Disparities by race in heat-related mortality in four US cities: the role of air conditioning prevalence

Daily mortality is typically higher on hot days in urban areas, and certain population groups experience disproportionate risk. Air conditioning (AC) has been recommended to mitigate heat-related illness and death. We examined whether AC prevalence explained differing heat-related mortality effects by race. Poisson regression was used to model daily mortality in Chicago, Detroit, Minneapolis, and Pittsburgh. Predictors included natural splines of time (to control seasonal patterns); mean daily apparent temperature on the day of death, and averaged over lags 1-3; barometric pressure; day of week; and a linear term for airborne particles. Separate, city-specific models were fit to death counts stratified by race (Black or White) to derive the percent change in mortality at 29 degrees C, relative to 15 degrees C (lag 0). Next, city-specific effects were regressed on city- and race-specific AC prevalence. Combined effect estimates across all cities were calculated using inverse variance-weighted averages. Prevalence of central AC among Black households was less than half that among White households in all four cities, and deaths among Blacks were more strongly associated with hot temperatures. Central AC prevalence explained some of the differences in heat effects by race, but room-unit AC did not. Efforts to reduce disparities in heat-related mortality should consider access to AC.

Mortality and socioeconomic deprivation in census tracts of an urban setting in southern Europe

In southern European cities, research on deprivation and mortality inequalities using small-area analysis is recent. In many countries, the census tract (CT) is the smallest territorial unit for which population data are available. The aim of this study was to examine the association between mortality from all causes and socioeconomic deprivation in CTs in Barcelona (Spain). A cross-sectional ecologic study was carried out using mortality data for 1987-1995 and 1991 census variables. Mortality data were obtained from death certificates. Socioeconomic deprivation indicators were drawn from the census and included unemployment, inadequate education, and low social class. They were correlated, and a deprivation index was elaborated with them. The analysis was descriptive, and multivariate Poisson regression models were adjusted. The most deprived CTs tend to present higher mortality (49.7% of CT in the quartile associated with greatest deprivation were included in the top male mortality quartile and 40.4% in the top female mortality quartile), whereas the less deprived ones present lower mortality. For male mortality, the risk of dying among those in the quartile representing most deprivation is from 25 to 29% higher (depending on the indicator chosen) than the least deprived quartile, and for women, it is from 12 to 14% higher. We concluded that the mortality from all causes in the CT of a southern European city has shown a clear positive association with a variety of socioeconomic deprivation indicators drawn from the census. Studies of this nature may help to orient more specific studies in which CTs are grouped together as a function of particular population and/or health characteristics.

Disease and injury among participants in the Agricultural Health Study

The Agricultural Health Study (www.aghealth.org) is a cohort of 89,658 pesticide applicators and their spouses from Iowa and North Carolina assembled between 1993 and 1997 to evaluate riskfactorsfor disease in ruralfarm populations. This prospective study is just now reaching sufficient maturity for analysis of many disease endpoints. Nonetheless, several analyses have already provided interesting and important leads regarding disease patterns in agricultural populations and etiologic clues for the general population. Compared to the mortality experience of the general population in the two states (adjusted for race, gender, age and calendar time), the cohort experienced a very low mortality rate overall and for many specific causes and a low rate of overall cancer incidence. A few cancers, however, appear elevated, including multiple myeloma and cancers of the lip, gallbladder, ovary, prostate, and thyroid, but numbers are small for many cancers. A study of prostate cancer found associations with exposure to several pesticides, particularly among individuals with a family history of prostate cancer. Links to pesticides and other agricultural factors have been found for injuries, retinal degeneration, and respiratory wheeze. Methodological studies have determined that information collected by interview is unbiased and reliable. A third round of interviews scheduled to begin in 2005 will collect additional information on agricultural exposures and health outcomes. The study can provide data to address many health issues in the agricultural community. The study investigators welcome collaboration with interested scientists.

The relationship between the supply of fast-food chains and cardiovascular outcomes

OBJECTIVE

To examine the extent to which inter-regional differences in fast-food concentrations account for variations in all-cause mortality and acute coronary syndromes throughout Ontario, Canada.

METHODS

Nine distinct fast-food chains were selected based on top sales data in 2001. The per capita rate of fast-food outlets per region was calculated for each of 380 regions throughout Ontario. Outcome measures, obtained using 2001 vital statistics data and hospital discharge abstracts, included regional per capita mortality rates and acute coronary syndrome hospitalization rates; head trauma served as a comparator. All regional outcomes were adjusted for age, gender, and socio-economic status, and were analyzed as continuous and rank-ordered variables as compared with the provincial average.

RESULTS

Mortality and admissions for acute coronary syndromes were higher in regions with greater numbers of fast-food services after adjustment for risk. Risk-adjusted outcomes among regions intensive in fast-food services were more likely to be high outliers for both mortality (Adjusted Odds Ratio (OR): 2.52, 95% confidence intervals (CI): 1.54 - 4.13, p < 0.001) and acute coronary hospitalizations (Adjusted OR: 2.62, 95% CI 1.42 - 3.59, p < 0.001) compared to regions with low fast-food service intensity. There was no relationship between the concentration of fast-food outlets and risk-adjusted head-trauma hospitalization rates.

INTERPRETATION

Inter-regional cardiac outcome disparities throughout Ontario were partially explained by fast-food service intensity. Such findings emphasize the need to target health promotion and prevention initiatives to highest-risk communities.

Changing profile of elderly patients undergoing coronary bypass surgery

OBJECTIVE

Are elderly patients now undergoing CABG at higher risk than several years ago?

METHODS

1536 patients, aged between 70 and 77 years, who underwent CABG between January 1987 and December 2001, were analysed. Group A 1987-1989 (n=177); group B 1990-1992 (n=243); group C 1993-1995 (n=362); group D 1996-1998 (n=418); and group E 1999-2001 (n=336). The Euroscore evaluated operative risk.

RESULTS

There was an increase in the percentage of the study population from 12.5 to 24.1% (p=0.000). Mean age increased from 72.1±1.8 to 73.2±1.9 years (p=0.047). The percentage of patients with neurological (p=0.002), renal (p=0.013) and lung disease (p=0.04), a previous PTCA (p=0.000), left main stenosis (p=0.003), impaired ventricular function (p=0.000) and reoperations (p=0.01) increased. Emergency/urgent operations (p=0.001) decreased. Hospital mortality decreased from 7.3 to 5.7% (p=0.34). Only neurological problems increased significantly (p=0.03). The calculated operative risk by Euroscore remained stable (p=0.28). To eliminate the influence of the urgent/emergency situation, the Euroscore was recalculated, supposing that all patients were elective. At that moment a significant increase in the operative risk was seen (p=0.02).

CONCLUSION

Over the last few years there has not only been an increase in the number of older patients undergoing CABG, but even in this older population there is an increasing number of high-risk patients.

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.

Prognostic factors of status epilepticus in children

We retrospectively reviewed the medical records of 189 children who were admitted to the Pediatric Neurology Department at Yonsei University College of Medicine with status epilepticus (SE) between April, 1994 and April, 2003. The children were followed up for a mean duration of 17 months. We analyzed the clinical findings and the relationships between neurologic sequelae, recurrence, age of onset, presumptive causes, types of seizure, seizure duration and the presence of fever. Mean age at SE onset was 37 months. Incidences by seizure type classification were generalized convulsive SE in 73.5%, and non-convulsive SE in 26.5%. The incidences of presumptive causes of SE were idiopathic 40.7%, epilepsy 29.1%, remote 16.4% and acute symptomatic in 13.3%. Among all the patients, febrile episodes occurred in 35.4%, especially in patients under 3 year old, and 38.4% of these were associated with febrile illness regardless of presumptive cause. Neurologic sequelae occurred in 33% and the mortality rate was 3%. Neurologic sequelae were lower in patients that presented with an idiopathic etiology and higher in generalized convulsive SE patients. The recurrence of SE was higher in patients with a remote symptomatic epileptic etiology, and generalized convulsive SE showed higher rates of recurrence. Based on this retrospective study, the neurologic outcomes and recurrence of SE were found to be strongly associated with etiology and seizure type. Age, seizure duration and the presence of febrile illness were found to have no effect on outcome.

Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles

OBJECTIVE

To evaluate the incidence and the clinical and echocardiographic features of infective endocarditis (IE) caused by Staphylococcus lugdunensis and to identify the prognostic factors of surgery and mortality in this disease.

