Cardiovascular diseases among emergency workers. Occupational and non-occupational risk factors, burden, and preventive strategies.

Introduzione. La morte cardiaca improvvisa (MCI) è una delle principali cause di morte in servizio tra i lavoratori dei servizi di emergenza statunitensi. Il nostro progetto di ricerca mirava a : 1) valutare l’incidenza della MCI; 2) identificare i trigger occupazionali di MCI; 3) descrivere la prevalenza dei fattori di rischio cardiovascolari personali tra i lavoratori dei servizi di emergenza statunitensi. Metodi. Sono stati condotti studi indipendenti tra i vigili del fuoco e gli agenti di polizia. Abbiamo consultato delle banche dati gestite da agenzie federali statunitensi e condotto ad hoc sondaggi nazionali (USA). Risultati principali. Tra il 1998 ed il 2012, il tasso di incidenza di MCI tra i vigili del fuoco in carriera è stato pari a 18.1 eventi per 100.000 anni-persona. La causa sottostante di morte più comune è stata la malattia coronarica. Tra i giovani vigili del fuoco (≤ 45 anni), il 63% delle MCI è stato osservato tra soggetti obesi. Questo dato è in linea con lo studio della dieta dei vigili del fuoco, che ha rivelato la necessità di condurre interventi per migliorare le abitudini alimentari in questa popolazione per diminuire la prevalenza dei comuni fattori di rischio cardiovascolare. Due studi hanno dimostrato che l’esecuzione di compiti fisicamente ed emotivamente intensi (ad esempio, lo spegnimento di incendi e le colluttazioni con sospetti) sono trigger importanti (rischi relativi superiori a 30) di MCI tra i vigili del fuoco e gli agenti di polizia. Conclusioni. La riduzione dell’incidenza di MCI tra i lavoratori dei servizi di emergenza rappresenta una priorità assoluta. L’alto carico di malattia è imputabile alla prevalenza dei fattori di rischio cardiovascolare tradizionali superiore a quanto comunemente pensato e all’esposizione a fattori di rischio professionali. Sono necessarie strategie di prevenzione primaria (es. variazioni delle abitudini alimentari) e secondarie (valutazione dell’idoneità alla mansione).Background. Sudden cardiac death (SCD) is a major cause of on-duty death among US emergency workers. We conducted a research project aimed to: 1) assessing the incidence of cardiovascular diseases; 2) identifying occupational triggers of SCD; 3) describing the prevalence of personal cardiovascular risk factors among US emergency workers. Methods. We performed separate investigations among firefighters and law enforcement officers. We obtained data on cardiovascular deaths from national databases maintained by federal agencies and we conducted a series of nationwide surveys. Main results. Between 1998 and 2012, the incidence rate of SCD among US career firefighters was 18.1 per 100,000 person-years. Coronary heart disease was the leading underlying cause of death. Among young firefighters (≤ 45 years), 63% of deaths were observed among obese subjects. This observation is in line with our study on firefighters’ diet, which highlighted the need for dietary intervention in order to decrease the extremely high prevalence of traditional cardiovascular risk factors in a cohort of active firefighters. Two independent studies showed that stressful duties (e.g. fire suppression or restraints and physical altercation) are important trigger of SCD (relative risks>30) among firefighters and law enforcement officers. Conclusions. The burden of sudden cardiac death among emergency workers is a major concern. On the one hand, emergency workers showed an unacceptably high prevalence of traditional risk factors, which were the main contributors of the observed incidence of coronary artery disease. On the other hand, law enforcement and firefighting involve extremely strenuous duties with may trigger cardiovascular events among susceptible individuals. The primary prevention of cardiovascular diseases in these populations must be considered a priority. In particular, dietary intervention might be particularly effective in decreasing the burden of SCD among emergency workers. As a secondary prevention strategy, emergency workers should receive sufficient evaluation to exclude underlying heart disease

Italy's health performance, 1990-2017: findings from the Global Burden of Disease Study 2017

