Alcohol consumption and mortality among middle-aged and elderly U.S. adults

BACKGROUND

Alcohol consumption has both adverse and beneficial effects on survival. We examined the balance of these in a large prospective study of mortality among U.S. adults.

METHODS

Of 490,000 men and women (mean age, 56 years; range, 30 to 104) who reported their alcohol and tobacco use in 1982, 46,000 died during nine years of follow-up. We compared cause-specific and rates of death from all causes across categories of base-line alcohol consumption, adjusting for other risk factors, and related drinking and smoking habits to the cumulative probability of dying between the ages of 35 and 69 years.

RESULTS

Causes of death associated with drinking were cirrhosis and alcoholism; cancers of the mouth, esophagus, pharynx, larynx, and liver combined; breast cancer in women; and injuries and other external causes in men. The mortality from breast cancer was 30 percent higher among women reporting at least one drink daily than among nondrinkers (relative risk, 1.3; 95 percent confidence interval, 1.1 to 1.6). The rates of death from all cardiovascular diseases were 30 to 40 percent lower among men (relative risk, 0.7; 95 percent confidence interval, 0.7 to 0.8) and women (relative risk, 0.6; 95 percent confidence interval, 0.6 to 0.7) reporting at least one drink daily than among nondrinkers, with little relation to the level of consumption. The overall death rates were lowest among men and women reporting about one drink daily. Mortality from all causes increased with heavier drinking, particularly among adults under age 60 with lower risk of cardiovascular disease. Alcohol consumption was associated with a small reduction in the overall risk of death in middle age (ages 35 to 69), whereas smoking approximately doubled this risk.

CONCLUSIONS

In this middle-aged and elderly population, moderate alcohol consumption slightly reduced overall mortality. The benefit depended in part on age and background cardiovascular risk and was far smaller than the large increase in risk produced by tobacco.

Early health effects of the emerging tobacco epidemic in China. A 16-year prospective study

CONTEXT

In recent decades, there has been a rapid and substantial increase in tobacco consumption in China, particularly by men, but little is known from local epidemiologic studies about the pattern of smoking-related deaths.

OBJECTIVE

To assess the current health effects of cigarette smoking in Shanghai, China.

DESIGN

Prospective observational study of mortality in relation to cigarette smoking.

SETTING

Eleven factories in urban Shanghai.

SUBJECTS

A total of 9351 adults (6494 men and 2857 women) aged 35 to 64 years at baseline survey during the 1970s.

OUTCOME MEASURES

All-cause and cause-specific mortality.

RESULTS

During an average follow-up of 16 years, 881 men and 207 women died. Among men, 61% had described themselves as current cigarette smokers at baseline, and their overall mortality was significantly greater than that of nonsmokers (relative risk [RR], 1.4; 95% confidence interval [CI], 1.2-1.7; P<.001). The excess was almost twice as great (RR, 1.8; 95% CI, 1.5-2.2 [corrected]; P<.001) among the men who had begun smoking before the age of 25 years and was significantly associated with the number of cigarettes smoked (P<.001 for trend) after adjustment for other major risk factors. The chief sources of the excess were lung cancer (RR, 3.8; 95% CI, 2.1-6.8; P<.001), esophageal cancer (RR, 3.6; 95% CI, 1.2-10.5; P=.02), liver cancer (RR, 2.0; 95% CI, 1.1-3.7; P=.03), coronary heart disease (RR, 1.8; 95% CI, 1.0-3.2; P=.04), and chronic obstructive pulmonary disease (RR, 2.5; 95% CI, 1.4-4.4; P<.01). Among the men in this Chinese population, about 20% (95% CI, 12%-29%) of all deaths during the study period could be attributed to cigarette smoking. Of these deaths, one third involved lung cancer, one third involved other cancers, and one third involved other diseases. Only 7% of women described themselves as current cigarette smokers at baseline, but among them there was also a statistically significant excess of overall mortality (RR, 1.7; 95% CI, 1.2-2.5; P<.01).

CONCLUSIONS

Cigarette smoking is already a major cause of death in China, and among middle-aged Shanghai men, about 20% of all deaths during the 1980s were due to smoking. The excess was greatest among men who began smoking before the age of 25 years, about 47% of whom would, at 1987 mortality rates, die between the ages of 35 and 69 years (compared with only 29% of nonsmokers). These estimates reflect the consequences of past smoking patterns. The future health effects of current smoking patterns are likely to be greater because of the recent large increase in cigarette consumption, particularly at younger ages, in China.