DESIGN

Prospective cohort study.

SETTING

Study at two centres (a tertiary care centre and a community hospital).

PATIENTS

10 patients with IE caused by S lugdunensis in 912 consecutive patients with IE between 1990 and 2003.

METHODS

Prospective study of consecutive patients carried out by the multidisciplinary team for diagnosis and treatment of IE from the study institutions. English, French, and Spanish literature was searched by computer under the terms "endocarditis" and "Staphylococcus lugdunensis" published between 1989 and December 2003.

MAIN OUTCOME MEASURES

Patient characteristics, echocardiographic findings, required surgery, and prognostic factors of mortality in left sided cases of IE.

RESULTS

10 cases of IE caused by S lugdunensis were identified at our institutions, representing 0.8% (four of 467), 1.5% (two of 135), and 7.8% (four of 51) of cases of native valve, prosthetic valve, and pacemaker lead endocarditis in the non-drug misusers. Native valve IE was present in four patients (two aortic, one mitral, and one pulmonary), prosthetic valve aortic IE in two patients, and pacemaker lead IE in the other four patients. All patients with left sided IE had serious complications (heart failure, periannular abscess formation, or shock) requiring surgery in 60% (three of five patients) of cases with an overall mortality rate of 80% (four of five patients). All patients with pacemaker IE underwent combined medical treatment and surgery, and mortality was 25% (one patient). In total 59 cases of IE caused by S lugdunensis were identified in a review of the literature. The combined analysis of these 69 cases showed that native valve IE (53 patients, 77%) is characterised by mitral valve involvement and frequent complications such as heart failure, abscess formation, and embolism. Surgery was needed in 51% of cases and mortality was 42%. Prosthetic valve endocarditis (nine of 60, 13%) predominated in the aortic position and was associated with abscess formation, required surgery, and high mortality (78%). Pacemaker lead IE (seven of 69, 10%) is associated with a better prognosis when antibiotic treatment is combined with surgery.

CONCLUSIONS

S lugdunensis IE is an uncommon cause of IE, involving mainly native left sided valves, and it is characterised by an aggressive clinical course. Mortality in left sided native valve IE is high but the prognosis has improved in recent years. Surgery has improved survival in left sided IE and, therefore, early surgery should always be considered. Prosthetic valve S lugdunensis IE carries an ominous prognosis.

Controversies in off-pump coronary artery surgery

Motivated by a desire to reduce the morbidity of a well-established and effective procedure for coronary artery disease, up to 25% of coronary artery bypass operations are being performed without the use of a heart-lung pump. Concerns remain about the quality of the coronary anastomoses and the completeness of revascularization. Randomized trials have not revealed the significant reduction in morbidity or mortality that the early enthusiasts had hoped for. Yet a number of non-randomized studies have shown clinical benefit from the avoidance of an extracorporeal circulation, but these have been criticized for potential bias in patient selection and management.A majority of surgeons have not yet adopted this technique and are waiting for the accumulation of more evidence.

Factors affecting outcome in liver resection

BACKGROUND

Studies demonstrate an inverse relationship between institution/surgeon procedural volumes and patient outcomes. Similar studies exist for liver resections, which recommend referral of patients for liver resections to 'high-volume' centers. These studies did not elucidate the factors that underlie such outcomes. We believe there exists a complex interaction of patient-related and perioperative factors that determine patient outcomes after liver resection. We sought to delineate these factors.

METHODS

Retrospective review of 114 liver resections by a single surgeon from 1993-2003: Records were reviewed for demographics; diagnosis; type/year of surgery; American Society of Anesthesiologists (ASA) score; preoperative albumin, creatinine, and bilirubin; operative time; intraoperative blood transfusions; epidural use; and intraoperative hypotension. Main outcome measurements were postoperative morbidities, mortalities and length of stay (LOS). Data were analyzed using a multivariate linear regression model (SPSS v10.1 statistical analysis program).

RESULTS

Primary indications for resections were hepatocellular carcinoma (HCC) (N=57), metastatic colorectal cancer (N=25), and benign disease (N=18). There were no intraoperative mortalities and 4 perioperative (30-day) mortalities (3.5%). Mortality occurred in patients with malignancies who were older than 50 years. Morbidity was higher in malignant (15.6%) versus benign (5.5%) disease. Complications included bile leak/stricture (N=6), liver insufficiency (N=3), postoperative bleeding (N=2), myocardial infarction (N=2), aspiration pneumonia (N=1), renal insufficiency (N=1), and cancer implantation into the wound (N=1). Average LOS for all resections was 8.6 days. Longer operative time (p=0.04), lower albumin (p<0.001), higher ASA score (p<0.001), no epidural use (p=0.04), and higher creatinine (p<0.001) all correlated positively with longer LOS. ASA score and creatinine were the strongest predictors of LOS. LOS was not affected by patient age, sex, diagnosis, presence of malignancy, intraoperative transfusion requirements, intraoperative hypotension, preoperative bilirubin, case volume per year or year of surgery.

CONCLUSIONS

Liver resections can be performed with low mortality/morbidity and with acceptable LOS by an experienced liver surgeon. Outcome as measured by LOS is most influenced by patient comorbidities entering into surgery. Annual case volume did not influence LOS and had no impact on patient safety. Length of stay may not reflect surgeon/institution performance, as LOS is multifactorial and likely related to patient population, patient selection and increased high-risk cases with a surgeon's experience.

Estimating the exposure-response relationships between particulate matter and mortality within the APHEA multicity project

Several studies have reported significant health effects of air pollution even at low levels of air pollutants, but in most of theses studies linear nonthreshold relations were assumed. We investigated the exposure-response association between ambient particles and mortality in the 22 European cities participating in the APHEA (Air Pollution and Health--A European Approach) project, which is the largest available European database. We estimated the exposure-response curves using regression spline models with two knots and then combined the individual city estimates of the spline to get an overall exposure-response relationship. To further explore the heterogeneity in the observed city-specific exposure-response associations, we investigated several city descriptive variables as potential effect modifiers that could alter the shape of the curve. We conclude that the association between ambient particles and mortality in the cities included in the present analysis, and in the range of the pollutant common in all analyzed cities, could be adequately estimated using the linear model. Our results confirm those previously reported in Europe and the United States. The heterogeneity found in the different city-specific relations reflects real effect modification, which can be explained partly by factors characterizing the air pollution mix, climate, and the health of the population.

Mortality of white Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies

The life expectancy of African Americans has been substantially lower than that of white Americans for as long as records are available. The life expectancy of all Americans has been lower than that of all Canadians since the beginning of the 20th century. Until the 1970s this disparity was the result of the low life expectancy of African Americans. Since then, the life expectancy of white Americans has not improved as much as that of all Canadians. This article discusses two issues: racial disparities in the United States, and the difference in life expectancy between all Canadians and white Americans. Each country's political culture and institutions have shaped these differences, especially national health insurance in Canada and its absence in the United States. The American welfare state has contributed to and explains these differences.

Complications of pancreatic surgery

Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe procedure with mortality rates of <5%. However, postoperative morbidity rates are still substantial. This article reviews the more common procedure-related complications, their prevention and their treatment.

The association of alcohol consumption with coronary heart disease mortality and cancer incidence varies by smoking history

OBJECTIVE

To evaluate the effect of alcohol on coronary heart disease (CHD), cancer incidence, and cancer mortality by smoking history.

DESIGN/SETTING

A prospective, general community cohort was established with a baseline mailed questionnaire completed in 1986.

PARTICIPANTS

A population-based sample of 41,836 Iowa women aged 55-69 years.

MEASUREMENTS

Mortality (total, cancer, and CHD) and cancer incidence outcomes were collected through 1999. Relative hazard rates (HR) were calculated using Cox regression analyses.

MAIN RESULTS

Among never smokers, alcohol consumption (> or =14 g/day vs none) was inversely associated with age-adjusted CHD mortality (HR, 0.40; 95% confidence interval [CI], 0.19 to 0.84) and total mortality (HR, 0.71; 95% CI, 0.55 to 0.92). Among former smokers, alcohol consumption was also inversely associated with CHD mortality (HR, 0.45; 95% CI, 0.23 to 0.88) and total mortality (HR, 0.78; 95% CI, 0.62 to 0.97), but was positively associated with cancer incidence (HR, 1.25; 95% CI, 1.03 to 1.51). Among current smokers, alcohol consumption was not associated with CHD mortality (HR, 1.05; 95% CI, 0.73 to 1.50) or total mortality (HR, 1.07; 95% CI, 0.92 to 1.25), but was positively associated with cancer incidence (HR, 1.30; 95% CI, 1.10 to 1.54).

