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Int. J. Environ. Res. Public Health, Volume 10, Issue 9 (September 2013) , Pages 3801-4506

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Open AccessArticle
Genetic Analysis of West Nile Virus Isolates from an Outbreak in Idaho, United States, 2006–2007
Int. J. Environ. Res. Public Health 2013, 10(9), 4486-4506; https://doi.org/10.3390/ijerph10094486 - 23 Sep 2013
Cited by 3 | Viewed by 2980
Abstract
West Nile virus (WNV) appeared in the U.S. in 1999 and has since become endemic, with yearly summer epidemics causing tens of thousands of cases of serious disease over the past 14 years. Analysis of WNV strains isolated during the 2006–2007 epidemic seasons [...] Read more.
West Nile virus (WNV) appeared in the U.S. in 1999 and has since become endemic, with yearly summer epidemics causing tens of thousands of cases of serious disease over the past 14 years. Analysis of WNV strains isolated during the 2006–2007 epidemic seasons demonstrates that a new genetic variant had emerged coincidentally with an intense outbreak in Idaho during 2006. The isolates belonging to the new variant carry a 13 nt deletion, termed ID-Δ13, located at the variable region of the 3′UTR, and are genetically related. The analysis of deletions and insertions in the 3′UTR of two major lineages of WNV revealed the presence of conserved repeats and two indel motifs in the variable region of the 3′UTR. One human and two bird isolates from the Idaho 2006–2007 outbreaks were sequenced using Illumina technology and within-host variability was analyzed. Continued monitoring of new genetic variants is important for public health as WNV continues to evolve. Full article
(This article belongs to the Special Issue Epidemiology of West Nile Virus)
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Open AccessReview
Lung Deposition Analyses of Inhaled Toxic Aerosols in Conventional and Less Harmful Cigarette Smoke: A Review
Int. J. Environ. Res. Public Health 2013, 10(9), 4454-4485; https://doi.org/10.3390/ijerph10094454 - 23 Sep 2013
Cited by 28 | Viewed by 4627
Abstract
Inhaled toxic aerosols of conventional cigarette smoke may impact not only the health of smokers, but also those exposed to second-stream smoke, especially children. Thus, less harmful cigarettes (LHCs), also called potential reduced exposure products (PREPs), or modified risk tobacco products (MRTP) have [...] Read more.
Inhaled toxic aerosols of conventional cigarette smoke may impact not only the health of smokers, but also those exposed to second-stream smoke, especially children. Thus, less harmful cigarettes (LHCs), also called potential reduced exposure products (PREPs), or modified risk tobacco products (MRTP) have been designed by tobacco manufacturers to focus on the reduction of the concentration of carcinogenic components and toxicants in tobacco. However, some studies have pointed out that the new cigarette products may be actually more harmful than the conventional ones due to variations in puffing or post-puffing behavior, different physical and chemical characteristics of inhaled toxic aerosols, and longer exposure conditions. In order to understand the toxicological impact of tobacco smoke, it is essential for scientists, engineers and manufacturers to develop experiments, clinical investigations, and predictive numerical models for tracking the intake and deposition of toxicants of both LHCs and conventional cigarettes. Furthermore, to link inhaled toxicants to lung and other diseases, it is necessary to determine the physical mechanisms and parameters that have significant impacts on droplet/vapor transport and deposition. Complex mechanisms include droplet coagulation, hygroscopic growth, condensation and evaporation, vapor formation and changes in composition. Of interest are also different puffing behavior, smoke inlet conditions, subject geometries, and mass transfer of deposited material into systemic regions. This review article is intended to serve as an overview of contributions mainly published between 2009 and 2013, focusing on the potential health risks of toxicants in cigarette smoke, progress made in different approaches of impact analyses for inhaled toxic aerosols, as well as challenges and future directions. Full article
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Open AccessArticle
A Content Analysis of Media Coverage of the Introduction of a Smoke-Free Bylaw in Vancouver Parks and Beaches
Int. J. Environ. Res. Public Health 2013, 10(9), 4444-4453; https://doi.org/10.3390/ijerph10094444 - 18 Sep 2013
Cited by 7 | Viewed by 3037
Abstract
The Board of Parks and Recreation in Vancouver, BC approved a smoke-free bylaw in the city’s parks, beaches and recreational facilities, effective 1 September 2010. We analyzed local news coverage and portrayal of the bylaw to understand the potential influence of news media [...] Read more.
The Board of Parks and Recreation in Vancouver, BC approved a smoke-free bylaw in the city’s parks, beaches and recreational facilities, effective 1 September 2010. We analyzed local news coverage and portrayal of the bylaw to understand the potential influence of news media on public perception of the bylaw in order to inform the media advocacy work of public health interest groups. We compiled a data set of newspaper articles (n = 90) and conducted a quantitative content analysis to examine content related to the outdoor smoke-free policy, including article slant, topics related to smoking and tobacco control, and any equity-related concerns raised. Newspaper coverage in Vancouver was largely supportive of the outdoor smoke-free bylaw. However, concerns over rights were frequently discussed in letters to the editor. Such equity concerns were rarely discussed in news articles, showing a potential disconnect between the concerns expressed in the media by members of the public and the coverage provided by print media. Full article
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Open AccessArticle
Natural Exposure of Horses to Mosquito-Borne Flaviviruses in South-East Queensland, Australia
Int. J. Environ. Res. Public Health 2013, 10(9), 4432-4443; https://doi.org/10.3390/ijerph10094432 - 17 Sep 2013
Cited by 17 | Viewed by 3481
Abstract
In 2011 an unprecedented epidemic of equine encephalitis occurred in south-eastern (SE) Australia following heavy rainfall and severe flooding in the preceding 2–4 months. Less than 6% of the documented cases occurred in Queensland, prompting the question of pre-existing immunity in Queensland horses. [...] Read more.