BACKGROUND: Through a comprehensive analysis of Italy's estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, we aimed to understand the patterns of health loss and response of the health-care system, and offer evidence-based policy indications in light of the demographic transition and government health spending in the country. METHODS: Estimates for Italy were extracted from GBD 2017. Data on Italy are presented for 1990 and 2017, on prevalence, causes of death, years of life lost, years lived with disability, disability-adjusted life-years (DALYs), life expectancy at birth and at age 65 years, healthy life expectancy, and Healthcare Access and Quality (HAQ) Index. We compared the estimates for Italy with those of 15 other western European countries. FINDINGS: The quality of the universal health system and healthy behaviours contribute to favourable overall health, even in comparison with other western European countries. In 2017, life expectancy and HAQ Index score in Italy were among the highest globally, with life expectancy at birth reaching 85·3 years for females and 80·8 for males in 2017, ranking Italy eighth globally for females and sixth for males, and an HAQ Index score of 94·9 in 2016 compared with 81·54 in 1990, keeping Italy ranked as ninth globally. Between 1990 and 2017 age-standardised death rates for cardiovascular diseases decreased by 53·7% (95% uncertainty interval -56·1 to -51·4), for neoplasms decreased by 28·2% (-32·3 to -24·6), and for transport injuries decreased by 62·1% (-64·6 to -59·2). However, population ageing is causing an increase in the burden of specific diseases, such as Alzheimer's disease and other dementias (DALYs increased by 77·9% [68·4 to 87·2]) and pancreatic (DALYs increased by 39·7% [28·4 to 51·7]) and uterine cancers (DALYs increased by 164·7% [129·7 to 202·5]). Behavioural risk factors, which are potentially modifiable, still have a strong effect, particularly on cardiovascular diseases and neoplasms. For instance, in 2017, 44 400 (41 200 to 47 800) cancer deaths were attributed to smoking, 12 000 (9600 to 14 800) to alcohol use, and 9500 (5400 to 14 200) to high body-mass index, while 47 000 (31 100 to 65 700) deaths due to cardiovascular diseases could be attributed to high LDL cholesterol, 28 700 (19 700 to 38 500) to diets low in whole grains, and 15 900 (8500 to 24 900) to low physical activity. INTERPRETATION: Italy provides an interesting example of the results that can be achieved by a mix of relatively healthy lifestyles and a universal health system. Two main issues require attention, population ageing and gradual decrease of public health financing, which both pose several challenges to the future of Italy's health status. Our findings should be useful to Italy's policy makers and health system experts elsewhere. FUNDING: Bill & Melinda Gates Foundation

Modified Mediterranean Diet Score and Cardiovascular Risk in a North American Working Population

Introduction: Greater adherence to a Mediterranean diet is linked to lower risk for cardiovascular morbidity/mortality in studies of Mediterranean cohorts, older subjects, and/or those with existing health conditions. No studies have examined the effects of this dietary pattern in younger working populations in the United States. We investigated the effects of Mediterranean diet adherence on cardiovascular disease (CVD) biomarkers, metabolic syndrome and body composition in an occupationally active, non-Mediterranean cohort. Methods: A cross-sectional study in a cohort of 780 career male firefighters, ages 18 years or older, from the United States Midwest. No dietary intervention was performed. A modified Mediterranean diet score (mMDS) was developed for assessment of adherence to a Mediterranean dietary pattern from a previously administered life-style questionnaire that examined pre-existing dietary habits. Clinical data from fire department medical examinations were extracted and analyzed. Results: Obese subjects had significantly lower mMDS, and they reported greater fast/take-out food consumption (p<0.001) and intake of sweetened drinks during meals (p = 0.002). After multivariate adjustment, higher mMDS was inversely related to risk of weight gain over the past 5 years (odds ratio [OR]: 0.57, 95% confidence interval [CI]: 0.39–0.84, p for trend across score quartiles: 0.01); as well as the presence of metabolic syndrome components (OR: 0.65, 95% CI: 0.44–0.94, p for trend across score quartiles: 0.04). Higher HDL-cholesterol (p = 0.008) and lower LDL-cholesterol (p = 0.04) were observed in those with higher mMDS in linear regression after multivariate adjustment for age, BMI and physical activity. Conclusions: In a cohort of young and active US adults, greater adherence to a Mediterranean-style dietary pattern had significant inverse associations with metabolic syndrome, LDL-cholesterol and reported weight gain, and was significantly and independently associated with higher HDL-cholesterol. Our results support the potential effectiveness of this diet in young, non-Mediterranean working cohorts, and justify future intervention studies

Law enforcement duties and sudden cardiac death among police officers in United States: case distribution study