CONCLUSIONS

Health behavior counseling regarding alcohol consumption for cardioprotection should include a discussion of the lack of a decreased risk of CHD mortality for current smokers and the increased cancer risk among former and current smokers.

Population-based epidemiology of intensive care: critical importance of ascertainment of residency status

INTRODUCTION

Few studies evaluating the epidemiology of critical illness have used strict population-based designs that exclude subjects external to the base population. The objective of this study was to evaluate the potential effects of inclusion of nonresidents in population-based studies in intensive care.

METHODS

A population-based cohort study including all adults admitted to Calgary Health Region (CHR) multidisciplinary and cardiovascular surgical intensive care units (ICUs) between 1 May 1999 and 30 April 2003 was conducted. A comparison of patients resident and nonresident in the base population was then performed.

RESULTS

A total of 12,193 adult patients had at least one admission to an ICU; 7767 (63.7%) were CHR residents, for an incidence of 263.7 per 100,000 per year. Male CHR residents were at significant increased risk for ICU admission as compared with females (330.5 per 100,000 versus 198.2 per 100,000; relative risk, 1.67; 95% confidence interval, 1.59-1.74; P < 0.0001), as were CHR residents aged 65 years and older as compared with younger patients (1719.9 per 100,000 versus 238.7 per 100,000; relative risk, 7.21; 95% confidence interval, 6.95-7.47; P < 0.0001). The mortality rate was significantly lower among non-CHR residents (12.7%) as compared with CHR residents (20.0%; P < 0.0001). Logistic regression modeling identified CHR residency as an independent risk factor for death (odds ratio, 1.4; 95% confidence interval, 1.2-1.5; P < 0.0001).

CONCLUSION

This study provides information on the incidence of and demographic risk factors for admission to ICUs in a defined population. Inclusion of patients that are nonresident in base study populations may lead to gross errors in determination of the occurrence and outcomes of critical illness.

Severe sepsis in managed care: analysis of incidence, one-year mortality, and associated costs of care

OBJECTIVE

To determine severe sepsis (SS) incidence, hospital mortality, 1-year mortality, and costs associated with care in a sample of enrollees in a nationally representative individual practice association (IPA)-network managed care organization (MCO).

METHODS

This was a retrospective analysis of administrative claims data for commercial (not managed Medicare) members. We identified MCO members hospitalized for SS between July 1995 and December 1998. SS cases were identified by a combination of ICD-9-CM codes for infection and organ dysfunction. Enrollment information, physician, facility, and pharmacy claims were analyzed. Subjects with continuous enrollment were followed for 1 full year of observation. Costs were health plan payments to providers, after subtraction of member cost-share amounts.

RESULTS

The incidence rate was 0.91 cases of SS per 1,000 enrollees, increasing with age. The mean age of SS patients was 50 years, and 53% were male. Approximately 63% received surgical intervention. Mortality was 21% during the first hospitalization and 36.1% at 1 year. During follow-up, 47.1% of survivors were rehospitalized. Mean index hospitalization length of stay and costs were 16 days and 26,820 dollars, with 1-year inpatient and outpatient costs totaling 48,996 dollars. Mean outpatient costs per survivor were 8,363 dollars, and mean per-patient-per-month (PPPM) outpatient costs were 906 dollars. Total follow-up costs including rehospitalization were similar for nonsurvivors compared with survivors (7,710 dollars versus 8,522 dollars, P=0.274), but PPPM costs were higher for nonsurvivors (1,760 dollars versus 699 dollars, P<0.001).

CONCLUSIONS

Incidence, hospital, and 1-year mortality rates were lower in this population compared with literature reports and were associated with a lower average age in this managed care population. Mean SS hospitalization costs were high, and nearly one half of survivors required rehospitalization within 1 year. Study results suggest the need to evaluate SS interventions for improvement in health outcomes and cost outcomes, particularly in postsurgical patients.

Assessing ozone-related health impacts under a changing climate

Climate change may increase the frequency and intensity of ozone episodes in future summers in the United States. However, only recently have models become available that can assess the impact of climate change on O3 concentrations and health effects at regional and local scales that are relevant to adaptive planning. We developed and applied an integrated modeling framework to assess potential O3-related health impacts in future decades under a changing climate. The National Aeronautics and Space Administration-Goddard Institute for Space Studies global climate model at 4 degrees x 5 degrees resolution was linked to the Penn State/National Center for Atmospheric Research Mesoscale Model 5 and the Community Multiscale Air Quality atmospheric chemistry model at 36 km horizontal grid resolution to simulate hourly regional meteorology and O3 in five summers of the 2050s decade across the 31-county New York metropolitan region. We assessed changes in O3-related impacts on summer mortality resulting from climate change alone and with climate change superimposed on changes in O3 precursor emissions and population growth. Considering climate change alone, there was a median 4.5% increase in O3-related acute mortality across the 31 counties. Incorporating O3 precursor emission increases along with climate change yielded similar results. When population growth was factored into the projections, absolute impacts increased substantially. Counties with the highest percent increases in projected O3 mortality spread beyond the urban core into less densely populated suburban counties. This modeling framework provides a potentially useful new tool for assessing the health risks of climate change.

Pathogen survival in the external environment and the evolution of virulence

Recent studies have provided evolutionary explanations for much of the variation in mortality among human infectious diseases. One gap in this knowledge concerns respiratory tract pathogens transmitted from person to person by direct contact or through environmental contamination. The sit-and-wait hypothesis predicts that virulence should be positively correlated with durability in the external environment because high durability reduces the dependence of transmission on host mobility. Reviewing the epidemiological and medical literature, we confirm this prediction for respiratory tract pathogens of humans. Our results clearly distinguish a high-virulence high-survival group of variola (smallpox) virus, Mycobacterium tuberculosis, Cornynebacterium diphtheriae, Bordetella pertussis, Streptococcus pneumoniae, and influenza virus (where all pathogens have a mean percent mortality > or = 0.01% and mean survival time >10 days) from a low-virulence low-survival group containing ten other pathogens. The correlation between virulence and durability explains three to four times of magnitude of difference in mean percent mortality and mean survival time, using both across-species and phylogenetically controlled analyses. Our findings bear on several areas of active research and public health policy: (1) many pathogens used in the biological control of insects are potential sit-and-wait pathogens as they combine three attributes that are advantageous for pest control: high virulence, long durability after application, and host specificity; (2) emerging pathogens such as the 'hospital superbug' methicillin-resistant Staphylococcus aureus (MRSA) and potential bioweapons pathogens such as smallpox virus and anthrax that are particularly dangerous can be discerned by quantifying their durability; (3) hospital settings and the AIDS pandemic may provide footholds for emerging sit-and-wait pathogens; and (4) studies on food-borne and insect pathogens point to future research considering the potential evolutionary trade-offs and genetic linkages between virulence and durability.

Development and validation of a functional morbidity index to predict mortality in community-dwelling elders

OBJECTIVE

Functional measures have a great appeal for prognostic instruments because they are associated with mortality, they represent the end-impact of disease on the patient, and information about them can be obtained directly from the patient. However, there are no prognostic indices that have been developed for community-dwelling elders based primarily on functional measures. Our objective in this study was to develop and validate a prognostic index for 2-year mortality in community-dwelling elders, based on self-reported functional status, age, and gender.

DESIGN

Population-based cohort study from 1993 to 1995.

SETTING

Community-dwelling elders within the United States.

PARTICIPANTS

Subjects, age > or =70 (N = 7,393), from the Asset and Health Dynamics Among the Oldest Old study. We developed the index in 4,516 participants (mean age 78, 84% white, 61% female), and validated it in 2,877 different participants (mean age 78, 73% white, 61% female).

MAIN OUTCOME MEASURES

Prediction of 2-year mortality using risk factors such as activities of daily living, instrumental activities of daily living, additional measures of physical function, age, and gender.