In 2011 an unprecedented epidemic of equine encephalitis occurred in south-eastern (SE) Australia following heavy rainfall and severe flooding in the preceding 2–4 months. Less than 6% of the documented cases occurred in Queensland, prompting the question of pre-existing immunity in Queensland horses. A small-scale serological survey was conducted on horses residing in one of the severely flood-affected areas of SE-Queensland. Using a flavivirus-specific blocking-ELISA we found that 63% (39/62) of horses older than 3 years were positive for flavivirus antibodies, and of these 18% (7/38) had neutralizing antibodies to Murray Valley encephalitis virus (MVEV), Kunjin virus (WNVKUN) and/or Alfuy virus (ALFV). The remainder had serum-neutralizing antibodies to viruses in the Kokobera virus (KOKV) complex or antibodies to unknown/untested flaviviruses. Amongst eight yearlings one presented with clinical MVEV-encephalomyelitis, while another, clinically normal, had MVEV-neutralizing antibodies. The remaining six yearlings were flavivirus antibody negative. Of 19 foals born between August and November 2011 all were flavivirus antibody negative in January 2012. This suggests that horses in the area acquire over time active immunity to a range of flaviviruses. Nevertheless, the relatively infrequent seropositivity to MVEV, WNVKUN and ALFV (15%) suggests that factors other than pre-existing immunity may have contributed to the low incidence of arboviral disease in SE-Queensland horses during the 2011 epidemic. Full article
(This article belongs to the Special Issue Epidemiology of West Nile Virus)
Open AccessArticle
Patterns of Smoking Prevalence among the Elderly in Europe
Int. J. Environ. Res. Public Health 2013, 10(9), 4418-4431; https://doi.org/10.3390/ijerph10094418 - 17 Sep 2013
Cited by 16 | Viewed by 3773
Abstract
Scant information is available on determinants of smoking prevalence in the vulnerable population of the elderly, particularly in Europe. Therefore, we analyzed smoking patterns among older adults (≥65 years old), using data from a representative survey based on 3,071 elderly, conducted in 17 [...] Read more.
Scant information is available on determinants of smoking prevalence in the vulnerable population of the elderly, particularly in Europe. Therefore, we analyzed smoking patterns among older adults (≥65 years old), using data from a representative survey based on 3,071 elderly, conducted in 17 European countries in 2010, within the Pricing Policies And Control of Tobacco in Europe (PPACTE) project. Overall smoking prevalence in 17 European countries was 11.5% (15.3% in men and 8.6% in women). An inverse relation with level of education was observed among men, while no specific pattern was evident among women. Smoking prevalence was highest in eastern/central Europe for men (20.3%) and northern Europe for women (13.1%). In both sexes combined, smokers were more frequent in countries with low implementation of tobacco control activities (14.9%). Anti-tobacco campaigns and smoking cessation interventions specifically targeted to the elderly are urgently needed in Europe. Full article
(This article belongs to the Special Issue Tobacco Control in Vulnerable Population Groups)
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Open AccessReview
Microbial Anaerobic Digestion (Bio-Digesters) as an Approach to the Decontamination of Animal Wastes in Pollution Control and the Generation of Renewable Energy
Int. J. Environ. Res. Public Health 2013, 10(9), 4390-4417; https://doi.org/10.3390/ijerph10094390 - 17 Sep 2013
Cited by 55 | Viewed by 5019
Abstract
With an ever increasing population rate; a vast array of biomass wastes rich in organic and inorganic nutrients as well as pathogenic microorganisms will result from the diversified human, industrial and agricultural activities. Anaerobic digestion is applauded as one of the best ways [...] Read more.
With an ever increasing population rate; a vast array of biomass wastes rich in organic and inorganic nutrients as well as pathogenic microorganisms will result from the diversified human, industrial and agricultural activities. Anaerobic digestion is applauded as one of the best ways to properly handle and manage these wastes. Animal wastes have been recognized as suitable substrates for anaerobic digestion process, a natural biological process in which complex organic materials are broken down into simpler molecules in the absence of oxygen by the concerted activities of four sets of metabolically linked microorganisms. This process occurs in an airtight chamber (biodigester) via four stages represented by hydrolytic, acidogenic, acetogenic and methanogenic microorganisms. The microbial population and structure can be identified by the combined use of culture-based, microscopic and molecular techniques. Overall, the process is affected by bio-digester design, operational factors and manure characteristics. The purpose of anaerobic digestion is the production of a renewable energy source (biogas) and an odor free nutrient-rich fertilizer. Conversely, if animal wastes are accidentally found in the environment, it can cause a drastic chain of environmental and public health complications. Full article
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Open AccessReview
Neural Tube Defects, Folic Acid and Methylation
Int. J. Environ. Res. Public Health 2013, 10(9), 4352-4389; https://doi.org/10.3390/ijerph10094352 - 17 Sep 2013
Cited by 77 | Viewed by 7558
Abstract
Neural tube defects (NTDs) are common complex congenital malformations resulting from failure of the neural tube closure during embryogenesis. It is established that folic acid supplementation decreases the prevalence of NTDs, which has led to national public health policies regarding folic acid. To [...] Read more.
Neural tube defects (NTDs) are common complex congenital malformations resulting from failure of the neural tube closure during embryogenesis. It is established that folic acid supplementation decreases the prevalence of NTDs, which has led to national public health policies regarding folic acid. To date, animal studies have not provided sufficient information to establish the metabolic and/or genomic mechanism(s) underlying human folic acid responsiveness in NTDs. However, several lines of evidence suggest that not only folates but also choline, B12 and methylation metabolisms are involved in NTDs. Decreased B12 vitamin and increased total choline or homocysteine in maternal blood have been shown to be associated with increased NTDs risk. Several polymorphisms of genes involved in these pathways have also been implicated in risk of development of NTDs. This raises the question whether supplementation with B12 vitamin, betaine or other methylation donors in addition to folic acid periconceptional supplementation will further reduce NTD risk. The objective of this article is to review the role of methylation metabolism in the onset of neural tube defects. Full article
(This article belongs to the Special Issue Birth Defect Prevention)
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Open AccessArticle
New Zealand’s Drug Development Industry
Int. J. Environ. Res. Public Health 2013, 10(9), 4339-4351; https://doi.org/10.3390/ijerph10094339 - 13 Sep 2013
Cited by 5 | Viewed by 2935
Abstract
The pharmaceutical industry’s profitability depends on identifying and successfully developing new drug candidates while trying to contain the increasing costs of drug development. It is actively searching for new sources of innovative compounds and for mechanisms to reduce the enormous costs of developing [...] Read more.
