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Asbestos manufacturing has been banned in the Czech Republic; however, about 280 workers in the 2nd-4th work category have been exposed during the remediation of asbestos, and the health consequences of the former use of asbestos will be apparent for many years. The incidence of mesothelioma in the Czech Republic is about 0.5/100,000 inhabitants, which places it among the lowest incidences of mesothelioma in Europe, and ranks the Czech Republic among the countries with the lowest rates in the world. The proportion of occupational mesotheliomas is only about one-tenth of these malignancies. These data show an underreporting of occupational cancers, most probably due to low awareness of the association of exposures more than 40 years ago with this disease. Physicians should focus more on the occupational history of these patients and refer them to the Departments of occupational diseases. Benefits are available for all patients with mesothelioma, in whom industrial hygienists confirm former exposure to asbestos, corresponding to the latency period.

By application of the real-time PCR we manage to confirm the diagnosis and occurrence of a disease, which is caused by Bordetella pertussis - pertussis. Using this method we have proven the presence of DNA of Bordetella pertussis in the biological materials (nasopharyngeal swabs). The presence of IS481 genome sequence of Bordetella pertussis was confirmed. This method of detection of pathogens seems to be very rapid, simple, and specific. In the case of adequate technical laboratory equipment it may become very suitable and important supporter in explanation and confirmation of the occurrence of bacterial infections.

Introduction: The aim of the study was to determine the prevalence of psychotropic drug use in active participants in traffic accidents who died during the accident or shortly after it due to injuries resulting from the accident.
Methods: A special mortality register containing data of all forensic autopsies was analysed. The studied sample consisted of persons who died during traffic accidents and were active participants in those ones (pedestrians, cyclists, or drivers), and were toxicologically tested during the forensic examination. Results: The sample consisted of 1,213 cases, 1,039 (85.7%) males and 174 (14.3%) females who died in 2003-2005. Ethanol was found in 34.7% of cases, however a significant declining trend over the years was noted. The proportion of positive detections for any psychotropic drug other than alcohol was 7.2%; benzodiazepines were found most frequently (3.6%), followed by cannabis (2.2%), and stimulants (1.7% of the sample). Positive findings of ethanol were significantly more common among males, whereas positive benzodiazepine tests were more frequent in females. Positive cases were significantly younger than negative ones for ethanol, volatile substances, stimulants, and cannabis; in cases of positive medicaments tests, the positive cases were significantly older than the negatives.

Staphylococci are ubiquitous microorganisms that predominate in normal skin and mucosal flora. Staphylococcus aureus and Staphylococcus epidermidis have been identified as a major cause of nosocomial infections, especially in patients with predisposing factors such as indwelling or implanted foreign bodies. The ability of both S. epidermidis and S. aureus to produce biofilm was compared between 116 clinically significant strains (46 from blood cultures of patients with bloodstream infection and 70 isolated from catheters) and 60 strains isolated from nasal swabs of healthy carriers from hospital staff. The presence of the intercellular adhesion genes (icaA and icaD) was determined by the Polymerase Chain Reaction method, and slime production was examined using qualitative Congo red agar technique. Among clinical strains, 35.2% (19/54) of S. aureus and 48.4% (30/62) of S.epidermidis were both positive icaA and icaD and they produced slime. Among carrier strains, 22.2% (8/36) of S. aureus and 33.3% (8/24) of S. epidermidis were positive for slime synthesis and exhibited ica genes. Our results suggest that the virulence factors contributing to the development of infections can be present in patient and hospital staff isolates. Thus, we consider it is important to detect healthy carriers of slime-producing staphylococci and to control the dissemination of these microorganisms especially in a hospital.

The internal tobacco industry documents have also been used to study tobacco industry operations outside the United States. The scope of the documents on a country outside the US is decided mainly by the extent to which documents and reports were transmitted from the abroad offices of the US tobacco companies to headquarters. We explored whether the material from a private archive of a Finnish public relation consultant to Philip Morris will augment or revise the earlier reports on tobacco industry manipulation in Finland. The private records add more details to previously published reports. The new information mainly concerned implementation of the tobacco industry strategies. A general conclusion is that tobacco industry documents may not give a detailed picture of tobacco industry activities in distant markets, which would be of interest locally, even if they provide sufficient information to convey a general view of tobacco industry strategies.