RESULTS

Overall mortality was 10% in the development cohort and 12% in the validation cohort. In the development cohort, 6 independent predictors of mortality were identified and weighted, using logistic regression models, to create a point scale: male gender, 2 points; age (76 to 80, 1 point; >80, 2 points); dependence in bathing, 1 point; dependence in shopping, 2 points; difficulty walking several blocks, 2 points; and difficulty pulling or pushing heavy objects, 1 point. We calculated risk scores for each patient by adding the points of each independent risk factor present. In the development cohort, 2-year mortality was 3% in the lowest risk group (0 to 2 points), 11% in the middle risk group (3 to 6 points), and 34% in the highest risk group (>7 points). In the validation cohort, 2-year mortality was 5% in the lowest risk group, 12% in the middle risk group, and 36% in the highest risk group. The c-statistics for the point system were 0.76 and 0.74 in the development and validation cohorts, respectively.

CONCLUSIONS

This prognostic index, which relies solely on self-reported functional status, age, and gender, provides a simple and accurate method of stratifying community-dwelling elders into groups at varying risk of mortality.

Weighing social and economic determinants related to inequalities in mortality

It is well known that there are social inequalities in health. Following the ecological approach, unemployment has been one of the most used indicators to study social inequalities. The aim of the present study was to investigate the relationships between indicators of extreme poverty and social unrest, along with unemployment, and mortality in Barcelona, during the years 1989 to 1993. A cross-sectional ecological study was carried out using Primary Health Care Areas (PHCAs) as the unit of analysis. The study population consisted of residents in Barcelona City. The indicators studied as dependent variables were the age-standardized mortality rates of the following causes of death: total mortality; lung cancer; bronchitis, emphysema, and asthma; cirrhosis; cerebrovascular disease; ischemic heart disease; breast cancer; traffic accidents; acquired immunodeficiency syndrome (AIDS); and drug overdose. Independent variables were male unemployment rate of the primary health care areas and indicators of extreme poverty and social conflict. A descriptive analysis, a bivariate analysis using Spearman correlation coefficients, and a multivariate analysis fitting Poisson regression models were carried out. For the main results, one group of causes of death was associated only with unemployment: bronchitis, emphysema and asthma, cerebrovascular disease, and ischemic heart disease (both men and women); lung cancer (only among men); total mortality and cirrhosis (only among women). Among men, another group of causes of death was associated with extreme poverty and/or social unrest, as well as unemployment: total mortality, cirrhosis, and drug overdose. AIDS in men was only associated with extreme poverty and social unrest. We concluded that we see different types of relationships between deprivation and mortality. Unemployment has been related to mortality because of pathologies with socially accepted risk factors (tobacco and alcohol). Causes of death with risk factors not socially accepted (illegal drug use) have been related to indicators of marginality as well as unemployment.

Divergent patterns of total and cancer mortality in ulcerative colitis and Crohn's disease patients: the Florence IBD study 1978-2001

BACKGROUND AND AIMS

Two divergent patterns of mortality for smoking related diseases in ulcerative colitis and Crohn's disease patients were suggested in a previous population based study in Florence, Italy. Long term follow up (median 15 years) was completed to re-evaluate mortality in this Mediterranean cohort.

PATIENTS AND METHODS

Overall, 920 patients with inflammatory bowel disease were followed until December 2001 or death, with seven patients (0.8%) lost to follow up. A total of 14 040 person years were available for analysis; 118 deaths were observed (81/689 in ulcerative colitis and 37/231 in Crohn's disease). Expected deaths were estimated using age, sex, and calendar specific national and local mortality rates; standardised mortality ratios (SMR) and 95% confidence interval (CI) were calculated.

RESULTS

Among Crohn's disease patients, mortality was strongly increased for gastrointestinal diseases (SMR 4.49 (95% CI 1.80-9.25)), all cancers (SMR 2.10 (95% CI 1.22-3.36)), and lung cancer (SMR 4.00 (95% CI 1.60-8.24)), leading to a significant 50% excess total mortality. Ulcerative colitis patients showed a significantly reduced total mortality because of lower cardiovascular (SMR 0.67 (95% CI 0.45-0.95)) and lung cancer (SMR 0.32 (95% CI 0.07-0.95)) mortality. No significant excess for colorectal cancer mortality was evident in this extended follow up.

CONCLUSIONS

These clearly divergent patterns of mortality correlate with documented differences in smoking habits between Crohn's disease and ulcerative colitis patients. Family doctors and gastroenterologists should consider stopping cigarette smoking a specific priority for Crohn's disease patients; the latter should be offered free participation in structured programmes for smoking cessation, with the aim of reducing smoking related excess mortality. Overall, no evidence of an increased mortality for large bowel cancer emerged in this series.

Influenza and pneumococcal vaccination demand responses to changes in infectious disease mortality

OBJECTIVE

To test the hypothesis that individuals are more likely to receive a vaccination against influenza or pneumonia as the perceived disease threat increases.

DATA SOURCES

This study uses two different national datasets. Individual-level information about the vaccination rates of 38,768 elderly persons are from the Behavioral Risk Factor Surveillance System, 1993-1998. Information on the combined influenza and pneumonia state mortality rates are measured from the Compressed Mortality File.

STUDY DESIGN

Using both cross-sectional and state fixed-effects panel data estimators, we model an individual's probability of having an influenza or pneumococcal vaccination as a function of the lagged state mortality rate. Multiyear lags are specified in order to estimate the duration of the effect of disease mortality on individual vaccination behavior.

PRINCIPAL FINDINGS

Results support our hypothesis that influenza vaccination behavior responds positively to disease mortality, even after a one-year lag. We further find that cross-sectional estimators used in previous work yield downward-biased estimates, although even for our preferred panel data models, the estimated effects are small.

CONCLUSIONS

The findings indicate that behavioral demand responses can help to limit infectious disease epidemics, and suggest further research on how public awareness campaigns can mediate this disease threat responsiveness behavior.

Should aspirin be continued in patients started on warfarin?

BACKGROUND AND OBJECTIVE

Clinicians frequently face the decision of whether to continue aspirin when starting patients on warfarin. We performed a meta-analysis to characterize the tradeoffs involved in this common clinical dilemma.

DATA SOURCES

Multiple computerized databases (1966 to 2003), reference lists of relevant articles, conference proceedings, and queries of primary authors.

STUDY SELECTION

Randomized trials comparing warfarin plus aspirin versus warfarin alone. Studies with target international normalized ratios (INRs) <2 were excluded.

DATA EXTRACTION

Two reviewers independently extracted baseline data and major outcomes: rates of thromboembolism, hemorrhage, and all-cause mortality.

DATA SYNTHESIS

Nine studies met the inclusion criteria. Of the five that enrolled patients with mechanical heart valves, four used the same target INR in both groups, while one used a reduced target INR for the warfarin plus aspirin group. Pooling the results of the first four studies demonstrated that combination of warfarin plus aspirin significantly decreased thromboembolic events (relative risk [RR], 0.33; 95% confidence interval [CI], 0.19 to 0.58), increased major bleeding (RR, 1.58; 95% CI, 1.02 to 2.44), and decreased all-cause mortality (RR, 0.43; 95% CI, 0.23 to 0.81) compared to warfarin alone. The one valve trial using a reduced INR in the warfarin plus aspirin group reported no difference in thromboembolic outcomes but found decreased major bleeding and a significant mortality benefit with combination therapy. Of the remaining trials, three evaluated a warfarin indication not routinely used in the United States (post-myocardial infarction), and the only trial that considered atrial fibrillation was terminated early due to inadequate enrollment.

CONCLUSIONS

For mechanical heart valve patients, the benefits of continuing aspirin when starting warfarin therapy are clear. For other routine warfarin indications, there are not adequate data to guide this common clinical decision.

Epidemiology of sepsis in Norway in 1999

INTRODUCTION

Sepsis and severe sepsis are associated with high hospital mortality. Little is known about the occurrence of sepsis in general hospital populations. The goal of the present study was to reveal the epidemiology of sepsis in Norwegian hospitals over 1 year.

METHODS

Patients admitted to all Norwegian hospitals during 1999 (n = 700,107) were analyzed by searching the database of the Norwegian Patient Registry for markers of sepsis, using International Classification of Diseases (ICD)-10 codes for sepsis and severe infections. In patients with such diagnoses, demographic data, hospital outcome data and ICD-10 codes for organ dysfunction were also retrieved. Sepsis was further classified as primary or secondary, and severe (sepsis with vital organ dysfunction) or nonsevere. The age-adjusted mortality rate, and the sepsis rates for all hospital admissions and in the Norwegian population were calculated.