The pharmaceutical industry’s profitability depends on identifying and successfully developing new drug candidates while trying to contain the increasing costs of drug development. It is actively searching for new sources of innovative compounds and for mechanisms to reduce the enormous costs of developing new drug candidates. There is an opportunity for academia to further develop as a source of drug discovery. The rising levels of industry outsourcing also provide prospects for organisations that can reduce the costs of drug development. We explored the potential returns to New Zealand (NZ) from its drug discovery expertise by assuming a drug development candidate is out-licensed without clinical data and has anticipated peak global sales of $350 million. We also estimated the revenue from NZ’s clinical research industry based on a standard per participant payment to study sites and the number of industry-sponsored clinical trials approved each year. Our analyses found that NZ’s clinical research industry has generated increasing foreign revenue and appropriate policy support could ensure that this continues to grow. In addition the probability-based revenue from the out-licensing of a drug development candidate could be important for NZ if provided with appropriate policy and financial support. Full article
(This article belongs to the Special Issue Economics of New Drug Development and Approval)
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Open AccessArticle
Appraisal of Hygiene Indicators and Farming Practices in the Production of Leafy Vegetables by Organic Small-Scale Farmers in uMbumbulu (Rural KwaZulu-Natal, South Africa)
Int. J. Environ. Res. Public Health 2013, 10(9), 4323-4338; https://doi.org/10.3390/ijerph10094323 - 13 Sep 2013
Cited by 7 | Viewed by 3555
Abstract
During October, November and December 2011 (when highest sales of Agri-Hub fresh produce are observed), irrigation water, compost, lettuce and spinach sampled from four different farmer cooperatives supplying the local Agri-Hub in uMbumbulu (KwaZulu-Natal, South Africa) were analyzed monthly for the presence of [...] Read more.
During October, November and December 2011 (when highest sales of Agri-Hub fresh produce are observed), irrigation water, compost, lettuce and spinach sampled from four different farmer cooperatives supplying the local Agri-Hub in uMbumbulu (KwaZulu-Natal, South Africa) were analyzed monthly for the presence of total and fecal coliforms and Escherichia coli using the most probable number (MPN) technique. The pH values for all irrigation water samples analyzed were within the acceptable range of 6.5–8.5 for agricultural use. Fecal coliform levels were <1,000 MPN per 100 mL irrigation water and <1,000 MPN per g of compost. The vegetables produced by Agri-Hub small-scale farmers met the requirements for total coliforms of <200/g set by the South African Department of Health at the time of sampling. E. coli MPN values for irrigation water and vegetables were below the limit of detection. In addition, the farming practices of 73 farmers were assessed via a survey. The results revealed that more than 40% of farmers used microbiologically safe tap water for irrigation and that trained farmers have a significantly better understanding of the importance of production hygiene than untrained farmers. These results reiterate the importance of interventions that build capacity in the area of food safety and hygiene of small-scale farmers for market access of formal value chains. Full article
(This article belongs to the Special Issue Food Safety and Public Health)
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Open AccessArticle
Differential Impact of Tobacco Control Policies on Youth Sub-Populations
Int. J. Environ. Res. Public Health 2013, 10(9), 4306-4322; https://doi.org/10.3390/ijerph10094306 - 12 Sep 2013
Cited by 20 | Viewed by 4002
Abstract
Background: While previous studies have demonstrated the efficacy of tobacco control interventions in reducing tobacco use among youth overall, there have been very few studies that examine the potential differential impact of tobacco control policies on various youth subgroups, defined by socio-economic [...] Read more.
Background: While previous studies have demonstrated the efficacy of tobacco control interventions in reducing tobacco use among youth overall, there have been very few studies that examine the potential differential impact of tobacco control policies on various youth subgroups, defined by socio-economic status (SES), race/ethnicity, and gender. Objective: We examined the relationship between state-level cigarette prices and smoke-free air laws and youth smoking prevalence and intensity for various youth sub-populations in the United States. Methods: We estimated a 2-part model of cigarette demand using data from the 1991 through 2010 nationally representative surveys of 8th-, 10th-, and 12th-grade students as part of the Monitoring the Future project. Findings: We found that real cigarette prices are strong determinants of youth smoking. Blacks, females, Hispanics, and low-SES subpopulations are found to have a larger price response with respect to smoking prevalence than the full sample. Smoke-free air laws are found to have a negative effect on smoking prevalence for the full sample and for the male, white, and high-SES sub-populations. Conclusions: This research concludes that higher cigarette prices will reduce smoking prevalence rates of Blacks, Hispanics, females, and low-SES subpopulations faster than the overall youth population and other youth sub-populations. Moreover, this research concludes that smoke-free air laws will reduce smoking prevalence for the overall youth population with the largest reductions in high SES and male subpopulations. Full article
(This article belongs to the Special Issue Tobacco Control in Vulnerable Population Groups)
Open AccessReview
Strategies to Minimize Antibiotic Resistance
Int. J. Environ. Res. Public Health 2013, 10(9), 4274-4305; https://doi.org/10.3390/ijerph10094274 - 12 Sep 2013
Cited by 129 | Viewed by 10156
Abstract
Antibiotic resistance can be reduced by using antibiotics prudently based on guidelines of antimicrobial stewardship programs (ASPs) and various data such as pharmacokinetic (PK) and pharmacodynamic (PD) properties of antibiotics, diagnostic testing, antimicrobial susceptibility testing (AST), clinical response, and effects on the microbiota, [...] Read more.
Antibiotic resistance can be reduced by using antibiotics prudently based on guidelines of antimicrobial stewardship programs (ASPs) and various data such as pharmacokinetic (PK) and pharmacodynamic (PD) properties of antibiotics, diagnostic testing, antimicrobial susceptibility testing (AST), clinical response, and effects on the microbiota, as well as by new antibiotic developments. The controlled use of antibiotics in food animals is another cornerstone among efforts to reduce antibiotic resistance. All major resistance-control strategies recommend education for patients, children (e.g., through schools and day care), the public, and relevant healthcare professionals (e.g., primary-care physicians, pharmacists, and medical students) regarding unique features of bacterial infections and antibiotics, prudent antibiotic prescribing as a positive construct, and personal hygiene (e.g., handwashing). The problem of antibiotic resistance can be minimized only by concerted efforts of all members of society for ensuring the continued efficiency of antibiotics. Full article
(This article belongs to the Special Issue Antimicrobial Resistance Prevention and Control)
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Open AccessReview
Epigenetic Findings in Autism: New Perspectives for Therapy
Int. J. Environ. Res. Public Health 2013, 10(9), 4261-4273; https://doi.org/10.3390/ijerph10094261 - 11 Sep 2013
Cited by 36 | Viewed by 8475
Abstract
Autism and autism spectrum disorders (ASDs) are complex neurodevelopmental disorders characterized by dysfunctions in social interactions, communications, restricted interests, and repetitive stereotypic behaviors. Despite extensive genetic and biological research, significant controversy surrounds our understanding of the specific mechanisms of their pathogenesis. However, accumulating [...] Read more.