HIV and STD prevention is an essential component of public health initiatives in countries throughout Central and Eastern Europe. Liberalization in sexual values, declining age at first sex, higher levels of sexual activity, and inconsistent condom use have been well-documented among young people in the region following the political, economic, and cultural transitions after the end of the state socialism era. Less well-understood are the reasons for high-risk sexual behavior and psychosocial factors that must be addressed in the development of effective HIV/STD prevention programs. This study recruited members of 12 high-risk social networks of young adult men and women (n= 66 participants) in two cities, St. Petersburg, Russia, and Budapest, Hungary. In-depth focus groups were conducted with all members of each network, and qualitatively analyzed to examine factors surrounding high-risk sexual behavior. Main themes that emerged were that STDs are less known and less feared than AIDS, HIV risk factors were relatively well known among young adults in both countries but vulnerability is perceived differently, pregnancy prevention is a more immediate concern than protection from HIV or STDs, condom use declines quickly following first sex with a new partner, reintroducing condom use in a relationship is very difficult, and young adults report many barriers to condom use including those related to alcohol or other substance use. HIV/STD prevention programs are needed that extend beyond risk education alone and that also address critical psychological, social, and relationship factors related to sexual risk behavior.

The rapid growth of medical knowledge creates a demand for new ways of providing information. Health professionals are dealing with a variety of cases, and as they have no time to visit the library, they need filtered information instantly. Medical knowledge databases and data sets are increasingly available in electronic form, particularly on the World Wide Web. The premise of this medium is that it offers a "world of` knowledge at your fingertips". The reality, however, is somewhat different, as information systems are not well integrated into clinical practice, they prove difficult to find specific information in, and contain content of varying quality. The continued evaluation of the medium in the future, should be beneficial as evidence-based resources available, and these resources are integrated into electronic medical record systems. The DIMDI and OVID CD-ROM databases are presented as vehicles of research in Bio-Medical Sciences.

The Public Health Institute in Trnava, Slovak Republic under coordination of the International Agency of Cancer Research (IARC) at Lyon, France, had completed a retrospective cohort study of cancer occurrence among nuclear workers at Jaslovské Bohunice, Slovak Republic, as part of a multicentric cohort study of 14 countries.
The objective of the study was to assess an impact of a long-term low level ionising radiation on cancer occurrence. In summary, 2776 employees had been selected for the follow-up period, which lasted since January 1, 1973 till December 31, 1993, it means for 21 years. Mean age at beginning of follow-up was 28.9 years and at the end of follow-up 39.6 years. The total number of person years was 27 742.1 of males and 2 442.2 of females. Exposure was expressed as annual cumulative dose of each cohort member. The total cumulative external gamma dose over the follow-up time was 58 187.9 mSv. The average external gamma dose per person years was 2.06 mSv of males and 0.37 of females. Socioeconomic status, described by the last job description and education were used as possible confounding variables.
All cause mortality, cancer caused mortality and cancer incidence were assessed comparing with general Slovak population using indirect standardised mortality ratio or incidence ratio calculations. There were 47 deaths reported, 44 males and 3 females, over 21 years of follow-up. The most frequent causes of death were cancer (about 30%), accidents, suicides and other external causes (about 26%), cardiovascular diseases (23%). Standardised mortality ratios of 0.39 (0.386-0.392) and 0.46 (0.27-0.59) for males and females, respectively were found in case of all cause mortality. In case of cancer mortality the standardised mortality ratios (SMR) were 0.44 (0.42-0.47) and 1.35 (0.84-1.86) for males and females, respectively. There were 32 incident cases of cancer observed during follow-up. Standardised incidence ratios as 0.508 (0.49-0.52) and 0.905 (0.74-1.06) for males and females, respectively were found. Dose response relation was measured using Poisson regression and Cox proportional hazard model. The estimated excess risks in both approaches and both for mortality and morbidity study were rather anecdotal due to lack of statistical significance caused by small number of cases.

