An investigation of the growing number of deaths of unidentified people in Russia

BACKGROUND

We examined mortality among working-age Russian men whose identity could not be determined, focusing on where and how they died.

METHODS

Employing micro-data from deaths that occurred in Izhevsk (Ural region) between June 2004 and September 2005, we analysed the characteristics of decedent men aged 25-54 (n = 2158). Differences between completely identified (n = 1699) and unidentified deaths (n = 282) were compared via logistic regression. Data on all deaths in Russia in 2002 were used for supplemental comparisons.

RESULTS

We found that relative to identified men, unidentified men were at a higher risk of death from exposure to natural cold, violence, alcoholic cardiomyopathy, acute respiratory infections and poisonings. Our results also revealed that alcohol played an important role in the mortality of unidentified men. The places and causes of death among these unidentified men provide substantial evidence of their homelessness and social isolation.

CONCLUSION

The increase in deaths among unidentified men of working-age indicates the emergence of a health threat associated with homelessness and social marginalization. This vulnerable group is exposed to different levels and causes of mortality compared with the larger population and represent a new challenge that requires serious and immediate scholarly attention and policy responses.

Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology, and policy

OBJECTIVE

Atypical antipsychotic drugs have been used off label in clinical practice for treatment of serious dementia-associated agitation and aggression. Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotics in elderly patients with dementia, the U.S. Food and Drug Administration (FDA) issued black box warnings for several atypical antipsychotics titled "Cerebrovascular Adverse Events, Including Stroke, in Elderly Patients With Dementia." Subsequently, the FDA initiated a metaanalysis of safety data from 17 registration trials across 6 antipsychotic drugs (5 atypical antipsychotics and haloperidol). In 2005, the FDA issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population.

PARTICIPANTS

Geriatric mental health experts participating in a 2006 consensus conference (Bethesda, Md., June 28-29) reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. EVIDENCE/CONSENSUS PROCESS: The participants concluded that, while problems in clinical trial designs may have been one of the contributors to the failure to find a signal of drug efficacy, the findings related to drug safety should be taken seriously by clinicians in assessing the potential risks and benefits of treatment in a frail population, and in advising families about treatment. Information provided to patients and family members should be documented in the patient's chart. Drugs should be used only when nonpharmacologic approaches have failed to adequately control behavioral disruption. Participants also agreed that there is a need for an FDA-approved medication for the treatment of severe, persistent, or recurrent dementia-related symptoms of agitation and aggression (even in the absence of psychosis) that are unresponsive to nonpharmacologic intervention.

CONCLUSIONS

This article outlines methodological enhancements to better evaluate treatment approaches in future registration trials and provides an algorithm for improving the treatment of these patients in nursing home and non-nursing home settings.

Effects of early changes in organ dysfunctions on the outcomes of critically ill patients in need of renal replacement therapy

INTRODUCTION

Acute kidney injury usually develops in critically ill patients in the context of multiple organ dysfunctions.

OBJECTIVE

To evaluate the effect of changes in associated organ dysfunctions over the first three days of renal replacement therapy on the outcomes of patients with acute kidney injury.

METHODS

Over a 19-month period, we evaluated 260 patients admitted to the intensive care units of three tertiary-care hospitals who required renal replacement therapy for > 48 h. Organ dysfunctions were evaluated by SOFA score (excluding renal points) on the first (D1) and third (D3) days of renal replacement therapy. Absolute (A-SOFA) and relative (Delta-SOFA) changes in SOFA scores were also calculated.

RESULTS

Hospital mortality rate was 75%. Organ dysfunctions worsened (A-SOFA>0) in 53%, remained unchanged (A-SOFA=0) in 17% and improved (A-SOFA<0) in 30% of patients; and mortality was lower in the last group (80% vs. 84% vs. 61%, p=0.003). SOFA on D1 (p<0.001), SOFA on D3 (p<0.001), A-SOFA (p=0.019) and Delta-SOFA (p=0.016) were higher in non-survivors. However, neither A-SOFA nor Delta-SOFA discriminated survivors from non-survivors on an individual basis. Adjusting for other covariates (including SOFA on D1), A-SOFA and Delta-SOFA were associated with increased mortality, and patients in whom SOFA scores worsened or remained unchanged had poorer outcomes.

CONCLUSIONS

In addition to baseline values, early changes in SOFA score after the start of renal replacement therapy were associated with hospital mortality. However, no prognostic score should be used as the only parameter to predict individual outcomes.

Morbidity and mortality associated with Paget's disease of bone: a population-based study

INTRODUCTION

Limited information is available about the clinical features of Paget's disease of bone among unselected patients in the community. We examined morbidity and mortality associated with this condition in a large inception cohort of Olmsted County, MN, residents with a new diagnosis of Paget's disease from 1950 through 1994.