Objective: To assess the association between risk of sudden cardiac death and stressful law enforcement duties compared with routine/non-emergency duties. Design: Case distribution study (case series with survey information on referent exposures). Setting: United States law enforcement. Participants: Summaries of deaths of over 4500 US police officers provided by the National Law Enforcement Officers Memorial Fund and the Officer Down Memorial Page from 1984 to 2010. Main outcome measures Observed and expected sudden cardiac death counts and relative risks for sudden cardiac death events during specific strenuous duties versus routine/non-emergency activities. Independent estimates of the proportion of time that police officers spend across various law enforcement duties obtained from surveys of police chiefs and front line officers. Impact of varying exposure assessments, covariates, and missing cases in sensitivity and stability analyses. Results: 441 sudden cardiac deaths were observed during the study period. Sudden cardiac death was associated with restraints/altercations (25%, n=108), physical training (20%, n=88), pursuits of suspects (12%, n=53), medical/rescue operations (8%, n=34), routine duties (23%, n=101), and other activities (11%, n=57). Compared with routine/non-emergency activities, the risk of sudden cardiac death was 34-69 times higher during restraints/altercations, 32-51 times higher during pursuits, 20-23 times higher during physical training, and 6-9 times higher during medical/rescue operations. Results were robust to all sensitivity and stability analyses. Conclusions: Stressful law enforcement duties are associated with a risk of sudden cardiac death that is markedly higher than the risk during routine/non-emergency duties. Restraints/altercations and pursuits are associated with the greatest risk. Our findings have public health implications and suggest that primary and secondary cardiovascular prevention efforts are needed among law enforcement officers

Sudden Cardiac Death Among Firefighters ≤45 Years of Age in the United States

Sudden cardiac death (SCD) is the leading cause of death in firefighters. Although on-duty SCD usually occurs in older victims almost exclusively because of coronary heart disease, no studies have examined causation across the career span. In the present retrospective case-control study, cases of SCD in young (aged ≤45 years) firefighters from the National Institute for Occupational Safety and Health fatality investigations (n = 87) were compared with 2 age- and gender-matched control groups: occupationally active firefighters (n = 915) and noncardiac traumatic firefighter fatalities (n = 56). Of the SCD cases, 63% were obese and 67% had a coronary heart disease-related cause of death. The SCD victims had much heavier hearts (522 ± 102 g) than noncardiac fatality controls (400 ± 91 g, p 450 g) was found in 66% of the SCD victims and conveyed a fivefold increase (95% confidence interval [CI] 1.93 to 12.4) in SCD risk. Furthermore, hypertension, including cases with left ventricular hypertrophy, increased SCD risk by 12-fold (95% CI 6.23 to 22.3) after multivariate adjustment. A history of cardiovascular disease and smoking were also independently associated with elevated SCD risk (odds ratio 6.89, 95% CI 2.87 to 16.5; and odds ratio 3.53, 95% CI 1.87 to 6.65, respectively). In conclusion, SCD in young firefighters is primarily related to preventable lifestyle factors. Obesity entry standards, smoking bans, and improved screening and/or wellness program are potential strategies to reduce SCD in younger firefighters

Observed Differences between Males and Females in Surgically Treated Carpal Tunnel Syndrome Among Non-manual Workers: A Sensitivity Analysis of Findings from a Large Population Study

Objectives: We aimed at assessing whether differences among males and females in carpal tunnel syndrome (CTS) epidemiology might be attributable to segregation with respect to occupational biomechanical exposures or differential access to care by sex. Methods: We analysed surgically treated cases of CTS occurring among non-manual workers in Tuscany between 1997 and 2000. We conducted a Monte Carlo simulation to estimate the difference in occupational biomechanical exposures between males and females necessary to explain the observed incidence rate ratios. We also accounted for the sex-specific probability of receiving surgery after the diagnosis of CTS, as women were reported to be more likely to undergo surgery in a subset of our study population. We quantified the hypothetical biomechanical overload through the hand activity level (HAL) metric proposed by the American Conference of Governmental Industrial Hygienists. To quantify the effect of HAL on CTS risk, we assumed a prior distribution based on findings from two large cohort studies of industrial workers. Results: After adjustment for the probability of receiving surgery, women showed a 4-fold incidence of CTS as compared with men. To explain this association among non-manual workers, women should have an average value of HAL at least 5 points higher. Conclusions: Our analysis does not support the hypothesis that the difference in CTS incidence between males and females is entirely attributable to occupational risk factors or to differential access to surgery. The causal pathway between sex and CTS might include more determinants such as hormonal factors, anthropometric characteristics, and non-occupational exposure to biomechanical overload (e.g. household tasks)