According to the WHO global polio eradication initiative acute flaccid paralysis (AFP) surveillance has been conducted in Belarus since 1996. For the period 1996-2002, 295 AFP cases were reported. The main indices of AFP surveillance in Belarus met the WHO criteria. All AFP cases, with the exception of one, were virologically examined. Polioviruses (PV) were isolated from 28 (9.5%) of them. Results of intratypic differentiation (a neutralization test with type-specific monoclonal antibodies and a restriction fragment length polymorphism assay) proved vaccine origin of all isolated PV. According to the final classification, 11 AFP cases were classified as vaccine-associated paralytic poliomyelitis (VAPP). Nine VAPP cases were recipient [six of them developed after the first, two - after the third and one - after the fourth oral poliovirus vaccine (OPV) dose] and two cases in non-vaccinated children were classified as contact VAPP cases. PV of all three serotypes were isolated with an equal frequency from the recipient cases and only PV2 - from contact ones. Immunological investigations of children with VAPP showed that the majority of them had disorders in B-cell immunity. A risk of one VAPP case per 96,000 first OPV doses and per 745,000 distributed ones was estimated. The other 284 AFP cases were classified as AFP of non-polio etiology (non-polio AFP). Among them Guillain-Barré syndrome (118 cases, 41.5% of all non-polio AFP cases), traumatic neuritis (63 cases, 22.2%), transient monoparesis of limb (35 cases, 12.3%), myelitis (26 cases, 9.2%) were registered most frequently. Vaccine PV were isolated from 19 (6.7%) children with non-polio AFP, 28 (9.9%) children excreted non-polio enteric viruses. In contrast to VAPP, other AFP with PV isolation had no clinical picture typical of poliomyelitis, and had no any residual paralysis 60 days after the onset of paralysis. PV isolation from them seemed to be not related to the etiology of the disease, but was a mere coincidence of paralysis with the recent vaccination. Results of AFP surveillance supported the previous data on the absence of classical poliomyelitis cases caused by wild PV in Belarus for more than 35 years.

Objective: To review strategies of multinational tobacco companies aimed at keeping tobacco products affordable to smokers in Hungary and to provide background information on the Hungarian request for the delayed introduction of minimum European Union tobacco excise duty levels.
Method: Review of internal tobacco industry documents available on the World Wide Web, downloaded between 26 July 2001 and 31 October 2002.
Conclusions: Appropriate pricing strategies and lobbying for low tobacco tax policies were used by the tobacco industry in Hungary to keep cigarettes affordable to the public. During the 1990s and in the early 2000s transnational tobacco companies (TTCs) were still able to prevent substantial cigarette price rises, which would have been desirable for more effective control of Hungarian tobacco use. Strategies used by TTCs included the creation of new partnerships, use of supportive MPs, communication around tobacco tax issues and also the successful management of the differences in approaches used by individual companies regarding taxation of tobacco products. These resulted in the adoption of governmental policy aimed at delaying the introduction of the EU directive on the minimum tax levels of retail prices of cigarettes.

Objective: To give an overview of available internal tobacco industry documents on the transnational tobacco companies' (TTCs) efforts to enter the new market of the emerging democracy of Hungary and how it developed allies in its efforts at resisting tobacco control regulations.
Method: Internal tobacco industry documents relevant to Hungary, available on the World Wide Web, were searched between 26 July and 30 November 2001. Documents on the identification of Central and Eastern Europe (CEE) as a great market potential have been reviewed; another set of reviewed documents are of particular relevance to Hungary, as they indicate who the main partners of the industry are. Conclusions: TTCs not only invaded the markets of the fragile new CEE democracies by making their product widely available, but also introduced sophisticated lobbying and marketing tactics. TTCs will try to shape the country's regulatory framework in a manner to help increase their profits. The fiercer the reaction of TTCs against a planned regulatory measure is, the more impact on the health of the population could be expected from the introduction and enforcement of that measure.

General population is exposed to nickel from various sources. Smoking presents a significant form of exposure. The research was conducted in period 2000-2003 in Institute of Public Health in Nis. The samples of tobacco and cigarettes (127 samples) were both domestic and imported, and samples of biological material (123 blood samples and 147 urine samples) were taken from occupationally unexposed persons (smokers and non-smokers). The analyses were performed by electrothermal atomization technique, by Perkin Elmer AAS M-1100.
The results obtained, revealed a high content of nickel in cigarettes (2.32-4.20 mg/kg) and in tobacco (2.20-4.91 mg/kg) regardless of the kind and the origin of tobacco. Nickel content in the blood of smokers (0.01-0.42 μg/l, median 0.07 μg/l) was higher than in the blood of non-smokers (0.01-0.26 μg/l, median 0.06 μg/l) although this difference was not statistically significant (p>0.05). In the urine of smokers (<0.01-8.20 μg/l, median 1.20 μg/l) there was a significantly higher concentration of nickel than in the urine of non-smokers (<0.01-4.60 μg/l, median 0.50 μg/l), p<0.05. The exposure of smokers to nickel through tobacco smoke was high regardless of the kind and the origin of tobacco and cigarettes. The content of nickel in tissue fluids established by biomonitoring shows that smokers can be far more exposed to this carcinogenic substance than non-smokers and that health risks for smokers are higher in this context.