Association of Helicobacter pylori infection with precancerous lesions and stomach cancer: a case-control study in Yangzhong County

Previous study has raised H. pylori infection as a suspected biologic risk factor for gastric cancer. A comparative case-control study involving precancerous lesions and gastric cancer was conducted in Yanzhong county, an area with one of the highest rates of gastric cancer in China to study the relationship between the H. pylori infection and gastric cancer. Subjects in the study were all randomly selected participants of a screening program for gastric cancer sponsored by the Cancer Institute of CAMS in cooperation with Yangzhong county Hospital. Totally, 125 normal controls, 108 superficial gastritis, 111 atrophic gastritis and 110 gastric cancer patients were included in our study according to endoscopy and pathology result. Status of H. pylori infection was evaluated by measuring IgG antibody in plasma with ELISA assay. Our result showed Odds ratios of H. pylori infection were higher among gastritis and cancer groups, 4.5 (95% CI 2.5-7.9) for superficial gastritis, 6.3 (95% CI 3.4-12) for atrophic gastritis, 3.3 (95% CI 1.9-5.9) for gastric cancer. It was found in our study that consumption of pickled vegetables and drinking dirty water increased the relative risk of H. pylori infection for both precancerous lesions and gastric cancer and that H. pylori infection had higher risk of atrophic gastritis and gastric cancer for males and also higher risk of atrophic gastritis for olders. Our results strongly support the casual role played by H. pylori infection in the carcinogenic process of gastric mucosa.

Chronic infections and coronary heart disease: is there a link?

A large number of studies have reported on associations of human coronary heart disease (CHD) and certain persistent bacterial and viral infections. We review the epidemiological and clinical evidence on CHD and Helicobacter pylori, Chlamydia pneumoniae, and cytomegalovirus (CMV), as well as possible mechanisms. The association between CHD and H pylori may be accounted for by residual confounding from risk factors. Although the association between C pneumoniae and CHD is stronger, the sequence of infection and disease is uncertain. As regards CMV, a limited number of patients with classic atherosclerotic coronary artery disease have been studied. Further studies are needed to resolve these uncertainties.

Hospital management of acute ischemic stroke in China

OBJECTIVE

Hospital management of acute ischemic stroke varies greatly within and between different countries. This study assesses the current practices and opinions of doctors in China routinely involved in the treatment of stroke, and compares them with those of British doctors.

METHODS

Questionnaires about the usual management of acute ischemic stroke were sent to 247 Chinese hospitals (mostly urban) collaborating in an acute stroke trial, seeking responses from five doctors (one consultant, two registrars, and two house officers) in each. After one mailing, 1,095 doctors (89%) responded.

RESULTS

Sixty-nine percent of the hospitals had computed tomography scanners, and 88% of the doctors in those hospitals reported that they would routinely scan acute stroke patients (78% usually within 24 hours of admission and 22% only later). Sixty-two percent of doctors reported average hospital stays of 2 to 4 weeks, whereas 36% reported longer average stays. Treatments reported to be used routinely within the first 48 hours of acute ischemic stroke included glycerol or mannitol (69% of doctors), Chinese herb products (66%), calcium antagonists (54%), and aspirin (53%); for each of these treatments, over 70% of all doctors believed it produced definite benefit. Reported routine use of dextran (44%), snake venom (32%), "photo-therapy" (22%), and steroids (19%) was also moderately common, and about half of all doctors believed each was beneficial. In contrast, routine use of thrombolytic agents (4%) or anticoagulants (1%) was uncommon. Only one third of the doctors reported active treatment of hypertension immediately after admission.

CONCLUSIONS

Comparison with a similar survey in Britain showed reported use of most treatments for acute ischemic stroke was more extensive in China, but that within both countries there was wide variation. The substantial variations in clinical practice both within and between China, the United Kingdom and other countries reflect, at least in part, the substantial uncertainty about the effectiveness of many of the possible treatments for acute ischemic stroke. Large-scale randomized evidence is needed to confirm or refute the efficacy of these and newer treatments for acute stroke.