Autism and autism spectrum disorders (ASDs) are complex neurodevelopmental disorders characterized by dysfunctions in social interactions, communications, restricted interests, and repetitive stereotypic behaviors. Despite extensive genetic and biological research, significant controversy surrounds our understanding of the specific mechanisms of their pathogenesis. However, accumulating evidence points to the involvement of epigenetic modifications as foundational in creating ASD pathophysiology. Epigenetic modifications or the alteration of DNA transcription via variations in DNA methylation and histone modifications but without alterations in the DNA sequence, affect gene regulation. These alterations in gene expression, obtained through DNA methylation and/or histone modifications, result from transcriptional regulatory influences of environmental factors, such as nutritional deficiencies, various toxicants, immunological effects, and pharmaceuticals. As such these effects are epigenetic regulators which determine the final biochemistry and physiology of the individual. In contrast to psychopharmacological interventions, bettering our understanding of how these gene-environmental interactions create autistic symptoms should facilitate the development of therapeutic targeting of gene expression for ASD biomedical care. Full article
(This article belongs to the Special Issue The Environment Risk of Autism)
Open AccessArticle
Interference in Pheromone-Responsive Conjugation of a High-Level Bacitracin Resistant Enterococcus faecalis Plasmid of Poultry Origin
Int. J. Environ. Res. Public Health 2013, 10(9), 4245-4260; https://doi.org/10.3390/ijerph10094245 - 11 Sep 2013
Cited by 2 | Viewed by 3004
Abstract
The current study reports on contact interference of a high-level bacitracin- resistant pheromone-responsive plasmid of Enterococcus faecalis strain 543 of poultry origin during conjugative transfer of bcr antimicrobial resistance genes using a polyclonal antiserum aggregation substance44–560 (AS). After induction with pheromones produced [...] Read more.
The current study reports on contact interference of a high-level bacitracin- resistant pheromone-responsive plasmid of Enterococcus faecalis strain 543 of poultry origin during conjugative transfer of bcr antimicrobial resistance genes using a polyclonal antiserum aggregation substance44–560 (AS). After induction with pheromones produced by the recipient strain E. faecalis JH2-2, clumping of the donor E. faecalis strain 543 was observed as well as high transfer frequencies of bcr in short time broth mating. Filter mating assays from donor strain E. faecalis 543 to the recipient strain E. faecalis JH2-2 revealed conjugative transfer of asa1 (AS), bcrRAB and traB (negative regulator pheromone response) genes. The presence of these genes in transconjugants was confirmed by antimicrobial susceptibility testing, PCR, Southern hybridization and sequencing. A significant reduction in formation of aggregates was observed when the polyclonal anti-AS44–560 was added in the pheromone-responsive conjugation experiments as compared to the induced state. Moreover, interference of anti-AS44–560 antibodies in pheromone-responsive conjugation was demonstrated by a reduction in horizontal transfer of asa1 and bcr genes between E. faecalis strain 543 and E. faecalis JH2-2. Reducing the pheromone-responsive conjugation of E. faecalis is of interest because of its clinical importance in the horizontal transfer of antimicrobial resistance. Full article
(This article belongs to the Special Issue Antimicrobial Resistance Prevention and Control)
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Open AccessReview
Achieving Smoke-Free Mental Health Services: Lessons from the Past Decade of Implementation Research
Int. J. Environ. Res. Public Health 2013, 10(9), 4224-4244; https://doi.org/10.3390/ijerph10094224 - 10 Sep 2013
Cited by 54 | Viewed by 4387
Abstract
The culture of smoking by patients and staff within mental health systems of care has a long and entrenched history. Cigarettes have been used as currency between patients and as a patient management tool by staff. These settings have traditionally been exempt from [...] Read more.
The culture of smoking by patients and staff within mental health systems of care has a long and entrenched history. Cigarettes have been used as currency between patients and as a patient management tool by staff. These settings have traditionally been exempt from smoke-free policy because of complex held views about the capacity of people with mental disorder to tolerate such policy whilst they are acutely unwell, with stakeholders’ continuing fierce debate about rights, choice and duty of care. This culture has played a significant role in perpetuating physical, social and economic smoking associated impacts experienced by people with mental disorder who receive care within mental health care settings. The past decade has seen a clear policy shift towards smoke-free mental health settings in several countries. While many services have been successful in implementing this change, many issues remain to be resolved for genuine smoke-free policy in mental health settings to be realized. This literature review draws on evidence from the international published research, including national audits of smoke-free policy implementation in mental health units in Australia and England, in order to synthesise what we know works, why it works, and the remaining barriers to smoke-free policy and how appropriate interventions are provided to people with mental disorder. Full article
(This article belongs to the Special Issue Tobacco Control in Vulnerable Population Groups)
Open AccessReview
A Review of Vaccine Approaches for West Nile Virus
Int. J. Environ. Res. Public Health 2013, 10(9), 4200-4223; https://doi.org/10.3390/ijerph10094200 - 10 Sep 2013
Cited by 21 | Viewed by 3614
Abstract
The West Nile virus (WNC) first appeared in North America in 1999. The North American lineages of WNV were characterized by the presence of neuroinvasive and neurovirulent strains causing disease and death in humans, birds and horses. The 2012 WNV season in the [...] Read more.
The West Nile virus (WNC) first appeared in North America in 1999. The North American lineages of WNV were characterized by the presence of neuroinvasive and neurovirulent strains causing disease and death in humans, birds and horses. The 2012 WNV season in the United States saw a massive spike in the number of neuroinvasive cases and deaths similar to what was seen in the 2002–2003 season, according to the West Nile virus disease cases and deaths reported to the CDC by year and clinical presentation, 1999–2012, by ArboNET (Arboviral Diseases Branch, Centers for Disease Control and Prevention). In addition, the establishment and recent spread of lineage II WNV virus strains into Western Europe and the presence of neurovirulent and neuroinvasive strains among them is a cause of major concern. This review discusses the advances in the development of vaccines and biologicals to combat human and veterinary West Nile disease. Full article
(This article belongs to the Special Issue Epidemiology of West Nile Virus)
Open AccessArticle
Gold Standard Program for Heavy Smokers in a Real-Life Setting
Int. J. Environ. Res. Public Health 2013, 10(9), 4186-4199; https://doi.org/10.3390/ijerph10094186 - 09 Sep 2013
Cited by 26 | Viewed by 3044
Abstract
Background: High-intensity smoking cessation programs generally lead to more continuous abstinence, however, lower rates of success have been reported among heavy smokers. The aim was to evaluate continuous abstinence among heavy smokers during the intensive 6-week Gold Standard Program (GSP) and to [...] Read more.