In the 2000 and 2001 years, there was performed a study which has given some insight on the knowledge of youths about ticks and tick-borne diseases. Two thousand seven hundred and sixty-three respondents from 6 to 26 years of age took part in this investigation. More than 98% of respondents knew about the existence of ticks. Almost 93% of children and 97% of adolescents reported that ticks feed on blood. Although the majority of respondents aged 10 to 26 years is convinced that ticks live on vegetation, 23% of them supposed that ticks jump on humans from trees. As many as 93.5% of youths knew that Lyme disease is transmitted by ticks. The main sources of information about Lyme disease for students and pupils older than 10 years of age are television and radio (40.9%) and the press (37.5%). The frequency of contact of young people with ticks is high - 90.4% of children younger than 12 years, and 93.7% of youths from 10 to 26 years of age had at least once an attached tick. 56.1 % of youths older than 10 years use oil to remove an attached tick. Almost 23.7% remove ticks with bare hands. People used those methods of tick removal although even children younger than 12 years of age knew that it was an incorrect habit. After removing, a tick is most frequently burned.

Introduction: The results of a number of epidemiological studies found relationship between low socioeconomic status (SES) and worse health status.
Objectives: The goal of the study is the evaluation of the health status in inhabitants of an industrial city, their different approach to health and preventive measures in relation with lifestyle factors and socioeconomic status (SES).
Methods: A structured questionnaire was elaborated, distributed to a random sample of some 3,000 aged 25-70 and collected by postal delivery.
Results: A total of 634 completed questionnaires were analysed. The subjective health status was reported as good in 75% of respondents; it was positively correlated with education (p<0.001), negatively with age; worse subjective health was significantly more reported in people economically non-active (p<0.001). More than a half of the study sample suffered a serious chronic disease, significantly more in men (p<0.01), in the less educated (p<0.001), and the prevalence increased with age (p<0.001). The health status improved with the level of education and economic situation and worsened with age. A better health status was identified in women and economically active people.
Women more frequently took care about their limit of weight (mostly for esthetical reasons), use more medicaments than men, they were more interested in protective health information (p<0.01). The use of medicaments was reported significantly less in economically active respondents than in non-active. About half of respondents regularly underwent preventive medical examinations at their practitioner (significantly more men - p<0.05, economically active people - p<0.001, and married - p<0.01). Diseased respondents in the sample were significantly more discontent, more often in a lack of psychological well-being and more passive in comparison with the group of healthy respondents. Contrary to prediction the behaviour of ill individuals was less risky as compared with healthy people. Conclusions: A significant relationship between the groups of healthy and ill respondents was found in respect to sex, age and all the SES factors (education, economic activity and economical situation of family) except for marital status and density of housing. The health status improved with the level of education and economic situation and worsened with age. A better health status was identified in women and economically active people.

Aim: To compare plasma concentration of α-tocopherol and ascorbic acid in healthy seniors (age over 65 years), senior patients with either diabetes mellitus, acute myocardial infarction or dyslipidemia and recommended values of these vitamins. Methods: Studied groups included 30 patients with diabetes mellitus (DM); 30 patients 1 - 2 weeks after acute myocardial infarction (AMI); 11 patients with lipid metabolism disorder (LD, total cholesterol > 6.2 mM); and control group of 27 healthy persons. Results: Concentration of α-tocopherol in DM group was 14.6 ± 5.3 µM, in AMI group 13.7 ± 5.6 µM, in LD group 15.9 ± 5.6 µM and in control group 12.9 ± 4.1 µM. No statistically significant differences were found. However, comparison of determined values with levels recommended for prevention revealed remarkable low plasma concentration of α-tocopherol in the Czech population. Plasma concentration of ascorbic acid in DM group was 47.07 ± 22.80 µM, in AMI group 33.15 ± 12.81 µM, in LD group 45.59 ± 23.02 µM and in control group 43.28 ± 26.57 µM. No statistically significant differences were found between the controls and individual groups of patients. Plasma concentrations of vitamin C reached the recommended value in all cases except the AMI group, where it was significantly lower. Conclusion: Seniors in the Czech population were proved to be significantly short of α-tocopherol, minor shortage of vitamin C was found only in group of patients with myocardial infarction.

