Comparison of a spatial perspective with the multilevel analytical approach in neighborhood studies: the case of mental and behavioral disorders due to psychoactive substance use in Malmo, Sweden, 2001

Most studies of neighborhood effects on health have used the multilevel approach. However, since this methodology does not incorporate any notion of space, it may not provide optimal epidemiologic information when modeling variations or when investigating associations between contextual factors and health. Investigating mental disorders due to psychoactive substance use among all 65,830 individuals aged 40-59 years in 2001 in Malmö, Sweden, geolocated at their place of residence, the authors compared a spatial analytical perspective, which builds notions of space into hypotheses and methods, with the multilevel approach. Geoadditive models provided precise cartographic information on spatial variations in prevalence independent of administrative boundaries. The multilevel model showed significant neighborhood variations in the prevalence of substance-related disorders. However, hierarchical geostatistical models provided information on not only the magnitude but also the scale of neighborhood variations, indicating a significant correlation between neighborhoods in close proximity to each other. The prevalence of disorders increased with neighborhood deprivation. Far stronger associations were observed when using indicators measured in spatially adaptive areas, centered on residences of individuals, smaller in size than administrative neighborhoods. In neighborhood studies, building notions of space into analytical procedures may yield more comprehensive information than heretofore has been gathered on the spatial distribution of outcomes.

Associations between income inequality and mortality among US states: the importance of time period and source of income data

OBJECTIVES

We used census data to examine associations between income inequality and mortality among US states for each decade from 1949 to 1999 and tax return income data to estimate associations for 1989.

METHODS

Cross-sectional correlation analyses were used to assess income inequality-mortality relationships.

RESULTS

Census income analyses revealed little association between income inequality and mortality for 1949, 1959, or 1969. An association emerged for 1979 and strengthened for 1989 but weakened for 1999. When income inequality was based on tax return data, associations were weaker for both 1989 and 1999.

CONCLUSIONS

The strong association between income inequality and mortality observed among US states for 1989 was not observed for other periods from 1949 through 1999. In addition, when tax return rather than census data were used, the association was weaker for 1989 and 1999. The potential for distal social determinants of population health (e.g., income inequality) to affect mortality is contingent on how such determinants influence levels of proximal risk factors and the time lags between exposure to those risk factors and effects on specific health outcomes.

Methodological issues in measuring health disparities

OBJECTIVES

This report discusses six issues that affect the measurement of disparities in health between groups in a population: Selecting a reference point from which to measure disparity. Measuring disparity in absolute or in relative terms. Measuring in terms of favorable or adverse events. Measuring in pair-wise or in summary fashion. Choosing whether to weight groups according to group size. Deciding whether to consider any inherent ordering of the groups. These issues represent choices that are made when disparities are measured.

METHODS

Examples are used to highlight how these choices affect specific measures of disparity.

RESULTS

These choices can affect the size and direction of disparities measured at a point in time and conclusions about the size and direction of changes in disparity over time. Eleven guidelines for measuring disparities are presented.

CONCLUSIONS

Choices concerning the measurement of disparity should be made deliberately, recognizing that each choice will affect the results. When results are presented, the choices on which the measurements are based should be described clearly and justified appropriately.

Preoperative Statin Therapy Does Not Reduce Cognitive Dysfunction After Cardiopulmonary Bypass

OBJECTIVE

The purpose of this study was to determine if patients receiving statin therapy before coronary artery bypass grafting surgery would have less cognitive dysfunction after cardiopulmonary bypass as a consequence of a diminished inflammatory response.

DESIGN

Retrospective observational study of patients undergoing coronary artery bypass grafting surgery.

SETTING

Referral center for cardiothoracic surgery at a university hospital.

PARTICIPANTS

Four hundred forty patients undergoing coronary artery bypass grafting surgery with cardiopulmonary bypass.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-five percent of patients received statins in the preoperative period. Multivariable analysis revealed no effect of preoperative statin therapy on cognitive function (p = 0.67). Post hoc analysis revealed that statin therapy at hospital discharge was associated with less improvement in cognitive performance at 6 weeks after surgery (p = 0.011). No significant differences were found between statin therapy groups in either range or maximum value of any of the cytokines (p > 0.05).