Background: High-intensity smoking cessation programs generally lead to more continuous abstinence, however, lower rates of success have been reported among heavy smokers. The aim was to evaluate continuous abstinence among heavy smokers during the intensive 6-week Gold Standard Program (GSP) and to identify modifiable factors associated with continuous abstinence. Methods: In this nationwide clinical study based on 36,550 smokers attending an intensive cessation program in Denmark. Heavy smoking was defined as ≥7 points in the Fagerström Nicotine Dependency Test, smoking ≥20 cigarettes daily or ≥20 pack-years. Results: Overall, 28% had a Fagerström score ≥7 points, 58% smoked ≥20 cigarettes daily and 68% smoked ≥20 pack-years. Continuous abstinence was 33% in responders (6-months response rate: 78%); however, abstinence was approximately 1–6% lower in the heavy smokers than the overall population. Attending GSP with an individual format (vs. group/other, OR 1.23–1.44); in a hospital setting (vs. pharmacy/municipality services, OR 1.05–1.11); and being compliant (attending the planned meetings OR 4.36–4.89) were associated with abstinence. Abstinence decreased in a dose-dependent manner with increasing smoking severity. Conclusions: Abstinence after GSP was 1–6% lower in the heavy smokers than in the overall study population. Modifiable factors may be used for small improvements in continued abstinence. However attempts to improve compliance seemed especially promising. Full article
(This article belongs to the Special Issue Tobacco Control in Vulnerable Population Groups)
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Open AccessArticle
Racial Differences in Survival among Hemodialysis Patients after Coronary Artery Bypass Grafting
Int. J. Environ. Res. Public Health 2013, 10(9), 4175-4185; https://doi.org/10.3390/ijerph10094175 - 06 Sep 2013
Cited by 6 | Viewed by 2658
Abstract
The aim of this study was to examine racial differences in long-term survival among hemodialysis patients after coronary artery bypass grafting (CABG). To our knowledge this has not been previously addressed in the literature. Black and white hemodialysis patients undergoing first-time, isolated CABG [...] Read more.
The aim of this study was to examine racial differences in long-term survival among hemodialysis patients after coronary artery bypass grafting (CABG). To our knowledge this has not been previously addressed in the literature. Black and white hemodialysis patients undergoing first-time, isolated CABG procedures between 1992 and 2011 were compared. Survival probabilities were computed using the Kaplan-Meier product-limit method and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model. A total of 207 (2%) patients were on hemodialysis at the time of CABG. White (n = 80) hemodialysis patients had significantly decreased 5-year survival compared with black (n = 127) patients (adjusted HR = 1.9, 95% CI = 1.2–2.8). Our finding provides useful outcome information for surgeons, primary care providers, and their patients. Full article
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Open AccessArticle
Mapping Disease at an Approximated Individual Level Using Aggregate Data: A Case Study of Mapping New Hampshire Birth Defects
Int. J. Environ. Res. Public Health 2013, 10(9), 4161-4174; https://doi.org/10.3390/ijerph10094161 - 06 Sep 2013
Cited by 4 | Viewed by 3259
Abstract
Background: Limited by data availability, most disease maps in the literature are for relatively large and subjectively-defined areal units, which are subject to problems associated with polygon maps. High resolution maps based on objective spatial units are needed to more precisely detect associations [...] Read more.
Background: Limited by data availability, most disease maps in the literature are for relatively large and subjectively-defined areal units, which are subject to problems associated with polygon maps. High resolution maps based on objective spatial units are needed to more precisely detect associations between disease and environmental factors. Method: We propose to use a Restricted and Controlled Monte Carlo (RCMC) process to disaggregate polygon-level location data to achieve mapping aggregate data at an approximated individual level. RCMC assigns a random point location to a polygon-level location, in which the randomization is restricted by the polygon and controlled by the background (e.g., population at risk). RCMC allows analytical processes designed for individual data to be applied, and generates high-resolution raster maps. Results: We applied RCMC to the town-level birth defect data for New Hampshire and generated raster maps at the resolution of 100 m. Besides the map of significance of birth defect risk represented by p-value, the output also includes a map of spatial uncertainty and a map of hot spots. Conclusions: RCMC is an effective method to disaggregate aggregate data. An RCMC-based disease mapping maximizes the use of available spatial information, and explicitly estimates the spatial uncertainty resulting from aggregation. Full article
(This article belongs to the Special Issue Spatial Epidemiology)
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Open AccessArticle
An Evaluation of Microbial and Chemical Contamination Sources Related to the Deterioration of Tap Water Quality in the Household Water Supply System
Int. J. Environ. Res. Public Health 2013, 10(9), 4143-4160; https://doi.org/10.3390/ijerph10094143 - 06 Sep 2013
Cited by 15 | Viewed by 3251
Abstract
The predominant microorganisms in samples taken from shower heads in residences in the Korean city “N” were Stenotrophomonas maltophilia, Sphingomonas paucimobilis, Acidovorax temperans, and Microbacterium lacticum. Legionella was not detected in this case. The volatile organic compounds [...] Read more.
The predominant microorganisms in samples taken from shower heads in residences in the Korean city “N” were Stenotrophomonas maltophilia, Sphingomonas paucimobilis, Acidovorax temperans, and Microbacterium lacticum. Legionella was not detected in this case. The volatile organic compounds (VOCs) vinylacetate, NN-DMA, cis-1,2-dichloroethylene, epichlorohydrin, and styrene were measured in five types of plastic pipes: PVC, PB, PP, PE, and cPVC. The rate of multiplication of the heterotrophic plate count (HPC) attached on the copper pipe in contact with hot tap water was higher than the rate for the copper pipe in contact with cold tap water. Biofilm accumulation on stainless steel pipes with added acetate (3 mg/L) was 2.56 times higher than the non-supplemented condition. Therefore, the growth of HPC in the pipe system was affected by the type and availability of nutrients and depended on variables such as heating during the hot water supply. Full article
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Open AccessArticle
The Performance of Children Prenatally Exposed to HIV on the A-Not-B Task in Kilifi, Kenya: A Preliminary Study
Int. J. Environ. Res. Public Health 2013, 10(9), 4132-4142; https://doi.org/10.3390/ijerph10094132 - 04 Sep 2013
Cited by 8 | Viewed by 2867
Abstract
The aim of the study was to investigate early executive functioning in young children from 6–35 months of age. The study involved 319 randomly selected children from the community, 17 HIV exposed but uninfected children and 31 HIV infected ARV-naive children. A variation [...] Read more.