MATERIALS AND METHODS

Survival was estimated using the Kaplan-Meier method. Cox proportional hazards models were used to assess the impact of various covariates on death.

RESULTS

Paget's disease of bone was diagnosed in 236 Olmsted County residents (mean age at diagnosis, 69.6 yr; 55% men). The majority were symptomatic at diagnosis (58%), and the proportion with symptoms did not change from the prescreening era (1950 to June 1974) to the postscreening era (July 1974-1994). Most patients had polyostotic disease (72%), and the pelvis (67%), vertebra (41%), and femur (31%) were the most common sites of involvement. Skeletal complications attributable to Paget's disease included bowing deformities (7.6%), fracture of pagetic bone (9.7%), and osteosarcoma (0.4%). Osteoarthritis was observed in 73% of patients, and 11% had a hip or knee replacement. Nonskeletal complications related to Paget's disease included cranial nerve (0.4%), peripheral nerve (1.7%), and nerve root (3.8%) compression, basilar invagination (2.1%), hypercalcemia (5.2%), and congestive heart failure (3.0%). Hearing loss, noted in 61%, was significantly higher than previously reported.

CONCLUSIONS

Compared with white Minnesota residents, overall survival was slightly better than expected (p = 0.010). No clinical risk factors were identified that were associated with an increased risk of death.

The changing Amazon forest

Long-term monitoring of distributed, multiple plots is the key to quantify macroecological patterns and changes. Here we examine the evidence for concerted changes in the structure, dynamics and composition of old-growth Amazonian forests in the late twentieth century. In the 1980s and 1990s, mature forests gained biomass and underwent accelerated growth and dynamics, all consistent with a widespread, long-acting stimulation of growth. Because growth on average exceeded mortality, intact Amazonian forests have been a carbon sink. In the late twentieth century, biomass of trees of more than 10cm diameter increased by 0.62+/-0.23tCha-1yr-1 averaged across the basin. This implies a carbon sink in Neotropical old-growth forest of at least 0.49+/-0.18PgCyr-1. If other biomass and necromass components are also increased proportionally, then the old-growth forest sink here has been 0.79+/-0.29PgCyr-1, even before allowing for any gains in soil carbon stocks. This is approximately equal to the carbon emissions to the atmosphere by Amazon deforestation. There is also evidence for recent changes in Amazon biodiversity. In the future, the growth response of remaining old-growth mature Amazon forests will saturate, and these ecosystems may switch from sink to source driven by higher respiration (temperature), higher mortality (as outputs equilibrate to the growth inputs and periodic drought) or compositional change (disturbances). Any switch from carbon sink to source would have profound implications for global climate, biodiversity and human welfare, while the documented acceleration of tree growth and mortality may already be affecting the interactions among millions of species.

High serum levels of neopterin in patients with Crimean-Congo hemorrhagic fever and its relation with mortality

OBJECTIVE

Neopterin is generated and released in increased amounts by macrophages upon activation by interferon-gamma during cellular immune response. In this study, we aimed to investigate serum neopterin levels in patients with Crimean-Congo hemorrhagic fever (CCHF) and its clinical significance as a predictor factor of mortality.

METHODS

Neopterin concentrations on the first day of hospitalization were measured in serum samples from 51 CCHF patients. Serum neopterin levels and other clinical-laboratory parameters for fatal and nonfatal CCHF patients were compared.

RESULTS

Serum neopterin levels (73.22+/-54.30 nmol/L) were highly elevated in all CCHF patients (p<0.0001) with higher levels in fatal group (153.66+/-81.34 nmol/L, p=0.0001) compared to nonfatal disease (55.99+/-24.09 nmol/L). In univariate analysis, the level of neopterin on the first day of hospitalization, bleeding, platelet count, aspartate transferase and lactate dehydrogenase were associated with mortality. In multivariate analysis, only the serum level of neopterin was associated with mortality. As a mortality risk factor, area under the curve was 0.939 (p=0.0001, 95% confidence interval: 0.85-1.00).

CONCLUSIONS

In this first study of serum neopterin levels for CCHF, elevated serum neopterin level showing strong activation of monocytes/macrophages was a risk factor for CCHF.

Impact of human factors on clinical protocol performance: a proposed assessment framework and case examples

BACKGROUND

Hyperglycemia is prevalent in critical care and tight control can save lives. Current ad-hoc clinical protocols require significant clinical effort and can often produce highly variable results. Thus, tight control remains elusive as there is not enough understanding of the relationship between control performance and protocol design, particularly with regard to how a given protocol is implemented.