O8D.8 Severity of carpal tunnel syndrome and manual work: findings from a case-control study

ObjectiveCarpal tunnel syndrome (CTS) is a socially relevant condition. This case-control study aims to investigate the association between CTS severity and manual work considering personal anthropometric risk factors as well.MethodsWe consecutively enrolled one CTS case for two controls (subjects without clinical and electrophysiological CTS signs) regardless of age and gender who were admitted to the same three outpatient electromyography labs.CTS cases were grouped in three classes of progressive clinical and electrophysiological severity according to two validated five-stage scales. Anthropometric measures and occupational history were collected. Job titles were coded according to the International Standard Classification of Occupations (ISCO 88) by two occupational physicians who were blind to case/control status. Job titles were grouped in two main occupational categories: manual workers and non-manual workers.To assess the association between CTS severity and manual work, ordered logistic regression models (adjusted for age, sex, wrist-palm ratio and waist-stature ratio) were performed. Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated.ResultsThis case-control study enrolled 370 cases and 747 controls. After the exclusion of retired subjects, subjects older than 65 years and subjects with no information about occupational history, we included 183 cases and 445 controls in the main analysis.For manual workers with respect to non-manual workers, the OR for the electrophysiological severity scale was 2.4 (95%CI 1.5–3.7). Regarding the clinical severity scale, the OR for manual workers compared to non-manual workers were 2.3 (95%CI 1.5–3.7).ConclusionThis study confirms that manual work is an important risk factor for CTS. The association between manual work and CTS severity tends to increase from mild to severe stage of both electrophysiological and clinical scale

Agreement between BMI and body fat obesity definitions in a physically active population

Body mass index (BMI) is a widely used proxy of body composition (BC). Concerns exist regarding possible BMI misclassification among active populations. We compared the prevalence of obesity as categorized by BMI or by skinfold estimates of body fat percentage (BF%) in a physically active population. Subjects and methods 3,822 military firefighters underwent a physical fitness evaluation including cardiorespiratory fitness (CRF) by the 12 min-Cooper test, abdominal strength by sit-up test (SUT) and body composition (BC) by BF% (as the reference), as well as BMI. Obesity was defined by BF% > 25% and BMI ≥ 30 kg/m2. Agreement was evaluated by sensitivity and specificity of BMI, positive and negative predictive values (PPV/NPV), positive and negative likelihood (LR+/LR-), receiver operating characteristic (ROC) curves and also across age, CRF and SUT subgroups. Results The prevalence of obesity estimated by BMI (13.3%) was similar to BF% (15.9%). Overall agreement was high (85.8%) and varied in different subgroups (75.3-94.5%). BMI underestimated the prevalence of obesity in all categories with high specificity (≥ 81.2%) and low sensitivity (≤ 67.0). All indices were affected by CRF, age and SUT, with better sensitivity, NPV and LR- in the less fit and older groups; and higher specificity, PPV and LR+ among the fittest and youngest groups. ROC curves showed high area under the curve (≥ 0.77) except for subjects with CRF ≥ 14 METs (= 0.46). Conclusion Both measures yielded similar obesity prevalences, with high agreement. BMI did not overestimate obesity prevalence. BMI ≥ 30 was highly specific to exclude obesity. Because of systematic under estimation, a lower BMI cut-off point might be considered in this population

Hypofractionated radiotherapy after conservative surgery may increase low-intermediate grade late fibrosis in breast cancer patients