RESULTS

A total of 6665 patients were classified as having sepsis, and of these 2121 (31.8%) had severe sepsis. The most frequent failing organ system was the circulatory system, and 1562 had septic shock. Mortality increased from 7.1% (in those with no documented organ dysfunction) to 71.8% (in those with three or more organ dysfunctions). The mean mortality was 13.5%, and the mortality of severe sepsis was 27%. The incidence of sepsis was 9.5/1000 hospital admissions and 1.49/1000 inhabitants in 1999.

CONCLUSION

Sepsis is not uncommon in Norwegian hospitals and is associated with high hospital mortality, which is similar to recent findings from the USA. Awareness of sepsis and its appropriate treatment is mandatory in Norway if we are to reduce mortality from sepsis by 25% in the next 5 years.

Effect of obstructive airway disease in patients with non-cystic fibrosis bronchiectasis

BACKGROUND

Extensive research has been devoted to cystic fibrosis-related brochiectasis, compared with non-cystic fibrosis bronchiectasis but the latter is more common and results in significant morbidity and mortality. We assessed the relationship between pulmonary function test (PFT) findings and sputum bacteriology, blood gases, number of hospital admissions and mortality in patients with non-cystic fibrosis bonchiectasis (NCFB).

METHODS

We conducted a retrospective review of 88 consecutive patients admitted with exacerbation of bronchiectasis over 5 years from 1996 to 2001. Demographic and clinical data collected included gender, age, pulmonary functions, arterial blood gases, sputum bacteriology during stable and exacerbation periods, and number of hospital admissions due to exacerbation of bronchiectasis. A comparison was made between patients having obstructive airway disease (OAD group) and patients with normal or restrictive pulmonary functions (non-OAD group).

RESULTS

OAD in patients with NCFB adversely affected clinical outcome. There was a significant increase in Pseudomonas colonization (60.3% vs. 16%; P<0.0003), hypercapnic respiratory failure (63.4% vs. 20%; P<0.0003), and mean number of admissions due to exacerbation (6 vs. 2; P<0.0001) in the OAD group as compared with the non-OAD group. Although mortality was increased in the OAD group, the difference was not statistically significant.

CONCLUSION

Patients with NCFB who have OAD have a significantly higher rate of colonization with Pseudomonas aeruginosa (PSA), hypercapnic respiratory failure, a greater number of hospital admissions due to exacerbation of bronchiectasis, and a higher mortality compared with patients with restrictive or normal pulmonary functions.

Demographic profile and outcome analysis of a tertiary level pediatric intensive care unit

OBJECTIVE

To study the profile and outcome of children admitted to a tertiary level pediatric intensive care unit (PICU) in India.

METHODS

Prospective study of patient demographics, PRISM III scores, diagnoses, treatment, morbidity and mortality of all PICU admissions.

RESULTS

948 children were admitted to the PICU. Mean age was 41.48 months. Male to female ratio was 2.95:1. Mean PRISM III score on admission was 18.50. Diagnoses included respiratory (19.7%), cardiac (9.7%), neurological (17.9%), infectious (12.5%), trauma (11.7%), other surgical (8.8%).196 children (20.68%) required mechanical ventilation. Average duration of ventilation was 6.39 days. 27 children (30.7 children /1000 admissions) had acute respiratory distress syndrome. Gross mortality was 6.7% (59 patients). PRISMIII adjusted mortality was directly proportional to PRISMIII scores. 49.5% of nonsurvivors had multiorgan failure. Average length of PICU stay was 4.52 +/- 2.6 days. Complications commonly encountered were atelectasis (6.37%), accidental extubation (2%), and pneumothorax (0.9%). Incidence of nosocomial infections was 16.86%.

CONCLUSION

Our data appears to be similar with regards to PRISMIII scores and adjusted mortality, length of the PICU stay, and duration of ventilation, to previously published western data. Multiorgan failure remains a major cause of death. As expected, Dengue and malaria were common. Incidence of nosocomial infections was somewhat high. Interestingly, more boys got admitted to the PICU as compared to girls. Clearly more studies are required to assess the overall outcomes of critically ill children in India.

Mortality associated with hormone replacement therapy in younger and older women: a meta-analysis

OBJECTIVE

To assess mortality associated with hormone replacement in younger and older postmenopausal women.

DESIGN

A comprehensive search of MEDLINE, CINAHL, and EMBASE databases was performed to identify randomized controlled trials of hormone replacement therapy from 1966 to September 2002. The search was augmented by scanning selected journals through April 2003 and references of identified articles. Randomized trials of greater than 6 months' duration were included if they compared hormone replacement with placebo or no treatment, and reported at least 1 death.

MEASUREMENTS

Outcomes measured were total deaths and deaths due to cardiovascular disease, cancer, or other causes. Odds ratios (OR) for total and cause-specific mortality were reported separately for trials with mean age of participants less than and greater than 60 years at baseline.

MAIN RESULTS

Pooled data from 30 trials with 26,708 participants showed that the OR for total mortality associated with hormone replacement was 0.98 (95% confidence interval [CI], 0.87 to 1.12). Hormone replacement reduced mortality in the younger age group (OR, 0.61; CI, 0.39 to 0.95), but not in the older age group (OR, 1.03; CI, 0.90 to 1.18). For all ages combined, treatment did not significantly affect the risk for cardiovascular or cancer mortality, but reduced mortality from other causes (OR, 0.67; CI, 0.51 to 0.88).

CONCLUSIONS

Hormone replacement therapy reduced total mortality in trials with mean age of participants under 60 years. No change in mortality was seen in trials with mean age over 60 years.

Infectious and immunologic consequences of blood transfusion

Blood transfusions remain common practice in the critical care and surgical settings. Transfusions carry significant risks, including risks for transmission of infectious agents and immune suppression. Transmission of bacterial infections, although rare, is the most common adverse event with transfusion. The risk for transmission of viral infections has decreased over time, clearly because tests are becoming more sensitive in detecting certain viral infections such as hepatitis B, hepatitis C, and HIV. Several immunomodulatory effects are thought to be related to transfusions, and these can result in cancer recurrence, mortality, and postoperative infections. Numerous studies have been performed to examine the role of leukoreduction in decreasing these transfusion-related complications but results remain contradictory. We review the infectious risks associated with blood transfusion and the most recent data on its immunologic effects, specifically on cancer recurrence, mortality, and postoperative infections in surgical patients. We also review the use of leukoreduction in blood transfusion and its role in preventing transfusion-transmitted infections and immunomodulatory complications.

Statin therapy and mortalitiy in patients with ST-segment elevation myocardial infarction treated with primary angioplasty

BACKGROUND

Statin therapy can reduce long-term mortality in several subgroups of patients with coronary artery disease, but the benefits after primary angioplasty for ST-segment elevation myocardial infarction (STEMI) have yet to be established. Thus the aim of the current study was to determine whether statin therapy is associated with a reduction in mortality in patients with STEMI treated with primary angioplasty.

METHODS

Our population is represented by a total of 1513 consecutive in-hospital survivors treated with primary angioplasty for STEMI between April 1997 and October 2001. Patients were divided into two groups according to statin therapy (statin group, n=893; control group, n=620) at discharge. Clinical follow-up was performed at one year. Multivariate analysis was performed including a propensity score for statin use.

RESULTS

At one-year follow-up statin therapy was associated with a significantly lower mortality (1.2 vs. 71.%, RR [95% CI] 0.16 [0.09-0.32], p<0.0001). Also at multivariate analysis, including the propensity score, statin therapy was associated with a significant mortality reduction (adjusted RR [95% CI] 0.24 [0.12-0.47], p<0.0001).

CONCLUSION

Statin therapy at discharge was associated with a significant reduction in one-year mortality after primary angioplasty for STEMI. Therefore, the use of statins after STEMI is highly recommended.

Balancing the risks and benefits of infliximab in the treatment of inflammatory bowel disease

Patients with moderate to severely active Crohn's disease treated with infliximab may have a small but real risk of developing severe infections, opportunistic infections, and non-Hodgkin's lymphoma.

