerance, Worried, Eye Openers, Amnesia, Kut Down) were the optimal tests for identification of alcohol dependence in women. The sensitivity of screening questionnaires for alcohol dependency may be affected by the race or ethnicity of the screened population. Although the CAGE questionnaire has performed adequately in predominantly black

populations of women, it has had a sensitivity of only 0.50 for past-year alcohol abuse and dependence in white female emergency department patients. Fewer data are available for the AUDIT or TWEAK questionnaires in predominantly black or white populations, but in emergency department patients, the AUDIT and TWEAK questionnaires tended toward increased sensitivity for alcohol dependence in black women.

Based on the data reviewed, the five-item TWEAK questionnaire appears to be the optimal screening questionnaire for identifying women with drinking problems or alcohol abuse and dependence in racially mixed populations. However, screening is only the first step in the assessment of alcohol problems. Other assessment areas include current drinking practices and symptoms of dependence.

Unintentional Injuries

Dog and Cat Bites: Epidemiologic Analyses Suggest Different Prevention Strategies.
G.R. Patrick and K.M. O’Rourke. Public Health Re-ports 113 (May/June 1998): 252-57.

Effective bite prevention programs need to address the finding that both restrained and unrestrained dogs may bite even when unprovoked and that unrestrained cats usually bite when provoked.

This study examined 300 randomly selected dog bite cases out of 2,177 reported and 343 cat bite cases (all reported cases) in El Paso, Texas, in 1995. The data included the breed of dog, whether the bite was provoked, and whether the animal was restrained. Provocation was defined as the animal having been picked up, petted, hit, kicked, or struck by a person with any object or part of the person’s body or any part of the animal’s body having been pulled, pinched, or squeezed.

The majority of cat bites (89.4 percent) were provoked, with females (57.5 percent) and adults (68.3 per-cent) more likely to be victims than males or children. Just under half of dog bites (44.6 percent) were provoked, with males (65.6 percent) and children (63 percent) more likely to be victims than females or adults.

The majority of cat bites (79.2 per-cent) involved unrestrained animals, while the majority of dog bites (55.7 percent) occurred either on the owner’s property or while the dog was leashed. The highest percentages of bites were from German shepherds (25.2 percent) and chow chows (18.5 percent).

Bite prevention recommendations include educating the public about the magnitude of the problem, increasing enforcement of leash laws, teaching children how to behave around dogs and cats, and encouraging owners to take more responsibility in training their pets.

Occupational Safety and Health

Occupational Skin Diseases in Washington State, 1989 Through 1993: Using Workers’ Compensation Data to Identify Cutaneous Hazards.
J.D. Kaufman, et al. American Journal of Public Health 88(July 1998): 1047-51.

Workers’ compensation data identify known and emerging workplace cutaneous hazards and show promise for targeting prevention efforts.

Worker’s compensation claims filed for skin disease in the Washington State Fund were analyzed for 1989 through 1993. Incidence rates for occupational skin disorders among all employers were calculated, as well as industry-specific rates. Cutaneous hazards associated with the highest rates of disease were identified. In the 5-year study period, 7,445 claims for occupational skin disorders were filed, representing 7,058 individuals. Nearly 90 percent of these claims were for dermatitis. Total medical bills were $1.22 million and time loss payments were $1.23 million. Most claims involved disorders affecting the hands, wrists, and/or fingers (39.5 percent) or the arms (17.8 percent). In 26.8 percent of claims, multiple body parts were affected. Among the major industrial sectors, the highest rates of accepted occupational skin disorder claims were in agriculture/forestry/fishing (2.8 per 1,000 full-time equivalent employee-years), manufacturing (1.8), and construction (1.3).

Environmental Health

Exposure of Young Infants to Environmental Tobacco Smoke: Breast Feeding Among Smoking Mothers.
M.A. Mascola, et al. American Journal of Public Health 88 (June 1998): 893-96.

Because breastfeeding may expose infants to the products of tobacco smoke, health care providers need to encourage mothers to stop smoking after their babies are born, especially mothers who plan to breastfeed.