The aim of the study was to investigate early executive functioning in young children from 6–35 months of age. The study involved 319 randomly selected children from the community, 17 HIV exposed but uninfected children and 31 HIV infected ARV-naive children. A variation of the A-not-B task was used. While there were no group differences in total correct, perseverative errors, nor maximum error run, a significant percentage of children were unable to complete the task as a consequence of the children becoming overtly distressed or refusing to continue. In a multivariate analysis we observed that the significant predictors of non-completion were HIV exposure (both infected and exposed) and being under 24 months of age. These patterns of results indicate that future work with a broader array of tasks need to look at the association of HIV and EF tasks and potential contribution of factors such as emotion regulation, persistence and motivation on performance on EF tasks. Full article
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Open AccessArticle
Asthma Associations in Children Attending a Museum of Science
Int. J. Environ. Res. Public Health 2013, 10(9), 4117-4131; https://doi.org/10.3390/ijerph10094117 - 04 Sep 2013
Cited by 2 | Viewed by 2901
Abstract
We explored the relative strength of environmental and social factors associated with pediatric asthma in middle class families and considered the efficacy of recruitment for an educational study at a science museum. Eligibility criteria were having a child aged 4–12 and English fluency. [...] Read more.
We explored the relative strength of environmental and social factors associated with pediatric asthma in middle class families and considered the efficacy of recruitment for an educational study at a science museum. Eligibility criteria were having a child aged 4–12 and English fluency. Our questionnaire included information on demographics, home environment, medical history, and environmental toxicant exposures. Statistically significant associations were found for: child’s age (t = −2.46; p = 0.014), allergies (OR = 11.5; 95%CI = 5.9–22.5), maternal asthma (OR = 2.2; 95%CI = 1.2–3.9), parents’ education level (OR = 0.5; 95%CI = 0.3–0.9), family income (OR = 2.4; 95%CI = 1.1–5.5), water damage at home (OR = 2.5; 95%CI = 1.1–5.5), stuffed animals in bedroom (OR = 0.4; 95%CI = 0.2–0.7), hospitalization within a week after birth (OR = 3.2; 95%CI = 1.4–7.0), diagnosis of pneumonia (OR = 2.8; 95%CI = 1.4–5.9), and multiple colds in a year (OR = 2.9; 95%CI = 1.5–5.7). Several other associations approached statistical significance, including African American race (OR = 3.3; 95%CI = 1.0–10.7), vitamin D supplement directive (OR = 0.2; 95%CI = 0.02–1.2), mice in the home (OR = 0.5, 95%CI = 0.2–1.1), and cockroaches in the home (OR = 4.3; CI = 0.8–21.6). In logistic regression, age, parents’ education, allergies, mold allergies, hospitalization after birth, stuffed animals in the bedroom, vitamin D supplement directive, and water damage in the home were all significant independent predictors of asthma. The urban science museum was a low-resource approach to address the relative importance of risk factors in this population. Full article
Open AccessArticle
Tobacco Use and Environmental Smoke Exposure among Taiwanese Pregnant Smokers and Recent Quitters: Risk Perception, Attitude, and Avoidance Behavior
Int. J. Environ. Res. Public Health 2013, 10(9), 4104-4116; https://doi.org/10.3390/ijerph10094104 - 03 Sep 2013
Cited by 15 | Viewed by 3179
Abstract
In this study, we conducted an empirical survey of the avoidance behaviors and risk perceptions of active and passive smoking pregnant smokers and recent quitters. We employed an online questionnaire survey by recruiting 166 voluntary participants from an online parenting community in Taiwan. [...] Read more.
In this study, we conducted an empirical survey of the avoidance behaviors and risk perceptions of active and passive smoking pregnant smokers and recent quitters. We employed an online questionnaire survey by recruiting 166 voluntary participants from an online parenting community in Taiwan. The results of the empirical survey revealed that three-fourths of smokers quit smoking during pregnancy and one-fourth continued smoking. All pregnant women who continued smoking had partners or lived with relatives who smoked. Current smokers and quitters differed significantly in their risk perceptions and attitudes toward smoking during pregnancy. Most pregnant smokers and quitters adopted passive smoking avoidance behaviors at home and in public. Nevertheless, one-fifth of pregnant women chose not to avoid passive smoking. We concluded that most women stop smoking during pregnancy; however, most women continue to be exposed to passive-smoking environments. Perceived fetal health risks and attitudes toward smoking during pregnancy are critical predictors of the anti-smoking behaviors of pregnant women. Full article
(This article belongs to the Special Issue Tobacco Control in Vulnerable Population Groups)
Open AccessArticle
Green Space and Stress: Evidence from Cortisol Measures in Deprived Urban Communities
Int. J. Environ. Res. Public Health 2013, 10(9), 4086-4103; https://doi.org/10.3390/ijerph10094086 - 02 Sep 2013
Cited by 174 | Viewed by 13970
Abstract
Contact with green space in the environment has been associated with mental health benefits, but the mechanism underpinning this association is not clear. This study extends an earlier exploratory study showing that more green space in deprived urban neighbourhoods in Scotland is linked [...] Read more.