Randomized placebo-controlled study of the effects of simvastatin on haemostatic variables, lipoproteins and free fatty acids. The Oxford Cholesterol Study Group

The Oxford Cholesterol Study is a randomized placebo-controlled trial designed primarily to assess the effects of simvastatin on blood cholesterol levels and side-effects in preparation for a large, long-term trial of the effects of cholesterol-lowering drug therapy on mortality. At present there is only limited evidence from randomized comparisons of the effects of HMG-CoA reductase inhibitors, such as simvastatin, on thrombogenic, as distinct from atherogenic, pathways in coronary heart disease. The present sub-study was carried out to assess the effects of simvastatin on a range of haemostatic variables, as well as on free fatty acids and on lipoprotein fractions not studied in detail previously. At an average of about 2 years after starting study treatment, non-fasting blood samples were obtained from a sequential sample of 162 participants who had been randomly allocated to receive 40 mg (54 patients) or 20 mg (57 patients) daily simvastatin or matching placebo treatment (51 patients). Only patients who reported taking their study treatment and who were not known to be diabetic or to be taking some other lipid lowering treatment were to be included. The principal comparisons were to be of those allocated simvastatin (i.e. 20 and 40 mg doses combined) vs those allocated placebo. Among patients allocated simvastatin, marginally significant lower factor VII antigen levels (12.10% +/- 6.08 of standard; 2P < 0.05) and non-significantly lower factor VII coagulant activity (8.24% +/- 4.99 of standard) and fibrinogen concentrations (0.10 +/- 0.08 g. l-1) were observed. In contrast, plasminogen activator inhibitor activity was significantly higher (2.62 +/- 1.03 IU; 2P < 0.01) among patients allocated simvastatin. No significant differences were seen in the other haemostatic factors studied (e.g. prothrombin fragment 1.2, factor XII and C1 inhibitor). Total free fatty acid concentration was marginally significantly reduced (2P = 0.02) with simvastatin, but none of the reductions in individual free fatty acids was significant. Lipoprotein fractions were only measured among patients allocated 40 mg daily simvastatin or placebo. Compared with placebo, simvastatin produced significant decreases not only in LDL cholesterol (1.74 +/- 0.15 mmol.1(-1): 2P < 0.0001) but also in VLDL cholesterol (0.28 +/- 0.08 mmol.1(-1); 2P < 0.001) and IDL cholesterol (0.17 +/- 0.03 mmol.1(-1); 2P < 0.0001). There were also lower triglyceride levels associated with LDL (0.07 +/- 0.01 mmol.1(-1); 2P < 0.0001), IDL (0.03 +/- 0.01 mmol.1(-1); 2P < 0.01) and VLDL (0.27 +/- 0.14; 2P = 0.05). The effects of simvastatin on haemostatic variables appear to be far less marked than its lipid effects. Given the associations of haemostatic factors with coronary heart disease incidence, larger randomized comparisons of the HMG-CoA reductase inhibitors (and of the newer fibrates which may produce greater effects) are needed to provide more reliable estimates of the extent to which they influence these variables.

Dietary lipids and blood cholesterol: quantitative meta-analysis of metabolic ward studies

OBJECTIVE

To determine the quantitative importance of dietary fatty acids and dietary cholesterol to blood concentrations of total, low density lipoprotein, and high density lipoprotein cholesterol.

DESIGN

Meta-analysis of metabolic ward studies of solid food diets in healthy volunteers.

SUBJECTS

395 dietary experiments (median duration 1 month) among 129 groups of individuals.

RESULTS

Isocaloric replacement of saturated fats by complex carbohydrates for 10% of dietary calories resulted in blood total cholesterol falling by 0.52 (SE 0.03) mmol/l and low density lipoprotein cholesterol falling by 0.36 (0.05) mmol/l. Isocaloric replacement of complex carbohydrates by polyunsaturated fats for 5% of dietary calories resulted in total cholesterol falling by a further 0.13 (0.02) mmol/l and low density lipoprotein cholesterol falling by 0.11 (0.02) mmol/l. Similar replacement of carbohydrates by monounsaturated fats produced no significant effect on total or low density lipoprotein cholesterol. Avoiding 200 mg/day dietary cholesterol further decreased blood total cholesterol by 0.13 (0.02) mmol/l and low density lipoprotein cholesterol by 0.10 (0.02) mmol/l.