CONCLUSIONS

Preoperative statin therapy did not decrease the inflammatory response to cardiopulmonary bypass or the cognitive dysfunction commonly seen after cardiac surgery.

A life course approach to chronic disease epidemiology

A life course approach to chronic disease epidemiology uses a multidisciplinary framework to understand the importance of time and timing in associations between exposures and outcomes at the individual and population levels. Such an approach to chronic diseases is enriched by specification of the particular way that time and timing in relation to physical growth, reproduction, infection, social mobility, and behavioral transitions, etc., influence various adult chronic diseases in different ways, and more ambitiously, by how these temporal processes are interconnected and manifested in population-level disease trends. In this review, we discuss some historical background to life course epidemiology and theoretical models of life course processes, and we review some of the empirical evidence linking life course processes to coronary heart disease, hemorrhagic stroke, type II diabetes, breast cancer, and chronic obstructive pulmonary disease. We also underscore that a life course approach offers a way to conceptualize how underlying socio-environmental determinants of health, experienced at different life course stages, can differentially influence the development of chronic diseases, as mediated through proximal specific biological processes.

The mediation proportion: a structural equation approach for estimating the proportion of exposure effect on outcome explained by an intermediate variable

It is often of interest to assess how much of the effect of an exposure on a response is mediated through an intermediate variable. However, systematic approaches are lacking, other than assessment of a surrogate marker for the endpoint of a clinical trial. We review a measure of "proportion explained" in the context of observational epidemiologic studies. The measure has been much debated; we show how several of the drawbacks are alleviated when exposures, mediators, and responses are continuous and are embedded in a structural equation framework. These conditions also allow for consideration of several intermediate variables. Binary or categorical variables can be included directly through threshold models. We call this measure the mediation proportion, that is, the part of an exposure effect on outcome explained by a third, intermediate variable. Two examples illustrate the approach. The first example is a randomized clinical trial of the effects of interferon-alpha on visual acuity in patients with age-related macular degeneration. In this example, the exposure, mediator and response are all binary. The second example is a common problem in social epidemiology-to find the proportion of a social class effect on a health outcome that is mediated by psychologic variables. Both the mediator and the response are composed of several ordered categorical variables, with confounders present. Finally, we extend the example to more than one mediator.

Bullying and symptoms among school-aged children: international comparative cross sectional study in 28 countries

BACKGROUND

There have been no large-scale international comparisons on bullying and health among adolescents. This study examined the association between bullying and physical and psychological symptoms among adolescents in 28 countries.

METHODS

This international cross-sectional survey included 123,227 students 11, 13 and 15 years of age from a nationally representative sample of schools in 28 countries in Europe and North America in 1997-98. The main outcome measures were physical and psychological symptoms.

RESULTS

The proportion of students being bullied varied enormously across countries. The lowest prevalence was observed among girls in Sweden (6.3%, 95% CI: 5.2-7.4), the highest among boys in Lithuania (41.4%, 95% CI 39.4-43.5). The risk of high symptom load increased with increasing exposure to bullying in all countries. In pooled analyses, with sex stratified multilevel logistic models adjusted for age, family affluence and country the odds ratios for symptoms among students who were bullied weekly ranged from 1.83 (95% CI 1.70-1.97) to 2.11 (95% CI 1.95-2.29) for physical symptoms (headache, stomach ache, backache, dizziness) and from 1.67 (95% CI 1.55-1.78) to 7.47 (95% CI 6.87-8.13) for psychological symptoms (bad temper, feeling nervous, feeling low, difficulties in getting to sleep, morning tiredness, feeling left out, loneliness, helplessness).

CONCLUSION

There was a consistent, strong and graded association between bullying and each of 12 physical and psychological symptoms among adolescents in all 28 countries.