METHODS

This article examines the role of human factors and how individuals relate to technological protocols in clinical settings. The study consists of an overall brief review that is used to create a first graphical representation of the impact of human factors in clinical medical protocol implementations. This initial framework is examined in the context of two similar, but different, case studies-the specialized relative insulin and nutrition tables glycemic control protocol and the TREAT system for antibiotic selection.

RESULTS

A graphical framework relating the human factors impact on medical protocol implementation is created. This framework describes the primary impacts on performance as resulting from clinical burden and protocol transparency. Their primary effect is on compliance with the protocol, which directly affects performance and outcome, particularly in long-term studies versus short pilot studies.

SUMMARY

Compliance is a key element in obtaining the best clinical outcome that a given protocol can provide. The issues that most affect compliance are quite often unrelated to the patient or treatment, but are a function of the protocol design and its ability to integrate (by its design) into a given clinical setting. A framework for examining these issues in design and in post-hoc assessment is therefore proposed and examined in two brief case studies.

Ethnic disparities among patients with systemic lupus erythematosus in South Carolina

OBJECTIVE

To evaluate whether ethnic disparities in mortality exist among hospitalized patients with systemic lupus erythematosus (SLE) in South Carolina, USA.

METHODS

Administrative data were obtained on all SLE patients (ICD-9 code 710.0) hospitalized in South Carolina between 1996 and 2003. An SLE-specific comorbidity index validated as a predictor of hospital mortality was used as a measure of overall comorbidity. Cox proportional hazards models were used to compare mortality rates between Caucasians and African Americans. Post-hoc analyses focused on determining whether disparities were present across different risk strata.

RESULTS

Of 6521 hospitalized patients with SLE (5728 female, 793 male), 1280 (19.6%) died. Annual mortality rates were 21.9% among Caucasians and 25.0% among African Americans. The comorbidity index score was significantly higher among African Americans [median 2.0 (interquartile range 0.0-4.0)] versus Caucasians [median 0.0 (IQR 0.0-3.0); p < 0.0001, Wilcoxon rank-sum test]; however, even after multivariate adjustment, African Americans had a 15% increased mortality risk (hazard ratio 1.15, 95% CI 1.02-1.29, p = 0.013). The disparity was strongest among those with less comorbidity (HR 1.39, 95% CI 1.05-1.81, p = 0.017). Among patients with low comorbidity index scores (n = 3485), the annual mortality rate was 8.1% among Caucasians and 9.7% among African Americans. No ethnic differences in mortality were seen for patients with higher comorbidity.

CONCLUSION

In South Carolina, ethnic disparities in SLE mortality exist, predominantly among those with the least illness severity. Studies are planned to help clarify whether access and quality of care play a role.

Association between the Center for Epidemiologic Studies Depression Scale (CES-D) and mortality in a community sample: An artifact of the somatic complaints factor?

Most previous studies of the depression-mortality association have not examined distinct depressive symptom clusters. This ex post facto study examined which aspects of depression may account for its association with mortality. The Center for Epidemiologic Studies Depression Scale (CES-D) was administered to 3,867 community dwelling adults. Cox proportional hazards procedures estimated the risk of mortality as a function of depression status and each of 4 CES-D factor scores. Depressed participants (CES-D ≥ 16) had a 1.23-fold higher risk of mortality (95% CI 1.03-1.49), adjusting for sociodemographics. Somatic Complaints (SC) was the only factor to predict mortality (HR 1.19, 95% CI 1.03-1.38). After excluding SC, CES-D scores no longer predicted mortality (HR .98, 95% CI .79-1.21). The association between CES-D depressive symptoms and mortality appears to be a function of the SC factor. The association between non-somatic depressive symptoms and mortality may not be as robust as past findings suggest.

Risk factors for neonatal mortality due to birth asphyxia in southern Nepal: a prospective, community-based cohort study

OBJECTIVE

Our goal was to identify antepartum, intrapartum, and infant risk factors for birth asphyxia mortality in a rural, low-resource, population-based cohort in southern Nepal.

PATIENTS AND METHODS

Data were collected prospectively during a cluster-randomized, community-based trial evaluating the impact of newborn skin and umbilical cord cleansing on neonatal mortality and morbidity in Sarlahi, Nepal. A total of 23662 newborn infants were enrolled between September 2002 and January 2006. Multivariable regression modeling was performed to determine adjusted relative risk estimates of birth asphyxia mortality for antepartum, intrapartum, and infant risk factors.