Contact with green space in the environment has been associated with mental health benefits, but the mechanism underpinning this association is not clear. This study extends an earlier exploratory study showing that more green space in deprived urban neighbourhoods in Scotland is linked to lower levels of perceived stress and improved physiological stress as measured by diurnal patterns of cortisol secretion. Salivary cortisol concentrations were measured at 3, 6 and 9 h post awakening over two consecutive weekdays, together with measures of perceived stress. Participants (n = 106) were men and women not in work aged between 35–55 years, resident in socially disadvantaged districts from the same Scottish, UK, urban context as the earlier study. Results from linear regression analyses showed a significant and negative relationship between higher green space levels and stress levels, indicating living in areas with a higher percentage of green space is associated with lower stress, confirming the earlier study findings. This study further extends the findings by showing significant gender differences in stress patterns by levels of green space, with women in lower green space areas showing higher levels of stress. A significant interaction effect between gender and percentage green space on mean cortisol concentrations showed a positive effect of higher green space in relation to cortisol measures in women, but not in men. Higher levels of neighbourhood green space were associated with healthier mean cortisol levels in women whilst also attenuating higher cortisol levels in men. We conclude that higher levels of green space in residential neighbourhoods, for this deprived urban population of middle-aged men and women not in work, are linked with lower perceived stress and a steeper (healthier) diurnal cortisol decline. However, overall patterns and levels of cortisol secretion in men and women were differentially related to neighbourhood green space and warrant further investigation. Full article
(This article belongs to the Special Issue Health Benefits of Nature)
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Open AccessArticle
Food Safety in Home Kitchens: A Synthesis of the Literature
Int. J. Environ. Res. Public Health 2013, 10(9), 4060-4085; https://doi.org/10.3390/ijerph10094060 - 02 Sep 2013
Cited by 71 | Viewed by 6452
Abstract
Although foodborne illness is preventable, more than 56,000 people per year become ill in the U.S., creating high economic costs, loss of productivity and reduced quality of life for many. Experts agree that the home is the primary location where foodborne outbreaks occur; [...] Read more.
Although foodborne illness is preventable, more than 56,000 people per year become ill in the U.S., creating high economic costs, loss of productivity and reduced quality of life for many. Experts agree that the home is the primary location where foodborne outbreaks occur; however, many consumers do not believe the home to be a risky place. Health care professionals need to be aware of consumers’ food safety attitudes and behaviors in the home and deliver tailored food safety interventions that are theory-based. Thus, the purpose of this paper is to synthesize/summarize the food safety literature by examining the following: consumers’ perceptions and attitudes towards food safety and their susceptibility to foodborne illness in the home, work, and school; common risky food safety practices and barriers to handling food safely; and the application of theory-based food safety interventions. Findings will help healthcare professionals become more aware of consumers’ food safety attitudes and behaviors and serve to inform future food safety interventions. Full article
(This article belongs to the Special Issue Food Safety and Public Health)
Open AccessReview
Using Inequality Measures to Incorporate Environmental Justice into Regulatory Analyses
Int. J. Environ. Res. Public Health 2013, 10(9), 4039-4059; https://doi.org/10.3390/ijerph10094039 - 30 Aug 2013
Cited by 13 | Viewed by 3762
Abstract
Formally evaluating how specific policy measures influence environmental justice is challenging, especially in the context of regulatory analyses in which quantitative comparisons are the norm. However, there is a large literature on developing and applying quantitative measures of health inequality in other settings, [...] Read more.
Formally evaluating how specific policy measures influence environmental justice is challenging, especially in the context of regulatory analyses in which quantitative comparisons are the norm. However, there is a large literature on developing and applying quantitative measures of health inequality in other settings, and these measures may be applicable to environmental regulatory analyses. In this paper, we provide information to assist policy decision makers in determining the viability of using measures of health inequality in the context of environmental regulatory analyses. We conclude that quantification of the distribution of inequalities in health outcomes across social groups of concern, considering both within-group and between-group comparisons, would be consistent with both the structure of regulatory analysis and the core definition of environmental justice. Appropriate application of inequality indicators requires thorough characterization of the baseline distribution of exposures and risks, leveraging data generally available within regulatory analyses. Multiple inequality indicators may be applicable to regulatory analyses, and the choice among indicators should be based on explicit value judgments regarding the dimensions of environmental justice of greatest interest. Full article
(This article belongs to the Special Issue Inequalities in Health)
Open AccessArticle
Prevalence of Mycobacterium avium in Slaughter Pigs Based on Serological Monitoring Results and Bacteriological Validation
Int. J. Environ. Res. Public Health 2013, 10(9), 4027-4038; https://doi.org/10.3390/ijerph10094027 - 30 Aug 2013
Cited by 4 | Viewed by 3054
Abstract
Mycobacterium avium (MA) is a potential food safety hazard in pigs. Blood samples of slaughtered pigs in the Netherlands and Germany were tested for the presence of MA antibodies to estimate the serological prevalence in the tested population. In the Dutch and German [...] Read more.
Mycobacterium avium (MA) is a potential food safety hazard in pigs. Blood samples of slaughtered pigs in the Netherlands and Germany were tested for the presence of MA antibodies to estimate the serological prevalence in the tested population. In the Dutch and German population 1.0% and 1.7% samples were positive, and 0.5% and 17.4% of the herds were at risk for having a MA infection respectively. The validity of the applied MA-ELISA was evaluated under field conditions. The specificity of the MA-ELISA was high (>98.4%). The average herd sensitivity was 18%. In the affected herds on average 50% of the animals were tested bacteriological positive for MA. It can be concluded that serological screening for the presence of MA antibodies is capable of identifying pig populations that are at risk for a MA infection. Full article
(This article belongs to the Special Issue Food Safety and Public Health)
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Open AccessArticle
Perception of Tourists Regarding the Smoke-Free Policy at Suvarnabhumi International Airport, Bangkok, Thailand
Int. J. Environ. Res. Public Health 2013, 10(9), 4012-4026; https://doi.org/10.3390/ijerph10094012 - 30 Aug 2013
Cited by 2 | Viewed by 3106
Abstract
This study was conducted during February-March 2012 to determine the perception and support regarding smoke-free policy among tourists at Suvarnabhumi International Airport, Bangkok, Thailand. In this cross-sectional study, 200 tourists (n = 200) were enrolled by convenience sampling and interviewed by structured [...] Read more.