CONCLUSIONS

In typical British diets replacing 60% of saturated fats by other fats and avoiding 60% of dietary cholesterol would reduce blood total cholesterol by about 0.8 mmol/l (that is, by 10-15%), with four fifths of this reduction being in low density lipoprotein cholesterol.

Clinical effects of anticoagulant therapy in suspected acute myocardial infarction: systematic overview of randomised trials

OBJECTIVES

Most randomised trials of anticoagulant therapy for suspected acute myocardial infarction have been small and, in some, aspirin and fibrinolytic therapy were not used routinely. A systematic overview (meta-analysis) of their results is needed, in particular to assess the clinical effects of adding heparin to aspirin.

DESIGN

Computer aided searches, scrutiny of reference lists, and inquiry of investigators and companies were used to identify potentially eligible studies. On central review, 26 studies were found to involve unconfounded randomised comparisons of anticoagulant therapy versus control in suspected acute myocardial infarction. Additional information on study design and outcome was sought by correspondence with study investigators.

SUBJECTS

Patients with suspected acute myocardial infarction.

INTERVENTIONS

No routine aspirin was used among about 5000 patients in 21 trials (including half of one small trial) that assessed heparin alone or heparin plus oral anticoagulants, and aspirin was used routinely among 68,000 patients in six trials (including the other half of one small trial) that assessed the addition of intravenous or high dose subcutaneous heparin.

MAIN OUTCOME MEASUREMENTS

Death, reinfarction, stroke, pulmonary embolism, and major bleeds (average follow up of about 10 days).

RESULTS

In the absence of aspirin, anticoagulant therapy reduced mortality by 25% (SD 8%; 95% confidence interval 10% to 38%; 2P = 0.002), representing 35 (11) fewer deaths per 1000. There were also 10 (4) fewer strokes per 1000 (2P = 0.01), 19 (5) fewer pulmonary emboli per 1000 (2P < 0.001), and non-significantly fewer reinfarctions, with about 13 (5) extra major bleeds per 1000 (2P = 0.01). Similar sized effects were seen with the different anticoagulant regimens studied. In the presence of aspirin, however, heparin reduced mortality by only 6% (SD 3%; 0% to 10%; 2P = 0.03), representing just 5 (2) fewer deaths per 1000. There were 3 (1.3) fewer reinfarctions per 1000 (2P = 0.04) and 1 (0.5) fewer pulmonary emboli per 1000 (2P = 0.01), but there was a small non-significant excess of stroke and a definite excess of 3 (1) major bleeds per 1000 (2P < 0.0001).

CONCLUSIONS

The clinical evidence from randomised trials dose not justify the routine addition of either intravenous or subcutaneous heparin to aspirin in the treatment of acute myocardial infarction (irrespective of whether any type of fibrinolytic therapy is used).

Breast cancer and hormonal contraceptives: further results. Collaborative Group on Hormonal Factors in Breast Cancer

The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on breast cancer risk and use of hormonal contraceptives. Original data from 54 studies, representing about 90% of the information available on the topic, were collected, checked and analysed centrally. The 54 studies were performed in 26 countries and include a total of 53,297 women with breast cancer and 100,239 women without breast cancer. The studies were varied in their design, setting and timing. Most information came from case-control studies with controls chosen from the general population; most women resided in Europe or North America and most cancers were diagnosed during the 1980s. Overall 41% of the women with breast cancer and 40% of the women without breast cancer had used oral contraceptives at some time; the median age at first use was 26 years, the median duration of use was 3 years, the median year of first use was 1968, the median time since first use was 16 years, and the median time since last use was 9 years. The main findings, summarised elsewhere, are that there is a small increase in the risk of having breast cancer diagnosed in current users of combined oral contraceptives and in women who had stopped use in the past 10 years but that there is no evidence of an increase in the risk more than 10 years after stopping use. In addition, the cancers diagnosed in women who had used oral contraceptives tended to be less advanced clinically than the cancers diagnosed in women who had not used them. Despite the large number of possibilities investigated, few factors appeared to modify the main findings either in recent or in past users. For recent users who began use before age 20 the relative risks are higher than for recent users who began at older ages. For women whose use of oral contraceptives ceased more than 10 years before there was some suggestion of a reduction in breast cancer risk in certain subgroups, with a deficit of tumors that had spread beyond the breast, especially among women who had used preparations containing the highest doses of oestrogen and progestogen. These findings are unexpected and need to be confirmed. Although these data represent most of the epidemiological evidence on the topic to date, there is still insufficient information to comment reliably about the effects of specific types of oestrogen or of progestogen. What evidence there is suggests, however, no major differences in the effects for specific types of oestrogen or of progestogen and that the pattern of risk associated with use of hormonal contraceptives containing progestogens alone may be similar to that observed for preparations containing both oestrogens and progestogens. On the basis of these results, there is little difference between women who have and have not used combined oral contraceptives in terms of the estimated cumulative number of breast cancers diagnosed during the period from starting use up to 20 years after stopping. The cancers diagnosed in women who have used oral contraceptives are, however, less advanced clinically than the cancers diagnosed in never users. Further research is needed to establish whether the associations described here are due to earlier diagnosis of breast cancer in women who have used oral contraceptives, to the biological effects of the hormonal contraceptives or to a combination of both. Little information is as yet available about the effects on breast cancer risk of oral contraceptive use that ceased more than 20 years before and as such data accumulate it will be necessary to re-examine the worldwide evidence.

