Known since 1885 but studied systematically only in the past four decades, the healthy worker effect (HWE) is a special form of selection bias common to occupational cohort studies. The phenomenon has been under debate for many years with respect to its impact, conceptual approach (confounding, selection bias, or both), and ways to resolve or account for its effect. The effect is not uniform across age groups, gender, race, and types of occupations and nor is it constant over time. Hence, assessing HWE and accounting for it in statistical analyses is complicated and requires sophisticated methods. Here, we review the HWE, factors affecting it, and methods developed so far to deal with it.

The incidence of opioid prescription at discharge (54.3%) closely matches the incidence of moderate to severe pain in trauma patients, indicating appropriate prescribing practices. We advocate that injury severity and level of pain-not arbitrary regulations-should inform the decision to prescribe opioids.

Introduction: In a populous city like Mumbai, which lacks an organized prehospital emergency medical services (EMS) system, there exists an informal network through which victims arrive at the trauma center. This baseline study describes the prehospital care and transportation that currently is available in Mumbai. Methods: A prospective trauma database was created by interviewing 170 randomly selected patients from a total of 454 admitted over a two-month period (July-August 2005) at a Level-I, urban, trauma center. Results: The injured victim in Mumbai usually is rescued by a good Samaritan passer-by (43.5%) and contrary to popular belief, helped by the police (89.7%). Almost immediately after rescue, the victim begins transport to the hospital. No one waits for the EMS ambulance to arrive, as there is none. A taxi cab is the most popular substitute for the ambulance (39.3%). The trauma patient in India usually is a young man in his late-twenties, from a lower socioeconomic class. He mostly finds himself in a government hospital, as private hospitals are reluctant to provide trauma care to the seriously injured. The injured who do receive prehospital care receive inadequate and inappropriate care due to the high cost of consumables in resuscitation, and in part due to the providers' lack of training in emergency care. Those who were more likely to receive prehospital care suffered from road traffic injuries (odds ratio (OR) = 2.3) and those transported by government ambulances (OR = 10.83), as compared to railway accident victims (OR = 0 .41) and those who came by taxi (OR = 0.54). Conclusions: Currendy, as a result of not having an EMS system, prehospital care is a citizen responsibility using societal networks. It is easy to eliminate this system and shift the responsibility to the state. The moot point is whether the state-funded EMS system will be robust enough in a resource-poor setting in which public hospitals are poorly funded. Considering the high funding cost of EMS systems in developed countries and the insufficient evidence that prehospital field interventions by the EMS actually have improved outcomes, Mumbai must proceed with caution when implementing advanced EMS systems into its congested urban traffic. Similar cities, such as Mexico City and Jakarta, have had limited success with implementing EMS systems. Perhaps reinforcing the existing network of informal providers of taxi drivers and police and with training, funding quick transport with taxes on roads and automobile fuels and regulating the private ambulance providers, could be more cost-effective in a culture in which sharing and helping others is not just desirable, but is necessary for overall economic survival. Roy N, Murlidhar V, Chowdhury R, Patil SB, Supe PA, Vaishnav PD, Vatkar A: Where there are no emergency medical services-Prehospital care for the injured in Mumbai, India. Prehosp D«

Summary Objective Redox status and inflammation are important in the pathophysiology of numerous chronic diseases. Epidemiological studies have linked vitamin D status to a number of chronic diseases. We aimed to examine the relationships between serum 25-hydroxyvitamin D (25(OH)D) and circulating thiol/disulfide redox status and biomarkers of inflammation. Design This was a cross-sectional study of N=693 adults (449 females, 244 males) in an apparently healthy, working cohort in Atlanta, GA. Plasma glutathione (GSH), cysteine (Cys), and their associated disulfides were determined with high performance liquid chromatography, and their redox potentials (Eh GSSG and Eh CySS) were calculated using the Nernst equation. Serum inflammatory markers included interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-α, assayed on a multiplex platform; and C-reactive protein (CRP), assayed commercially. Relationships were assessed with multiple linear regression analyses. Results Serum 25(OH)D was positively associated with plasma GSH (β ± SE: 0.002 ± 0.0004) and negatively associated with plasma Eh GSSG (β ± SE: −0.06 ± 0.01) and Cys (β ± SE: −0.01 ± 0.003) (P<0.001 for all); statistical significance remained after adjusting for age, gender, and race, percent body fat, and traditional cardiovascular risk factors (P=0.01-0.02). The inverse relationship between serum 25(OH)D and CRP was confounded by percent body fat, and full adjustment for covariates attenuated serum 25(OH)D relationships with other inflammatory markers to non-statistical significance. Conclusions Serum 25(OH)D concentrations were independently associated with major plasma thiol/disulfide redox systems, suggesting that vitamin D status may be involved in redox-mediated pathophysiology.