This study was conducted during February-March 2012 to determine the perception and support regarding smoke-free policy among tourists at Suvarnabhumi International Airport, Bangkok, Thailand. In this cross-sectional study, 200 tourists (n = 200) were enrolled by convenience sampling and interviewed by structured questionnaire. Descriptive statistics, chi-square, and multinomial logistic regression were adopted in the study. Results revealed that half (50%) of the tourists were current smokers and 55% had visited Thailand twice or more. Three quarter (76%) of tourists indicated that they would visit Thailand again even if it had a 100% smoke-free regulation. Almost all (99%) of the tourists had supported for the smoke-free policy (partial ban and total ban), and current smokers had higher percentage of support than non-smokers. Two factors, current smoking status and knowledge level, were significantly associated with perception level. After analysis with Multinomial Logistic Regression, it was found that perception, country group, and presence of designated smoking room (DSR) were associated with smoke-free policy. Recommendation is that, at institution level effective monitoring system is needed at the airport. At policy level, the recommendation is that effective comprehensive policy needed to be emphasized to ensure smoke-free airport environment. Full article
(This article belongs to the Special Issue Tobacco Control in Vulnerable Population Groups)
Open AccessArticle
The Patient’s Perspective of in-Home Telerehabilitation Physiotherapy Services Following Total Knee Arthroplasty
Int. J. Environ. Res. Public Health 2013, 10(9), 3998-4011; https://doi.org/10.3390/ijerph10093998 - 30 Aug 2013
Cited by 25 | Viewed by 4511
Abstract
This study aimed at exploring patients’ perceptions regarding telerehabilitation services received post total knee replacement. In this qualitative embedded single case study, semi-structured interviews were conducted with five patients who had previously received in-home telerehabilitation post total knee arthroplasty. Participants were asked to [...] Read more.
This study aimed at exploring patients’ perceptions regarding telerehabilitation services received post total knee replacement. In this qualitative embedded single case study, semi-structured interviews were conducted with five patients who had previously received in-home telerehabilitation post total knee arthroplasty. Participants were asked to reflect on their 8-week rehabilitation process and on their experience with the home telerehabilitation program. Interviews were transcribed and a qualitative thematic analysis was conducted. Six overarching themes emerged from the patients’ perceptions: (1) improving access to services with reduced need for transportation; (2) developing a strong therapeutic relationship with therapist while maintaining a sense of personal space; (3) complementing telerehabilitation with in-person visits; (4) providing standardized yet tailored and challenging exercise programs using telerehabilitation; (5) perceived ease-of-use of telerehabilitation equipment; and (6) feeling an ongoing sense of support. Gaining a better understating of the patient’s experience in telerehabilitation will be essential as programs continue to be developed and implemented. Full article
(This article belongs to the Special Issue Advances in Telehealthcare)
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Open AccessArticle
Association between Metabolic Syndrome and Chronic Kidney Disease in Perimenopausal Women
Int. J. Environ. Res. Public Health 2013, 10(9), 3987-3997; https://doi.org/10.3390/ijerph10093987 - 30 Aug 2013
Cited by 10 | Viewed by 3323
Abstract
The purpose of the study was to explore the association between metabolic syndrome (MetS) and chronic kidney disease (CKD) in perimenopausal women. A cross-sectional study was conducted in Zhuhai from June to October 2012. Perimenopausal women (n = 685) were included in the [...] Read more.
The purpose of the study was to explore the association between metabolic syndrome (MetS) and chronic kidney disease (CKD) in perimenopausal women. A cross-sectional study was conducted in Zhuhai from June to October 2012. Perimenopausal women (n = 685) were included in the study. All participants were divided into three subgroups: Group 1, 40 years old ≤ Age < 50 years old; Group 2, 50 years old ≤ Age < 60 years old; Group 3, 60 years old ≤ Age ≤ 65 years old. MetS was associated with CKD (p < 0.01) in the unadjusted analyses in total subjects. After adjusting the potential confounders, the odd ratios of CKD for MetS was 2.66 (95% CI 1.56 to 4.49, p < 0.001). There was no relationship between MetS and CKD in both Group 1 and Group 3. MetS was associated with CKD (p < 0.001) in the unadjusted analyses in Group 2. After adjusting for potential confounders, MetS was significantly associated with CKD. The odd ratios for MetS was 6.79 (95% CI 2.30 to 20.09, p < 0.001). There was no relationship between elevated blood pressure, elevated fasting glucose, abdominal obesity, Low HDL cholesterol, elevated triglycerides and CKD in both Group 1 and Group 3. Elevated blood pressure was associated with CKD in Group 2 (unadjusted Odds ratio: 4.52 (1.28–16.02), p = 0.02). After adjusting for potential confounders, there was no relationship between elevated blood pressure and CKD (p = 0.78). Elevated fasting glucose was associated with CKD in Group 2 (unadjusted Odds ratio: 3.69 (1.10–12.38), p = 0.03). After adjusting for potential confounders, there was no relationship between elevated fasting glucose and CKD (p = 0.15). There was no relationship between abdominal obesity, Low HDL cholesterol, elevated triglycerides and CKD in Group 2. These findings suggest that in perimenopausal women aged from 50 or older to 60 MetS was associated with CKD. There is no relationship between MetS and CKD in perimenopausal women aged from 40 or older to 50 and aged from 60 or older to 65. Full article
Open AccessArticle
The Physical Activity Scale for the Elderly (PASE) Questionnaire; Does It Predict Physical Health?
Int. J. Environ. Res. Public Health 2013, 10(9), 3967-3986; https://doi.org/10.3390/ijerph10093967 - 30 Aug 2013
Cited by 21 | Viewed by 5755
Abstract
A lack of physical activity is common in older adults. With the increasing Canadian senior population, identifying the minimum amount of physical activity required to maintain the health of older adults is essential. This study determined whether relationships existed between the Physical Activity [...] Read more.
A lack of physical activity is common in older adults. With the increasing Canadian senior population, identifying the minimum amount of physical activity required to maintain the health of older adults is essential. This study determined whether relationships existed between the Physical Activity Scale for the Elderly (PASE) questionnaire scores and health-related measurements in community-dwelling older adults who were meal delivery volunteers. Based on observed relationships between PASE scores and health parameters, the study attempted to predict an optimal PASE score that would ensure health parameters fell in desired ranges for older adults. 297 community-dwelling older adults (61.3% female) 60–88 years (72.1 ± 6.5) completed the PASE and were measured for body composition, cardiovascular and blood parameters, flexibility, and handgrip strength. Significant regression models using PASE were produced for the health-related measures, but the relationships were not meaningful due to low predictive capacity. However, correlational data suggested that a minimum PASE score of ~140 for males and ~120 for females predicted a favorable waist circumference. In conclusion, findings demonstrated that PASE scores cannot be used to predict healthy physical measures, although the relationships between PASE and WC could be used to encourage older adults to become more physically active. Full article
(This article belongs to the Special Issue Health Care for Old People)
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