An audit of mattresses in one teaching hospital

The poor state of some hospital mattresses has been associated with the formation of pressure sores and the spread of infection. Nurses need to be aware of potential problems with old, faulty or poor-quality mattresses. Mattresses must be checked regularly.

Lack of effect of long-term supplementation with beta carotene on the incidence of malignant neoplasms and cardiovascular disease

BACKGROUND

Observational studies suggest that people who consume more fruits and vegetables containing beta carotene have somewhat lower risks of cancer and cardiovascular disease, and earlier basic research suggested plausible mechanisms. Because large randomized trials of long duration were necessary to test this hypothesis directly, we conducted a trial of beta carotene supplementation.

METHODS

In a randomized, double-blind, placebo-controlled trial of beta carotene (50 mg on alternate days), we enrolled 22,071 male physicians, 40 to 84 years of age, in the United States; 11 percent were current smokers and 39 percent were former smokers at the beginning of the study in 1982. By December 31, 1995, the scheduled end of the study, fewer than 1 percent had been lost to follow-up, and compliance was 78 percent in the group that received beta carotene.

RESULTS

Among 11,036 physicians randomly assigned to receive beta carotene and 11,035 assigned to receive placebo, there were virtually no early or late differences in the overall incidence of malignant neoplasms or cardiovascular disease, or in overall mortality. In the beta carotene group, 1273 men had any malignant neoplasm (except nonmelanoma skin cancer), as compared with 1293 in the placebo group (relative risk, 0.98; 95 percent confidence interval, 0.91 to 1.06). There were also no significant differences in the number of cases of lung cancer (82 in the beta carotene group vs. 88 in the placebo group); the number of deaths from cancer (386 vs. 380), deaths from any cause (979 vs. 968), or deaths from cardiovascular disease (338 vs. 313); the number of men with myocardial infarction (468 vs. 489); the number with stroke (367 vs. 382); or the number with any one of the previous three end points (967 vs. 972). Among current and former smokers, there were also no significant early or late differences in any of these end points.

CONCLUSIONS

In this trial among healthy men, 12 years of supplementation with beta carotene produced neither benefit nor harm in terms of the incidence of malignant neoplasms, cardiovascular disease, or death from all causes.

Serologically diagnosed infection with human papillomavirus type 16 and risk for subsequent development of cervical carcinoma: nested case-control study

OBJECTIVE

To study human papillomavirus type 16 in the aetiology of cervical carcinoma.

DESIGN

Within a cohort of 18814 Finnish women followed up to 23 years a nested case-control study was conducted based on serological diagnosis of past infection with human papillomavirus type 16.

SUBJECTS

72 women (27 with invasive carcinoma and 45 with in situ carcinoma) and 143 matched controls were identified during the follow up.

MAIN OUTCOME MEASURE

Relative risk of cervical carcinoma in presence of IgG antibodies to human papillomavirus type 16.

RESULTS

After adjustment for smoking and for antibodies to various other agents of sexually transmitted disease, such as herpes simplex virus type 2 and Chlamydia trachomatis, the only significant association was with infection with human papillomavirus type 16 (odds ratio 12.5; 95% confidence interval 2.7 to 57, 2P<0.001).

CONCLUSION

This prospective study provides epidemiological evidence that infection with human papillomavirus type 16 confers an excess risk for subsequent development of cervical carcinoma.