The New York Cancer Project: rationale, organization, design, and baseline characteristics

Cancer is the second leading cause of death in New York City, with nearly 15,000 deaths each year. The urban setting of New York City provides ready access to large and diverse populations for whom racial/ethnic disparities in cancer risk and outcomes can be examined. A new cohort study was undertaken with several aims: (1) to provide a database and biorepository for studies of cancer etiology and pathogenesis, including host genetics; (2) to differentiate risk factors that contribute to racial/ethnic disparities in cancer risk, prevention, control, incidence, mortality, and survival; (3) to provide timely data on cancer risk and preventive behaviors that can be used to mobilize and then evaluate public health programs. Scientists from multiple institutions contributed to protocol design and implementation. Study instruments included demographics, personal and family history of cancer, risk and prevention efforts. End points include linkage with registries and medical record reviews. Using venue-based sampling with quotas, 18,187 adults aged 30 years or older were recruited over a year to undergo a baseline questionnaire, venipuncture, and contact information. The sample was 39% male, 37% older than 50 years, 58% white, 20% African American, 18% Hispanic, and 9% Asian. In terms of family history of cancer, 21% reported mother, 21% reported father, and 5.9% reported both parents with cancer; 8.5% reported any sibling with cancer. At baseline, 1,231 participants reported prior cancer. Showing the feasibility of constructing a cohort based in New York City, plans proceed for additional recruitment and analyses on the salient questions about cancer.

Predictors of early mortality in a cohort of human immunodeficiency virus type 1-infected african children

BACKGROUND

Pediatric human immunodeficiency virus type 1 (HIV-1) infection follows a bimodal clinical course with rapid progression in 10-45% of children before the age of 2 years and slower progression in the remainder. A prospective observational study was undertaken to determine predictors of mortality in HIV-1-infected African infants during the first 2 years of life.

METHODS

Infants in a perinatal cohort identified to be HIV-1-infected by DNA PCR were followed monthly to 1 year, then quarterly to 2 years or death.

RESULTS

Among 62 HIV-1-infected infants, infection occurred by the age of 1 month in 56 (90%) infants, and 32 (52%) died at median age of 6.2 months. All infant deaths were caused by infectious diseases, most frequently pneumonia (75%) and diarrhea (41%). Univariate predictors of infant mortality included maternal CD4 count <200 cells/microl [hazard ratio (HR), 3.4; P = 0.008], maternal anemia (HR = 3.7; P = 0.005), delivery complications (HR = 2.7; P = 0.01), low birth weight (HR = 4.1; P = 0.001), weight, length and head circumference </=5th percentile at age 1 month (HR = 3.7, P = 0.003; HR = 5.8, P < 0.001; and HR = 10.4, P < 0.001, respectively), formula-feeding (HR = 4.0; P = 0.01), infant CD4% </=15% (HR = 5.5; P = 0.01), infant CD4 count <750 (HR = 9.7; P = 0.006) and maternal death (HR = 2.9, P = 0.05). In multivariate analysis, maternal CD4 count <200 (HR = 2.7; P = 0.03) and delivery complications (HR = 3.4; P = 0.005) were independently associated with infant mortality.

CONCLUSIONS

Advanced maternal HIV disease, maternal anemia, delivery complications, early growth faltering, formula-feeding and low infant CD4 were predictors of early mortality in African HIV-1-infected infants. In resource-poor settings, these predictors may be useful for early identification and treatment of high risk infants.

Sex change towards female in dying Acer rufinerve trees

BACKGROUND AND AIMS

Sex changes within the genus Acer (Aceraceae) may occur because of associations of sex expression and plant health. In this study, a natural population of Acer rufinerve was monitored to clarify the sex change patterns, the relationship between sex expression and plant health, and the causal environmental conditions that precede sex changes.

METHODS

Sex expression, growth rate and mortality of A. rufinerve trees in a natural population were monitored from 1992 to 1997.

KEY RESULTS

Three types of sex expression were observed among A. rufinerve: male, female and bisexual. Among the three types of sex expression, sex changes occurred in all directions. In the growing season of 1994, precipitation was reduced. Stem growth rate decreased and mortality was high in 1994. In the spring of 1995, a drastic sex change from male to female or to bisexual occurred. As a result, the sex ratio became female-biased in 1995, although it had been male-biased from 1992 to 1994. In 1996 and 1997, the proportion of males in the population increased, partly as a result of female mortality and partly as a result of female-to-male sex changes. Sex expression of A. rufinerve was associated with their growth rate and mortality. The growth rate decreased for trees whose sex changed from male to female or to bisexual, and increased for trees whose sex changed from female to male or to bisexual. Dead trees reproduced as females before they died, except for those that died as males in 1994.

CONCLUSIONS

One explanation for the sex change towards increasing femaleness for this A. rufinerve population in 1995 was the deterioration of plant health in the previous growing season, because of reduced precipitation. Sex changes of unhealthy and dying A. rufinerve towards femaleness may facilitate re-occupancy by offspring in gaps created by the death of A. rufinerve trees.

Infliximab in inflammatory bowel disease: clinical outcome in a population based cohort from Stockholm County

BACKGROUND

Several placebo controlled studies have demonstrated the efficacy of infliximab in inflammatory bowel disease (IBD) but the potential toxicity of this new biological compound has been less studied.

AIM

To assess the use of infliximab in IBD in a population based cohort, with special emphasis on the occurrence of severe adverse events and mortality.

PATIENTS

All patients with IBD treated with infliximab between 1999 and 2001 in Stockholm County were evaluated.

METHODS

Prospective registration of clinical data was carried out. Retrospective analyses were made of possible adverse events occurring in relation to infliximab treatment. Adverse events requiring pharmacological treatment or hospitalisation were defined as severe. Clinical response was assessed as remission, response, or failure.

RESULTS

A cohort comprising 217 patients was assembled: 191 patients had Crohn's disease (CD), and infliximab was used off label for ulcerative colitis (UC) in 22 patients. Four patients were treated for indeterminate colitis (IC). Mean age was 37.6 (0.9) years (range 8-79). The mean number of infliximab infusions was 2.6 (0.1) (range 1-11). Forty two severe adverse events were registered in 41 patients (CD, n = 35). Eleven of the severe adverse events occurred postoperatively (CD, n = 6). Three patients with CD developed lymphoma (of which two were fatal), opportunistic infections occurred in two patients (one with UC, fatal), and two patients with severe attacks of IBD died due to sepsis (one with CD, one postoperatively with UC). One additional patient with UC died from pulmonary embolism after colectomy. Mean age in the group with fatal outcome was 62.7 years (range 25-79). The overall response rate was 75% and did not differ between the patient groups.

CONCLUSIONS

Infliximab was efficacious as an anti-inflammatory treatment when assessed in a population based cohort of patients with IBD. However, there appear to be a significant risk of deleterious and fatal adverse events, particularly in elderly patients with severe attacks of IBD. Off label use of infliximab in UC and IC should be avoided until efficacy is proven in randomised controlled trials. The underlying risk of developing malignancies among patients with severe or chronically active CD in need of infliximab treatment is not known but the finding of a 1.5% annual incidence of lymphoma emphasises the need for vigilant surveillance with respect to this malignant complication.

Long term prognosis of fatty liver: risk of chronic liver disease and death

BACKGROUND AND AIMS

Fatty liver is a common histological finding in human liver biopsy specimens. It affects 10-24% of the general population and is believed to be a marker of risk of later chronic liver disease. The present study examined the risk of development of cirrhotic liver disease and the risk of death in a cohort diagnosed with pure fatty liver without inflammation.

METHODS

A total of 215 patients who had a liver biopsy performed during the period 1976-1987 were included in the study. The population consisted of 109 non-alcoholic and 106 alcoholic fatty liver patients. Median follow up time was 16.7 (0.2-21.9) years in the non-alcoholic and 9.2 (0.6-23.1) years in the alcoholic group. Systematic data collection was carried out by review of all medical records. All members of the study cohort were linked through their unique personal identification number to the National Registry of Patients and the nationwide Registry of Causes of Death, and all admissions, discharge diagnoses, and causes of death were obtained.

RESULTS

In the non-alcoholic fatty liver group, one patient developed cirrhosis during the follow up period compared with 22 patients in the alcoholic group. Survival estimates were significantly (p<0.01) different between the two groups, for men as well as for women, with a higher death rate in the alcoholic fatty liver group. Survival estimates in the non-alcoholic fatty liver group were not different from the Danish population.

CONCLUSIONS

This study revealed that patients with type 1 non-alcoholic fatty liver disease have a benign clinical course without excess mortality.

Association between Alcohol Drinking and Cardiovascular Disease Mortality and All-cause Mortality: Kangwha Cohort Study

OBJECTIVE

This study sought to examine relationships between alcohol drinking and cardiovascular disease mortality and all-cause mortality.