Anästhesiekomplikationen bei primärer und sekundärer Schnittentbindung

In spite of an increase in the number of caesarean sections, the incidence of anaesthetic-related complications remains low. This is due primarily to the increasing use of regional anaesthesia (spinal and or epidural anaesthesia) as general anaesthesia is associated with a 17-fold increase in complications, in particular failed endotracheal intubation, aspiration of gastric contents and hypoxia. It is most important that all obstetric patients deemed at risk for general anaesthesia (e. g. morbidly obese, hypertension, placenta praevia) should be identified as such by the obstetricians and referred to the anaesthetic department at an early stage. Furthermore there should be common procedural guidelines to define the degree of urgency of caesarean section as most anaesthetic complications occur during "emergency" cases under general anaesthesia. Many of these so-called emergency cases are not real emergencies and could be equally well performed under regional anaesthesia. A continuing audit of maternal deaths in Germany should be established along similar lines to the Confidential Enquiries into Maternal Deaths in the United Kingdom. Most importantly, the increasing use of regional anaesthesia should be propagated as its use in Germany still lies well behind other countries such as Switzerland, the USA and the United Kingdom.

A cell forin situdynamic X-ray diffraction studies: application to the dehydration of zeolite SrX

A new compact cell forin situsynchrotron X-ray diffraction studies of adsorption or catalysis reactions has been designed to enable high performance whilst minimizing difficulties in use. It includes a system for simple insertion and alignment of capillary samples and an original miniaturized furnace providing excellent temperature homogeneity along the sample (temperature gradient less than 1 K over a 6 mm zone at 530 K). The efficiency of this setup is illustrated byin situcharacterization of a zeolite (SrX) at four hydration levels.

Metropolitan income inequality and working-age mortality: a cross-sectional analysis using comparable data from five countries

The relationship between income inequality and mortality has come into question as of late from many within-country studies. This article examines the relationship between income inequality and working-age mortality for metropolitan areas (MAs) in Australia, Canada, Great Britain, Sweden, and the United States to provide a fuller understanding of national contexts that produce associations between inequality and mortality. An ecological cross-sectional analysis of income inequality (as measured by median share of income) and working-age (25-64) mortality by using census and vital statistics data for 528 MAs (population >50,000) from five countries in 1990-1991 was used. When data from all countries were pooled, there was a significant relationship between income inequality and mortality in the 528 MAs studied. A hypothetical increase in the share of income to the poorest half of households of 1% was associated with a decline in working-age mortality of over 21 deaths per 100,000. Within each country, however, a significant relationship between inequality and mortality was evident only for MAs in the United States and Great Britain. These two countries had the highest average levels of income inequality and the largest populations of the five countries studied. Although a strong ecological association was found between income inequality and mortality across the 528 MAs, an association between income inequality and mortality was evident only in within-country analyses for the two most unequal countries: the United States and Great Britain. The absence of an effect of metropolitan-scale income inequality on mortality in the more egalitarian countries of Canada, Australia, and Sweden is suggestive of national-scale policies in these countries that buffer hypothetical effects of income inequality as a determinant of population health in industrialized economies.

A common LRRK2 mutation in idiopathic Parkinson's disease

Mutations in the leucine-rich repeat kinase 2 (LRRK2) gene have been shown to cause autosomal dominant Parkinson's disease. Few mutations in this gene have been identified. We investigated the frequency of a common heterozygous mutation, 2877510 g-->A, which produces a glycine to serine aminoacid substitution at codon 2019 (Gly2019 ser), in idiopathic Parkinson's disease. We assessed 482 patients with the disorder, of whom 263 had pathologically confirmed disease, by direct sequencing for mutations in exon 41 of LRRK2. The mutation was present in eight (1.6%) patients. We have shown that a common single Mendelian mutation is implicated in sporadic Parkinson's disease. We suggest that testing for this mutation will be important in the management and genetic counselling of patients with Parkinson's disease.