patients Abstract Fulltext Metrics Get Permission Cite this article Authors Diges\uf9 C, Deodato F, Macchia G, Cilla S, Pieri M, Zamagni A, Farioli A, Buwenge M, Ferrandina G, Morganti AG Received 12 March 2018 Accepted for publication 23 May 2018 Published 3 October 2018 Volume 2018:10 Pages 143\u2014151 DOI https://doi.org/10.2147/BCTT.S167914 Checked for plagiarism Yes Review by Single-blind Peer reviewer comments 3 Editor who approved publication: Professor Pranela Rameshwar Article has an altmetric score of 2 Cinzia Diges\uf9,1 Francesco Deodato,1 Gabriella Macchia,1 Savino Cilla,2 Martina Pieri,3 Alice Zamagni,4 Andrea Farioli,5 Milly Buwenge,4 Gabriella Ferrandina,6,* Alessio G Morganti4,* 1Radiotherapy Unit, General Oncology Unit, Fondazione Giovanni Paolo II, Campobasso, Italy; 2Medical Physics Unit, Fondazione Giovanni Paolo II, Campobasso, Italy; 3Radiotherapy Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, Meldola, Italy; 4Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy; 5Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; 6Department of Woman and Child Health, Gynecologic Oncology Unit, Fondazione \u201cPoliclinico Universitario A. Gemelli\u201d, IRCSS, Universita\u2019 Cattolica Sacro Cuore, Rome, Italy *These authors contributed equally to this work Aim: To compare late toxicity after postoperative hypofractionated radiotherapy (RT) and standard fractionated RT in patients with early-stage breast carcinoma. Methods: This retrospective study included 447 patients (Modulated Accelerated Radiotherapy [MARA-1]: 317 patients, and control group [CG]: 130 patients). In the CG, the whole breast received 50.4 Gy in 28 fractions (fx) using 3D-radiotherapy, plus a sequential electron boost (10 Gy in 4 fx) to tumor bed. In MARA-1 group, a forward-planned intensity-modulated radiotherapy technique with 40 Gy in 16 fx with a concomitant boost of 4 Gy to breast was used. The primary endpoint was to evaluate late toxicity, and secondary endpoints were acute toxicity, local control, and survival. ClinicalTrials.gov: NCT03461224. Results: Median follow-up was 52 months (range: 3\u2013115 months). Late skin and subcutaneous toxicity were acceptable: 5-year actuarial cumulative incidence of Grade (G) 3 late skin toxicity was 1.5% in CG and 0.0% in MARA-1. Five-year actuarial cumulative incidence of G3 late subcutaneous toxicity was 0.8% in CG and 0.3% in MARA-1. On multivariate analysis, tobacco smoking and planning target volume were associated with an increased risk of late G1 skin toxicity (HR: 2.15, 95% CI: 1.38\u20133.34 and HR: 1.12, 95% CI: 1.07\u20131.18, respectively), whereas patients with a larger planning target volume also showed an increased risk of G1 and G2 late subcutaneous toxicity (HR: 1.14, CI 95%: 1.08\u20131.20 and HR: 1.14, 95% CI: 1.01\u20131.28, respectively). MARA-1 patients also showed an increased risk of late G1 and G2 subcutaneous toxicity (HR: 2.35, 95% CI: 1.61\u20133.41 and HR: 3.07, 95% CI: 1.11\u20138.53, respectively) compared to CG. Conclusion: In this retrospective analysis, postoperative accelerated-hypofractionated RT for early-stage-breast carcinoma was associated with higher incidence of subcutaneous side effects. However, this increase was limited to G1\u2013G2 toxicity. In the future, development of predictive models could help in tailoring dose and fractionation based on the risk of toxicity

Search strings for the study of putative occupational determinants of disease

Objective To identify efficient PubMed search strategies to retrieve articles regarding putative occupational determinants of conditions not generally considered to be work related. Methods Based on MeSH definitions and expert knowledge, we selected as candidate search terms the four MeSH terms describing 'occupational disease', 'occupational exposure', 'occupational health' and 'occupational medicine' (DEHM) alongside 22 other promising terms. We first explored overlaps between the candidate terms in PubMed. Using random samples of abstracts retrieved by each term, we estimated the proportions of articles containing potentially pertinent information regarding occupational aetiology in order to formulate two search strategies (one more 'specific', one more 'sensitive'). We applied these strategies to retrieve information on the possible occupational aetiology of meningioma, pancreatitis and atrial fibrillation. Results Only 20.3% of abstracts were retrieved by more than one DEHM term. The more 'specific' search string was based on the combination of terms that yielded the highest proportion (40%) of potentially pertinent abstracts. The more 'sensitive' string was based on the use of broader search fields and additional coverage provided by other search terms under study. Using the specific string, the numbers of abstracts needed to read to find one potentially pertinent article were 1.2 for meningioma, 1.9 for pancreatitis and 1.8 for atrial fibrillation. Using the sensitive strategy, the numbers needed to read were 4.4 for meningioma, 8.9 for pancreatitis and 10.5 for atrial fibrillation. Conclusions The proposed strings could help health care professionals explore putative occupational aetiology for diseases that are not generally thought to be work relate