METHODS

From March 1985 through December 1999, 2, 696 males and 3, 595 females aged 55 or over as of 1985 were followed up for their mortality until 31 December 1999. We calculated the mortality risk ratios by level of alcohol consumption. Among the drinker, the level of alcohol consumption was calculated by the frequency of alcohol comsumption and the type of alcohol. Cox proportional hazard model was used to adjust for confounding factors.

RESULTS

Among males, compared to abstainer, heavy drinker had significantly higher mortality in all cause (Risk ratio=1.35), cardiovascular disease (Risk ratio=1.52) and cerebrovascular disease (Risk ratio =1.66). Although not significant, moderate drinker had lower ischemic heart disease mortality (Risk ratio =0.38). Among females, there was no statistically significant association between alcohol comsumption and mortality.

CONCLUSIONS

The results of this study suggest that alcohol drinking has harmful effect on all-cause mortality, cardiovascular disease mortality and cerebrovascular disease mortality among males, especially in heavy drinker among males. Minimal evidence on protective effect for cardiovascular disease mortality in low or moderate drinker is observed.

Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database

INTRODUCTION

The present paper describes the methods of data collection and validation employed in the Intensive Care National Audit & Research Centre Case Mix Programme (CMP), a national comparative audit of outcome for adult, critical care admissions. The paper also describes the case mix, outcome and activity of the admissions in the Case Mix Programme Database (CMPD).

METHODS

The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised.

RESULTS

The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions.

CONCLUSIONS

The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.

Does activity in research correlate with visibility?

BACKGROUND

A previous survey has highlighted the fact that most individuals in chemical pathology identifiable from specialist society membership failed to publish material in Medline cited journals during a five year period. It could be considered that published research that is not cited in other work is not useful unless it has achieved visibility, as demonstrated by citation in another research publication.

AIMS

To determine whether the frequency of research publication is associated with research visibility.

METHODS

A random selection from the previous survey was investigated to determine whether the frequency of research publication is associated with research visibility.

RESULTS

There was a logarithmic relation between the frequency of publication and visibility, with an increasing probability of citation as publication frequency increases.

CONCLUSIONS

If academic activity is to survive then individuals must stay active in research; this requires a continuing commitment to a tradition of support for individuals at all stages of their careers engaging in research.

Epidemiologic characteristics of death by poisoning in 1991-2001 in Korea

The purpose of this study was to investigate the epidemiologic characteristics of the death by poisoning in Korea. We recoded the Death Certificates Database by injury based on the short version of the International Classification of External Causes of Injuries (ICECI). We evaluated the mortality rate by total injury and poisoning, and analyzed the mortality rate by age, gender, year and month, toxic agent, and intent. Adjusted odds ratios were calculated to evaluate the effects of socioeconomic factors on suicidal poisoning death. The total number of death cases by injury was 346,656. The proportion of death cases by injury decreased from 13.53% of all death cases in 1991 to 11.89% in 2001. However, the mortality rate by poisoning increased rapidly from 1998, and then remained stable. The number of suicidal poisoning deaths has gradually increased, and its mortality rate was 6.41 (per 100,000) in 2001. Major toxic agents were pesticides and herbicides (50.90%) in 2001. Adjusted odds ratios of suicidal poisoning versus other poisonings showed significant differences in education attainment, region, and marital status. In conclusion, the mortality rate by poisoning has increased, and the proportion of suicidal poisoning also has increased compared to that of accidental poisoning.

The mortality risk of elevated serum transferrin saturation and consumption of dietary iron

BACKGROUND

Recent data shows an increased mortality risk associated with elevated transferrin saturation. Because ingestion of dietary iron may contribute to iron overload in persons with elevated transferrin saturation, we investigated the relationship between elevated transferrin saturation, ingestion of dietary iron and red meat, and mortality.

METHODS

This 12-year cohort study used data from the second National Health and Nutrition Examination Survey 1976-1980 (NHANES II) and the NHANES II Mortality Study 1992. Population estimates were based on 9,229 persons aged 35 to 70 years at baseline. A Cox proportional hazards analysis was performed based on levels of transferrin saturation, intake of dietary iron, and intake of red meat. The analysis was conducted while controlling for demographics, severity of illness, body mass index, and smoking status.

RESULTS

Unadjusted analyses indicated that those who had a high transferrin saturation and reported high dietary iron or red meat consumption had an increased mortality risk. The adjusted survival analysis indicated that persons with elevated transferrin saturation who reported high dietary iron intake had a hazard ratio for death of 2.90 (95% confidence interval [CI], 1.39-6.04) compared with those with normal transferrin saturation levels and reported low dietary iron intake. Persons who had a high transferrin saturation and reported high red meat consumption also had an increased hazard ratio for death (2.26; 95% CI, 1.45-3.52) compared with those who had normal transferrin saturation and reported low red meat consumption.

CONCLUSIONS

Ingestion of large quantities of dietary iron and red meat in persons with high transferrin saturation is associated with an increase in mortality. Simple dietary restrictions may reduce the mortality risk associated with high transferrin saturation.

The changes in the mortality rates of low birth weight infant and very low birth weight infant in Korea over the past 40 years

Total 36 reports on the mortality rates (MRs) of low birth weight infants (LBWI) and very LBWI (VLBWI) in Korea from the 1967 through 2001 were analyzed. We compared the changes in the MR by 5 and 10-yr interval. The MRs observed by 5-yr intervals from the early 1960s through the 1990s have drastically decreased. The MRs of LBWI are as follows: 23.1% and 23.6% in the 1960s, 17.3% and 16.8% in the 1970s, 14.1% and 14.4% in the 1980s, and 8.1% in the early 1990s. The MRs of VLBWI have also fallen and were reported as follows: 68.2% and 63.7% in the 1960s, 55.8% and 57.6% in the 1970s, 56.2% and 48.1% in the 1980s, 33.5% and 24.5% in the 1990s, and 11.7% in the early 2000s. In every 10-yr period, the MRs of LBWI have decreased from 23.4% in 1960, to 17.0% in 1970, to 14.2% in 1980, and to 8.1% in 1990. The MRs of VLBWI also have decreased from 66.2% in 1960, to 56.7% in 1970, to 50.8% in 1980, to 32.9% in 1990, and to 11.7% in 2000. The MR of LBWI and VLBWI has gone down remarkably due to improvements in neonatology in Korea as shown above.

Do regulations limiting residents' work hours affect patient mortality?

OBJECTIVE

To conduct a statewide analysis of the effect of New York's regulations, limiting internal medicine and family practice residents' work hours, on patient mortality.

DESIGN

Retrospective study of inpatient discharge files for 1988 (before the regulations) and 1991 (after the regulations).

SETTING AND PATIENTS

Adult patients discharged from New York teaching hospitals (170214) and nonteaching hospitals (143,455) with a principal diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia, for the years 1988 and 1991 (periods before and after Code 405 regulations went into law). Patients from nonteaching hospitals served as controls.

MEASUREMENT

In-hospital mortality.

RESULTS

Combined unadjusted mortality for congestive heart failure, acute myocardial infarction, and pneumonia patients declined between 1988 and 1991 in both teaching (14.1% to 13.0%; P =.0001) and nonteaching hospitals (14.0% to 12.5%; P =.0001). Adjusted mortality also declined between 1988 and 1991 in both teaching (odds ratio [OR], death 1991/1988, 0.868; 95% confidence interval [CI], 0.843 to 0.894; P =.0001) and nonteaching hospitals (OR, death 1991/1988, 0.853; 95% CI, 0.826 to 0.881; P =.0001). This beneficial trend toward lower mortality over time was nearly identical between teaching and nonteaching hospitals (P =.4348).

CONCLUSION

New York's mandated limitations on residents' work hours do not appear to have positively or negatively affected in-hospital mortality from congestive heart failure, acute myocardial infarction, or pneumonia in teaching hospitals.

[Mortality due to asthma in the city of Barcelona (1983-1993)]

OBJECTIVE

To find asthma mortality in the city of Barcelona.

DESIGN

Descriptive study of mortality.

SETTING

City of Barcelona.

MAIN MEASUREMENTS

Deaths due to asthma in the city of Barcelona in the period 1983-1993 were studied through the register of mortality at Barcelona's Municipal Institute of Health, which in turn is supplied by the Statistical Gazette of Deaths. Rates of mortality per 100,000 inhabitants were calculated, overall and broken down by sex and by age. The ratio of mortality comparing city districts and the place and season of decease was also worked out.