This study examined the differences in exposure to tobacco smoke among breastfed infants whose mothers smoked and bottle-fed infants whose mothers smoked. In addition, the study collected data on infants in both categories according to whether other smokers were present in the household, regardless of whether their mothers smoked. The study population consisted of 330 mother-infant pairs from an urban clinic in Boston. Of these, 103 mothers smoked; 90 of the mothers who smoked bottle fed their infants, and the remaining 13 breastfed their infants. Exposure to nicotine was determined on the basis of the levels of cotinine in the infants’ urine. Urine samples were collected and analyzed one or more times during the first 12 months of life.

Results indicated that breastfed infants of mothers who smoked had median levels of cotinine up to 10 times higher than their bottle-fed counterparts (400 ng/mg vs. 53 ng/ mg). Infants of nonsmoking mothers who were exposed to environmental tobacco smoke in the household had higher levels of cotinine than the infants from nonsmoking households, but there was no significant difference between the bottle-fed and breastfed infants in this group.

According to this study, for infants of smoking mothers, breast-feeding is the most important determinant of urine cotinine levels. It is possible that adverse health consequences attributed solely to environmental tobacco smoke exposure by inhalation also may result from exposure to both environmental tobacco smoke and the breast milk of smoking mothers.

Oral Health

Knowledge, Opinions and Practices of General Dentists Regarding Oral Cancer: A Pilot Survey.
J. Yellowitz, et al. The Journal of the American Dental Association (May 1998): 579-83.

Armed with current information about practitioners’ knowledge, opinions, and practices regarding oral cancer, dental educators can develop and initiate appropriate educational interventions.

This study examined 243 usable responses to a pilot survey completed by a random sample of 500 general dentists. The findings of this 43-item questionnaire indicate that although dentists understand the health risks associated with oral cancer and the importance of early detection, they are inconsistent in their dental practices. For example, 90.8 percent and 99.6 percent of respondents identified alcohol use and tobacco use as risk factors for oral cancer, respectively, but only 45 percent ask their patients about alcohol use and only 86 percent inquire about tobacco use. In addition, nearly all respondents (97.6 per-cent) said that oral cancer exams should be provided annually for patients 40 years and older, yet only 70 percent reported that they conducted such exams at initial visits and only 59 percent conducted such exams at repeat visits.

Incorrect responses to some questions regarding possible oral cancer risks, such as low fruit and vegetable consumption, indicates that many general dentists require more current information on the disease.

Heart Disease and Stroke

Effects of Diet and Exercise in Men and Postmenopausal Women With Low Levels of HDL Cholesterol and High Levels of LDL Cholesterol.
M.L. Stefanick, et al. New England Journal of Medicine 339 (July 2, 1998): 12-20.

Physical activity plays an important role in the treatment of elevated LDL cholesterol levels; dietary changes alone will not lower cholesterol. This study examined plasma lipoprotein levels in 180 postmenopausal women (45-64) and 197 men (30-64) who had low high-density lipoprotein (HDL) cholesterol levels (<44 mg/dL in women and <59 mg/dL in men) and moderately elevated levels of low-density lipoprotein (LDL) cholesterol (>125 mg/dL but <210 mg/dL in women and >125 mg/dL but <190 mg/dL in men). The subjects were randomly assigned to aerobic exercise, the National Cholesterol Education Program (NCEP) Step 2 diet, diet plus exercise, or a control group that received no intervention.

Dietary intake of fat and cholesterol decreased during the 1-year study, as did body weight, in women and men in either the diet group or the diet-plus-exercise group, compared with the controls and the exercise group, in which dietary intake and body weight were unchanged. The serum level of LDL cholesterol was significantly reduced among women (a decrease of 14.5±22.2 mg/dL) and men (a decrease of 20.0±17.3 mg/dL) in the diet-plus-exercise group, compared with the controls (women had a decrease of 2.5±16.6 mg/dL and men had a decrease of 4.6±21.1 mg/dL).The reduction in LDL cholesterol in men in the diet-plus-exercise group was also significant compared with that among the men in the exercise group (3.6±18.8 mg/dL). In contrast, changes in LDL cholesterol levels were not significant among the women (a decrease of 7.3±18.9 mg/dL) or the men (10.8±18.8 mg/dL) in the diet group, compared with the controls. Significant changes in HDL levels were not observed for either sex, which indicates that despite some concerns, exercise does not lower HDL levels.