BackgroundSupplemental melatonin may ameliorate metabolic syndrome (MetS) components, but data from placebo-controlled trials are lacking.MethodsWe conducted a double-blind, placebo-controlled, crossover, Phase II randomized pilot clinical trial to estimate the effects of melatonin supplementation on MetS components and the overall prevalence of MetS. We randomized 39 subjects with MetS to receive 8.0 mg oral melatonin or matching placebo nightly for 10 weeks. After a 6-week washout, subjects received the other treatment for 10 more weeks. We measured waist circumference, triglycerides, HDL cholesterol, fasting glucose, and blood pressure (BP) in each subject at the beginning and end of both 10-week treatment periods. The primary outcome was the mean 10-week change in each MetS component, and a secondary outcome was the proportion of subjects free from MetS, after melatonin versus placebo.ResultsThe mean 10-week change for most MetS components favored melatonin over placebo (except fasting glucose): waist circumference -0.9 vs. +1.0 cm (p = 0.15); triglycerides -66.3 vs. -4.2 mg/dL (p = 0.17); HDL cholesterol -0.2 vs. -1.1 mg/dL (p = 0.59); fasting glucose +0.3 vs. -3.1 mg/dL (p = 0.29); systolic BP -2.7 vs. +4.7 mmHg (p = 0.013); and diastolic BP -1.1 vs. +1.1 mmHg (p = 0.24). Freedom from MetS tended to be more common following melatonin versus placebo treatment (after the first 10 weeks, 35.3% vs. 15.0%, p = 0.25; after the second 10 weeks, 45.0% vs. 23.5%, p = 0.30). Melatonin was well-tolerated.ConclusionsMelatonin supplementation modestly improved most individual MetS components compared with placebo, and tended to increase the proportion of subjects free from MetS after treatment.Trial registrationNCT01038921, clinicaltrials.gov

Objective To examine geographic variation in motor vehicle crash (MVC)-related pediatric mortality and identify state-level predictors of mortality. Study design Using the 2010–2014 Fatality Analysis Reporting System, we identified passengers <15y involved in fatal MVCs, defined as crashes on U.S. public roads with ≥1 death (adult or pediatric) within 30d. We assessed passenger, driver, vehicle, crash, and state policy characteristics as factors potentially associated with MVC-related pediatric mortality. Our outcomes were age-adjusted, MVC-related mortality rate per 100,000 children (AAMR) and percentage of children that died of those in fatal MVCs. Unit of analysis was U.S. state. We used multivariable linear regression to define state characteristics associated with higher levels of each outcome. Results Of 18,116 children in fatal MVCs, 15.9% died. AAMR varied from 0.25 in Massachusetts to 3.23 in Mississippi (mean national rate=0.94). Predictors of greater AAMR included greater percentage of children unrestrained/inappropriately restrained (p<0.001) and greater percentage of crashes on rural roads (p=0.016). Additionally, greater percentages of children died in states without red light camera legislation (p<0.001). For 10% absolute improvement in appropriate child restraint use nationally, our risk-adjusted model predicted >1,100 pediatric deaths averted over 5y. Conclusions MVC-related pediatric mortality varied by state and was associated with restraint nonuse/misuse, rural roads, vehicle type, and red light camera policy. Revising state regulations and improving enforcement around these factors may prevent substantial pediatric mortality.

SummaryObjectiveThe aim of this study was to determine if the association with adiposity varies by the type (added vs. naturally occurring) and form (liquid vs. solid) of dietary sugars consumed.MethodsData from the 10‐year National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study (n = 2,021 girls aged 9–10 years at baseline; n = 5,156 paired observations) were used. Using mixed linear models, 1‐year changes in sugar intake, body mass index z‐score (BMIz) and waist circumference (WC) were assessed.ResultsThe results showed mean daily added sugar (AS) intake: 10.3 tsp (41 g) liquid; 11.6 tsp (46 g) solid and naturally occurring sugar intake: 2.6 tsp (10 g) liquid; 2.2 tsp (9 g) solid. Before total energy adjustment, each additional teaspoon of liquid AS was associated with a 0.222‐mm increase in WC (p = 0.0003) and a 0.002 increase in BMIz (p = 0.003). Each teaspoon of solid AS was associated with a 0.126‐mm increase in WC (p = 0.03) and a 0.001 increase in BMIz (p = 0.03). Adjusting for total energy, this association was maintained only between liquid AS and WC among all and between solid AS and WC among those overweight/obese only. There was no significant association with naturally occurring sugar.ConclusionsThese findings demonstrate to suggest a positive association between AS intake (liquid and solid) and BMI that is mediated by total energy intake and an association with WC that is independent of it.

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