RESULTS

There were 716 deaths due to asthma (overall rate of 3.82/100,000 inhabitants; 3.3 in men and 4.33 in women). Almost two-thirds of deaths occurred in people over 65. Mortality was stable in the entire period except in the over-65s, in which a downwards trend was discerned (beta=-0.63; P=.037). For the 5-34 year old group, the rate oscillated between 0.1 and 0.6/100,000 inhabitants. The number of deaths in the over-65s was greater in winter (31.7%; 95% CI, 27.8-35.7). 56.2% of deaths occurred at home. Hospital deaths were more common among women (P<.001) and the under-65s, and their trend is upwards (P=.004).

CONCLUSIONS

Asthma mortality in the city of Barcelona was stable during the period studied. Its rate for the 5-34 year-old age group was higher than for Spain and slightly greater than in similar nearby countries.

Mortality rates and causes of death in a cohort of HIV-infected and uninfected women, 1993-1999

HIV/AIDS-associated and non-HIV/AIDS-associated death rates and causes of death between 1993 and 1999 were examined in 885 HIV-infected women and 425 uninfected women of the HIV Epidemiology Research Study cohort. Causes of death were determined by review of death certificates and the National Death Index. Adjusted hazard ratios were calculated for mortality risk factors. In the 885 HIV-infected women and 425 uninfected women, 234 deaths and 8 deaths, respectively, occurred by December 31, 1999. All-cause death rates in the HIV-infected women were unchanged between the pre-HAART (1993-1996) and HAART eras (1997-1999)-5.1 versus 5.4 deaths per 100 person-years (py). AIDS as a cause of death decreased from 58% of all deaths in 1996 to 19% in 1999, while HAART use increased to 42% by the end of 1999. In spite of the modest proportion ever using HAART, HIV-related mortality rates did decline, particularly in women with CD4+ cell counts less than 200/mm(3). Drug-related factors were prominent: for the 129 non-AIDS-defining deaths, hepatitis C positivity (relative hazard [RH] 2.6, P <.001) and injection drug use (RH 1.7, P = 0.02) were strong predictors of mortality, but were not significant in the Cox model for 105 AIDS-defining deaths (RH 0.9, P >.30 and RH 0.7, P >.30, respectively. The regression analysis findings, along with the high percentage of non-AIDS deaths attributable to illicit drug use, suggest that high levels of drug use in this population offset improvements in mortality from declining numbers of deaths due to AIDS.

Identification of patients at risk for early out-of-hospital mortality after redocoronary artery surgery

OBJECTIVE

Analyse risk factors and construct a predictive model for identification of patients at risk of early out-of-hospital mortality after coronary reoperations (RECABG).

METHODS

505 patients, discharged from hospital after a RECABG (1987-1998), were studied by univariate and multivariate analysis. A stepwise selective procedure (p<0.05) was used to identify a subset of variables with prognostic value for early out-of-hospital mortality. This subset was used to calculate a prognostic score 'S' and a predicted probability 'p' for early out-of-hospital mortality, p=1/1+ e^-s. Sensitivity analysis was used for evaluation.

RESULTS

The best predictive variables for early out-of-hospital mortality were diabetes (p=0.002), lung disease (p=0.05), emergency operation (p=0.0001) and a perioperative myocardial infarction (p=0.0001). Emergency operation (p=0.001) and antegrade/retrograde cardioplegia (p<0.0000) were independent predictors of a perioperative myocardial infarction. The prognostic accuracy (ROC area) was 86%. Patients were classified into low risk (5%), intermediate risk (15%), high risk (30%) and very high risk (≥40%). A predicted probability of ≥0.40 was used as cut-off point. The specificity of this test was 99%, sensitivity 33%, predictive value of a positive test 79%, and 95% for a negative test.

CONCLUSION

The results show that patients discharged from hospital after RECABG can be stratified according to their early out-of-hospital risk. A perioperative myocardial infarction is the major independent risk factor and can be affected by use of retrograde cardioplegia.

Spinal stenosis surgery in Sweden 1987-1999

Despite being recognised for many years as a clinical diagnosis, no exact definition of spinal stenosis has yet been agreed, leading to difficulties in interpreting and comparing studies of the incidence, prevalence and treatment. This study presents the first analysis of national data to be reported. It is a retrospective population-based national register study, aimed at analyzing surgical interventions in patients with lumbar spinal stenosis, patient characteristics, subsequent development, and case fatality rate, based on Swedish national data for 1987-1999. Complete follow-up data were obtained of incidence and type of spinal stenosis surgery, rate of multiple operations, mortality, underlying causes of death, length of hospital stay, and case fatality rate by linkage of the National Inpatient Register and Swedish Death Register. The study cohort consisted of 10,494 patients. Laminectomy was performed in 89%, and additional fusion in 11%. The mean annual rate of operations was 9.7 per 100,000 inhabitants, the annual number of operations performed increased from 4.7 to 13.2 per 100,000 inhabitants per year. The case fatality rate within 30 days after surgery was 3.5 per 1000 operations. Cardiovascular disease was the most common cause of death (46%). Relative risk of dying within 30 days of admission was doubled in men, and for fusion surgery, and increased four fold in patients older than 80 years. The relative risk of dying decreased during the study period. The results show that spinal stenosis surgery in Sweden has increased, and is associated with a low risk. Within an ageing group of patients, mortality has declined.

Could we have known? A qualitative analysis of data from women who survived an attempted homicide by an intimate partner

OBJECTIVE

To examine in-depth the lives of women whose partners attempted to kill them, and to identify patterns that may aid in the clinician's ability to predict, prevent, or counsel about femicide or attempted femicide.

DESIGN

Qualitative analysis of 30 in-depth interviews.

SETTING

Six U.S. cities.

PARTICIPANTS

Thirty women, aged 17-54 years, who survived an attempted homicide by an intimate partner.

RESULTS

All but 2 of the participants had previously experienced physical violence, controlling behavior, or both from the partner who attempted to kill them. The intensity of the violence, control, and threats varied greatly, as did the number of risk factors measured by the Danger Assessment, defining a wide spectrum of prior abuse. Approximately half (14/30) of the participants did not recognize that their lives were in danger. Women often focused more on relationship problems involving money, alcohol, drugs, possessiveness, or infidelity, than on the risk to themselves from the violence. The majority of the attempts (22/30) happened around the time of a relationship change, but the relationship was often ending because of problems other than violence.

CONCLUSIONS

Clinicians should not be falsely reassured by a woman's sense of safety, by the lack of a history of severe violence, or by the presence of few classic risk factors for homicide. Efforts to reduce femicide risk that are targeted only at those women seeking help for violence-related problems may miss potential victims.

Fatal occupational injuries among self-employed workers in North Carolina

BACKGROUND

Research suggests that rates of occupational injury and death may be higher among self-employed workers than in the wage and salaried population. This analysis was conducted to describe the demographic and occupational characteristics, as well as injuries, activities, and occupations of self-employed workers who are fatally injured on the job.

METHODS

Characteristics of workers by type of employment were compared using data from the North Carolina Office of the Chief Medical Examiner, 1978-1994. Age-, activity-, and industry-specific fatality rates in self-employed workers (N=395) were contrasted to those privately employed (N=1,654).

RESULTS

Highest fatal injury rates among the self-employed occurred in agriculture, retail, and transportation industries. Homicide deaths occurred more frequently among self-employed workers; deaths resulting from unintentional injuries occurred more frequently among non-self-employed workers.

CONCLUSIONS

Elevated occupational fatality death rates among self-employed workers, especially in retail and transportation industries, provide justification for addressing work-related conditions of self-employed workers in North Carolina.

Nonmalarial infant deaths and DDT use for malaria control

Although dichlorodiphenyl trichloroethane (DDT) is being banned worldwide, countries in sub-Saharan Africa have sought exemptions for malaria control. Few studies show illness in children from the use of DDT, and the possibility of risks to them from DDT use has been minimized. However, plausible if inconclusive studies associate DDT with more preterm births and shorter duration of lactation, which raise the possibility that DDT does indeed have such toxicity. Assuming that these associations are causal, we estimated the increase in infant deaths that might result from DDT spraying. The estimated increases are of the same order of magnitude as the decreases from effective malaria control. Unintended consequences of DDT use need to be part of the discussion of modern vector control policy.