Aims: Exposure of children to passive smoking is significantly associated with respiratory morbidity. Youngest children between 0-2 years are harmed in the most significant way, while, together with the growing age a decrease is observed of prevalence of respiratory diseases and influence of passive smoking.
Methods: During repeated investigations of children from European Longitudinal Study of Pregnancy and Childhood (ELSPAC) it was assessed, whether and how in the period from the birth to five years of age varied the rate of children exposed to environment filled with smoke and what were the differences in the frequency of diseases among the groups of children with different exposure level. Some selected characteristics of health were chosen from documentation provided in the 6th, 18th month and 5 years of children's age and processed in four children groups that differ in smoking behaviour of their mothers. The differences were statistically assessed in SPSS programme.
Results: In all compared age categories were children of smoking mothers more often exposed to stay in environment filled with smoke: children of middle and heavy smokers more, children of light smokers less. In all groups of smoking mothers, children were more often protected from exposure to passive smoking in the age of six months than after they reached 18 months and 5 years of age: differences were mostly statistically significant on the level of 1% of significance. Attending the kindergarten presents significant protecting factor for five years old children: they are more exposed during weekends than on week days (p < 0.001, resp. p < 0.01). Both respiratory symptomatology and morbidity were highly significantly increased in previous life periods of those children, whose mothers smoked. At the age of five, life in smoking household causes more frequent incidence of asthmatic symptomatology: wheezing and apnoe, and higher prevalence of allergies against home and pollen dust with breathlessness and wheezing as well (p < 0.05).
Conclusions: ELSPAC study ascertained significant influence of maternal smoking on children's health in relation to passive smoking. Consequences of exposure clinically manifest themselves especially in increased incidence of respiratory and allergic morbidity.

Objective: Although there are several dietary guidelines accepted at the international and national level, there are indications that dietary habits in Greece have been changing, moving away from the traditional Mediterranean diet pattern. The aim of this work was to evaluate the dietary habits of a randomly selected sample from the general adult population, in Greece.
Subjects: The "ATTICA" study is a prospective health and nutrition survey. For the purpose of this study, 3,042 adults, from whom 1514 were men (48%) and 1,528 were women (52%), were selected from the greater Athens area during 2001 and 2002. The assessment of the dietary habits was carried out using a validated food frequency questionnaire.
Results: Dietary intakes of red meat and sweets were higher (p<0.005), and dietary intakes of fish, poultry, dairy products, vegetables, and cereals were lower (p<0.05) than the ones recommended by the Hellenic Ministry of Health.
Conclusion: The results from the present study indicate a change in the dietary habits towards an unhealthier type of diet.

The authors analyzed two hospital outbreaks of epidemic keratoconjunctivitis (EKC), one at the Department of Ophthalmology (30 cases) and another one at the Department of Premature Newborns (22 cases). In both outbreaks, EKC was diagnosed in inpatients (16 and 6 respectively), outpatients (5 and 3 respectively), healthcare workers (HCWs) (3 and 5 respectively), and relatives of EKC patients (6 and 8 respectively). Implemented infection control measures included isolation precautions, improved disinfection and hand-washing of both hospital and outpatient department personnel. Shortly after implementation of control measures the rate of infection transmission started to decrease significantly.

The paper is an effort to find what determined the success of Polish health reform implemented in 1999 in the Silesian Voivodeship. The problem has been referred to "social capital" proposed by R. Putnam; the first part of the article contains a short description of this approach. Then data concerning health insurance performance in Poland are presented, which confirm that the Silesian Regional Sickness Fund functioned most effectively. As a possible factor influencing present decentralised institutions performance, the situation of the Silesian Region during the mid-war period was described. Autonomy of the region, as well as tradition of social voluntary activity may be a source of "social capital" in Putnam's meaning. Besides, continuity of the Prussian bismarckian health insurance system is presented as a potential source of "institutional memory" also increasing the present reform's chances for success. In the last part of the paper, limitations of applying the "social capital" approach to the Silesian case are presented, such as shortness of the mid-war autonomy period and changes in the cultural structure of Upper Silesia caused by migrations after World War II. Other factors, which could increase the efficacy of the health insurance system, such as relatively high incomes of the region's inhabitants, are also described. Nevertheless, the final conclusion is that social and cultural conditions deriving from historical traditions could have had a significant influence on the process of implementing health reform in 1999.