Because the benefits of exercise in reducing the risk of cardiovascular disease extend beyond improvements in the lipoprotein profile, increased physical activity is recommended for patients at all cholesterol levels.

Diabetes and Chronic Disabling Conditions

Obesity Without Sleep Apnea Is Associated With Daytime Sleepiness.
A.N. Vgontzas, et al. Archives of Internal Medicine 158 (June 22, 1998): 1333-37.

Daytime sleepiness is a morbid characteristic of obese patients with a potentially significant impact on their lives and public safety.

This study examined sleep patterns of 73 obese patients without sleep apnea, upper airway resistance syndrome, or hypoventilation syndrome who were consecutively referred for treatment of their obesity and 45 controls matched for age. All patients and healthy controls were monitored in the sleep laboratory for 8 hours at night and at two daytime naps, each for 1 hour the following day.

Obese patients compared with controls were sleepier during the day and their nighttime sleep was disturbed. In the morning nap, 100 percent of obese patients and 28.1 percent of the controls had some sleep. In the afternoon nap, 100 percent of obese patients and 80.4 percent of controls had some sleep. Wake time after sleep onset was significantly power for obese patients (4.7 vs. 1.4 minutes), as was total wake time (18.5 vs. 2.6 minutes). The percentage of sleep time was significantly higher (69.3 vs. 49.4 minutes). During the nighttime testing, obese patients compared with controls demonstrated significantly higher wake time after onset of sleep (82.4 vs. 46.1 minutes) and a lower percentage of sleep time (75.5 percent vs. 84.9 percent).

The primary finding of this study is that severe obesity even in the absence of sleep apnea or other breathing disorders in sleep is associated with increased daytime sleepiness. An analysis of the relation between nighttime and daytime sleep suggested that daytime sleepiness in obese patients is a result of a circadian abnormality rather than just being secondary to nighttime sleep disturbance. Addressing this problem is important because of the negative consequences of fatigue, such as motor vehicle crashes.

Adolescents and Young Adults

The Association Between Health Risk Behaviors and Sexual Orientation Among a School-based Sample of Adolescents.
R. Garofalo, et al. Pediatrics (May 1998): 895-902.

Because gay, lesbian, and bisexual (GLB) youth are more likely than their heterosexual counterparts to engage in a variety of high-risk behaviors, efforts to educate about the hazards of these risky behaviors and to remove the stigma placed on homosexuality will play critical roles in the physical and emotional development of GLB youth.

This study was conducted on an anonymous representative sample of 4,159 high school students from Massachusetts’ expanded Youth Risk Behavior Survey. A question pertaining to sexual orientation was included. The survey offered data presenting the association between being a GLB youth (2.5 percent of the survey sample) and possessing certain high-risk behaviors such as substance abuse, sexual activity, violence, and suicide attempts. Use of cocaine before age 13 was strongly associated with GLB orientation (odds ratio, 6.10). Early initiation of sexual inter-course (odds ratio, 2.15), marijuana use (odds ratio, 1.98), and alcohol use (odds ratio, 1.82) also were associated with GLB orientation. Other areas associated with GLB orientation included frequency of crack cocaine use (odds ratio, 1.38), inhalant use (odds ratio, 1.30), and number of sexual partners (odds ratio, 1.27). In addition, having one’s property stolen or deliberately damaged was associated with GLB orientation (odds ratio, 1.23). Overall, GLB respondents engaged disproportionately in multiple risk behaviors compared with the rest of the student population.

The findings suggest that educational efforts, prevention programs, and health services must be designed to address the unique needs of GLB youth.

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