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This paper examines the association between US county occupational structure, services availability, prevalence of risk factors, and coronary mortality rates by sex and race, for 1984-1998. The 3137 US counties were classified into five occupational structure categories; counties with the lowest percentages of the labor force in managerial, professional, and technical occupations were classified in category I (5-16%), counties with the highest percentages were in category V (32-59%). Directly age-adjusted coronary heart disease (CHD) mortality rates, for aged 35-64 years, (from vital statistics and Census data), per-capita services (County Business Patterns), and the prevalence of CHD risk factors (Behavioral Risk Factor Surveillance Surveys data) were calculated for each occupational structure category. CHD mortality rates and the prevalence of risk factors were inversely monotonically associated with occupational structure categories for white men and women but not among black men and women. Numbers of producer services for banking, business credit, overall business services and personnel/employment services were 2-12 times greater in category V versus I counties. Consumer services such as fruit/vegetable markets, fitness facilities, doctor offices and social services were 1.6-3 times greater in category V versus I counties. Residential racial segregation scores remained high in most areas despite declines during 1980-1990; occupational segregation by race and gender were shown indicating continued institutional racism. An ecological model for conceptualizing communities and health and the overall influence of state and national occupational structure is discussed; intervention strategies such as decreased wage disparities and 'living wage' standards and development is discussed. Keywords: Coronary heart disease: Community health: Social class; US counties

Smoking is known to raise blood pressure while the cigarette is smoked and for 20 to 30 minutes afterwards, but the blood pressure of smokers and nonsmokers as measured in the physician's office is similar. To determine whether the blood pressure in everyday life of smokers is higher than that of nonsmokers, a review was carried out of the medical records of 59 cigarette smokers and 118 nonsmokers (the groups were matched for age, sex, race, and weight). All subjects had hypertension (elevated blood pressure) but were not taking antihypertensive medication. These patients had undergone 24-hour blood-pressure monitoring while carrying on their activities as usual; at regular intervals, their blood pressure was measured with a special inflatable device. Patients kept activity diaries so that the relationship between blood pressure and activity could be determined; smoking was not systematically recorded. Results showed no differences in blood pressure between the two groups (smokers, 141/93 mm Hg; nonsmokers, 142/93) when blood pressure was taken at the office. However, the systolic value (top number of a blood-pressure measurement, reflecting the arterial pressure as the heart contracts) during awake periods was significantly higher for smokers (145.0) than for nonsmokers (140.4). No differences in systolic values with respect to smoking status were seen during sleep, or in diastolic values (the bottom number) during sleep or wakefulness. The difference noted between smokers and nonsmokers in systolic blood pressure was only present in smokers 50 years of age or older. The higher blood pressure levels in smokers during the day are probably the result of smoking cigarettes, but the fact that the effect was confined to older subjects suggests that other factors besides the physiological effects of nicotine are operative. (Consumer Summary produced by Reliance Medical Information, Inc.)

Responds to comments on the article 'Evaluation of Ambulatory Systolic Blood Pressure in Hypertensive Smokers: A Case-Control Study,' published in a 1991 issue of the 'Journal of the American Medical Association.'

Background: Oronasal fistulas (ONF) following cleft palate repair are commonly encountered and remain a challenging problem. With reported recurrence rates between 33% and 37%, this urges us to critically evaluate the current treatment and propose a surgical management protocol., Methods: A retrospective study of patients treated for ONF by a single surgeon between 1995 and 2005 was performed. Data regarding cleft type, age at palate repair, complications, location and size of fistula, tissue condition, surgical technique employed, and success rate were gathered., Results: There were 64 patients (33 male and 31 female), and 44% of them had bilateral cleft lip and palate. Hypernasality and regurgitation were the major presenting symptoms of these patients with ONF. Fistulas mostly occurred in the hard palate area (53.1%). Severe scarring surrounding the ONF was reported in 31.2% of patients. Local flap and two-flap palatoplasty were the most common techniques (62.5%) used for closure of the ONF. Twenty-five percent of patients needed more than one repair to close the fistula. However, the overall success rate of closure was high (90.5%). Velopharyngeal (VP) function was significantly improved: only 26.8% of patients had adequate VP function before ONF closure and 64.3% patients had adequate VP function after ONF closure. However, the VP function of twenty patients remained inadequate or marginal., Conclusions: A high success rate was achieved for closure of cleft ONF, although a certain percentage of patients required re-operation. Multiple fistulas and severely scarred palates made closure difficult. Successful closure of a fistula improved VP function but VP surgery was still indicated in certain patients. Based on the findings, an algorithm for management of cleft ONF was proposed.