One thousand and twenty Polish men and women and 1,011 Swedish men and women aged 50 and recruited through primary health care took part in a survey relating to their knowledge of health-related behaviour, attitudes to health-related behaviour and self-reported risk behaviour. The results reveal that Poles know as much about cardiovascular risk factors as Swedes, but that Swedes feel that it is more important to change their dietary habits and to influence factors in the working environment to avoid the risk of developing CVD than did Poles. Swedes also displayed less risk behaviour than Poles and more Swedes than Poles had successfully stopped smoking. These findings suggest that differences in stages of health-related behavior that have previously been observed at an individual level may sometimes also be discerned at a national level.

Substantial social and environmental changes in a global world as well as a new paradigm of medicine emphasizing high technology and evidence based approach bring to the current medicine many paradoxes. Undoubtedly, new era creates many positive opportunities and challenges for medical professionals. On the other side, traditional concept of medicine as basically humanistic "helping profession" is rather threatened. In this context, there is a need for a re-defining of medical curricula and to offer to the medical students the concepts and ideas which reflect a current development. Traditional public health terms such as "Primary Prevention", "Health Promotion", "Health Protection", "Health Determinants" should be re-defined and the new ones such as "Quality of Life" and "Sustainable Future" must be introduced as an integral part of medical education. The relevant concepts are discussed in the context of specific situation of the health care transformation in Central and Eastern European Countries.

The aim of this cross-sectional cohort study was to examine practices of clinical examination of heart failure patients in three primary health care regions in northern Finland. Altogether, 825 randomly selected heart failure patients aged 45 years or older, who had special reimbursement for drugs for the treatment of heart failure, were included. Main outcome measures were the frequency of medical visits and the mode of clinical examinations during control visits and symptomatic visits due to heart failure made by general practitioners.
The prevalence of heart failure was 2% among those aged 45-75 years and 18% among the older ones. No differences existed in the incidence of all medical visits made as a result of heart failure, between the regions. ECG recordings, auscultation of the heart and lungs, measurements of blood pressure and recordings of ankle swelling were carried out in 72%, 79%, 85%, 90% and 59% of cases of control visits, and in 78%, 63%, 79%, 77% and 49% of cases in symptomatic visits, respectively. Chest X-ray examinations and recording of liver size were seldom carried out: 16% and 12% in control visits, and 19% and 11% in symptomatic visits, respectively. Important prognostic markers of heart failure were recorded even more rarely: jugular venous pressure, in 1% of control visits and 3% of symptomatic visits and the third heart sound not at all. NYHA grading had been carried out in 8% and echocardiography in 13% of cases.
The prevalence of heart failure was higher than in many clinical studies, suggesting high number of false positive heart failure diagnoses made in primary health care. Some clinical examinations of significant prognostic value in heart failure are underused by general practitioners. Therefore, further education among general practitioners is needed to improve the practices of clinical examination in heart failure patients.

Changes in self-rated health and its determinants have been analyzed in the group of 551 community-dwelling older age citizens of Krakow during the 12-year interval observation.
Multidimensional model showed that changes in self-rated health between the studies have been significantly determined by such variables like age and self-evaluation of health status in the Ist study. Self-rated health was also less markedly decreased in men, who continued professional activity in the Ist study. Among variables analyzed in the IInd study it was age-related functional disability reported by men and reported chronic conditions that deteriorated self-rated health significantly.
Changes in self-rated health between the Ist and the IInd study among women were determined by the same variables as in men (except for the continuation of professional activities in the Ist study). Significantly diminished scores were found in women with higher level of functional activity in the Ist study and greater independence in performing daily activities in the IInd study. Analysis of the summary effect of chronic diseases on self-rated health has shown significantly greater deterioration of self-rated health between the first and the second study related to the number of diseases reported in the Ist study.