The contribution of childhood and adult socioeconomic position to adult obesity and smoking behaviour: an international comparison

BACKGROUND

Our objective was to investigate the contribution of childhood and adult socioeconomic position (SEP) to adult obesity and smoking behaviour, in particular to establish the role of childhood circumstances across different studies in Europe and the US.

METHODS

Seven population-based surveys in six Western countries (Britain, Denmark, Finland, Netherlands, Sweden, US) were examined, with participants aged 30-50 yr and born between 1910 and 1960. Adult smoking was analysed using three outcomes (ever, current, or ex-) and adult obesity was defined as body mass index (kg/m(2)) > or =30.

RESULTS

A strong effect of adult social position was observed for smoking outcomes and obesity. For example, manual SEP in adulthood increased the risk of ever smoking (adjusted odds ratio (OR) 1.47-2.00 for men; 0.94-1.81 for women), and obesity (adjusted OR 1.06-2.24 for men, 1.21-3.26 for women). In most studies, childhood position was not associated with ever-smoking. For current smoking, manual childhood position was associated among women (adjusted OR 1.09-1.54), but no consistent pattern was seen for men. For ex-smoking, manual childhood origins lowered the chance of quitting among women (adjusted OR 0.64-0.81) except in the US (OR = 1.17); among men this association was seen in fewer studies (adjusted OR 0.74-1.09). For obesity, manual origins increased the risk for women (adjusted OR 0.96-2.50); effects were weaker among men but mostly in the same direction (adjusted OR 0.79-1.42).

CONCLUSIONS

As expected, adult SEP was an important influence on smoking behaviour and obesity. In addition, factors related to disadvantaged social origins appeared to increase the risk of obesity and reduce the probability of quitting smoking in adulthood, particularly in women.

Combined external beam radiotherapy and Pd-103 brachytherapy boost improves biochemical failure free survival in patients with clinically localized prostate cancer: results of a matched pair analysis

BACKGROUND

Dose escalation has resulted in improved biochemical control in patients with clinically localized prostate cancer treated with conformal external beam radiation (EBRT). Conformal dose distributions may also be achieved with brachytherapy. Therefore, biochemical control was evaluated for patients treated with combined external radiation therapy and low dose rate brachytherapy (EBRT + LDR).

METHODS

A matched pair analysis was performed to compare biochemical control of patients treated with EBRT + LDR to patients treated with EBRT alone. The study endpoints were biochemical control and late toxicities.

RESULTS

The 5-year biochemical failure free survival (BFFS) was 86% for patients treated with EBRT + LDR and 72% for patients treated with EBRT (P = 0.03). Both treatments were associated with comparable incidences of late genitourinary (GU) side effects (18-19%). Late rectal toxicity was decreased by 15% in patients treated with EBRT + LDR (P = 0.0003).

CONCLUSIONS

These results support EBRT followed by brachytherapy boost as a safe and effective method for dose escalation in the treatment of prostate cancer.

Hurling alone? How social capital failed to save the Irish from cardiovascular disease in the United States

OBJECTIVES

We performed a historical review of cardiovascular risk profiles of Irish immigrants to the United States, 1850-1970, in regard to lifestyle, socio-economic circumstances, and social capital.

METHODS

We analyzed US Census data from 1850-1970, area-based social and epidemiological data from Boston, data from Ireland's National Nutrition Surveillance Centre, and literature on Irish migration.

RESULTS

The Irish were consistently at increased risk of cardiovascular diseases, a risk that related initially to material deprivation, across the life course of at least 2 generations.

CONCLUSIONS

The principal difference between the Irish and other disadvantaged immigrant groups, such as the Italians, was dietary habits influenced by experiences during the Irish famine. Although there was a psychosocial component to the disadvantage and discrimination they experienced as an ethnic group, the Irish also exhibited strong community networks and support structures that might have been expected to counteract discrimination's negative effects. However, the Irish's high levels of social capital were not protective for cardiovascular disease.