RESULTS

Birth asphyxia deaths (9.7/1000.0 live births) accounted for 30% of neonatal mortality. Antepartum risk factors for birth asphyxia mortality included low paternal education, Madeshi ethnicity, and primiparity. Facility delivery; maternal fever; maternal swelling of the face, hands, or feet; and multiple births were significant intrapartum risk factors for birth asphyxia mortality. Premature infants (<37 weeks) were at higher risk, and the combination of maternal fever and prematurity resulted in a 7-fold elevation in risk for birth asphyxia mortality compared to term infants of afebrile mothers.

CONCLUSIONS

Maternal infections, prematurity, and multiple births are important risk factors for birth asphyxia mortality in the low-resource, community-based setting. Low socioeconomic status is highly associated with birth asphyxia, and the mechanisms leading to mortality need to be elucidated. The interaction between maternal infections and prematurity may be an important target for future community-based interventions to reduce the global impact of birth asphyxia on neonatal mortality.

Influenza-related hospitalisation and death in Australians aged 50 years and older

Estimating the true burden of influenza is problematic because relatively few hospitalisations or deaths are specifically coded as influenza related. Statistical regression techniques using influenza and respiratory syncytial virus surveillance data were used to estimate the number of excess hospitalisations and deaths attributable to influenza. Several International Classification of Diseases 10th Revision (ICD-10) groupings were used for both hospitalisation and mortality estimates, including influenza and pneumonia, other respiratory disorders, and circulatory disorders. For Australians aged 50-64 years, the annual excess hospitalisations attributable to influenza were 33.3 (95%CI: 23.2-43.4) per 100,000 for influenza and pneumonia and 57.6 (95%CI: 32.5-82.8) per 100,000 for other respiratory disorders. For Australians aged > or =65 years, the annual excess hospitalisations attributable to influenza were 157.4 (95%CI: 108.4-206.5) per 100,000 for influenza and pneumonia and 282.0 (95%CI: 183.7-380.3) per 100,000 for other respiratory disorders. The annual excess all-cause mortality attributable to influenza was 6.4 (95%CI: 2.6-10.2) per 100,000 and 116.4 (95%CI: 71.3-161.5) per 100,000, for Australians aged 50-64 years and those aged > or =65 years, respectively. In the age-group > or =65 years, a significant association was found between influenza activity and circulatory mortality. We conclude that influenza is responsible for a substantial amount of mortality and morbidity, over and above that which is directly diagnosed as influenza in Australians aged > or =50 years.

Mortality following myocardial infarction in women and men: an analysis of insurance claims data from inpatient hospitalizations

INTRODUCTION

The results of previous studies of the association between gender and mortality following hospital admission due to acute myocardial infarction are inconsistent. National data for Germany have been lacking to date. Hence the objective of this study was to analyze this association on the basis of a nationwide dataset.

METHODS

The analysis was carried out using insurance claims data from inpatients insured by the statutory health insurer AOK, whose main diagnosis was acute myocardial infarction and who were discharged from hospital in the years 2004 and 2005. Several mortality endpoints were used, including 30-day mortality and one-year mortality.

RESULTS

132 774 male and female patients were included. Crude analyses showed a pronounced excess mortality in women (odds ratio 30-day mortality = 1.65; 95% confidence interval = 1.59 to 1.70). However, after adjustment for age (in decentiles) practically equal mortality was observed for female and male patients (odds ratio 30-day mortality = 1.00; 95% confidence interval = 0.96 to 1.03). Only in the comparatively small group of male and female patients up to the age of 50 was a slightly increased mortality observed in women (odds ratio 30-day mortality = 1.09; 95% confidence interval = 0.85 to 1.40).

DISCUSSION

To our knowledge, this study is the first nationwide analysis focusing on the association between gender and survival following hospital admission due to acute myocardial infarction. Different results from earlier regional studies may be explained by selection bias or inadequate risk adjustment.

Infective endocarditis in haemodialysis patients: 16-year experience at one institution

Objectives. To ascertain the characteristics, outcomes and correlates of mortality in chronic haemodialysis patients with confirmed infective endocarditis (IE).

Methods. Patients were identified by computerized discharge diagnosis and chart review of admissions to Saint Louis University hospital from January 1990 through January 2006. Modified Duke Criteria were retrospectively applied to confirm the diagnosis of IE. Survivors and non-survivors were compared to identify clinical correlates of IE mortality.

Results. We identified 59 patients with IE who had received dialysis for a mean duration of 52.9 ± 58.0 months prior to IE diagnosis. Dialysis access comprised 28 (47.5%) catheters, 26 (44.1%) arteriovenous grafts, 3 (5.1%) arteriovenous fistulas and 2 (3.4%) life sites. The causative organisms were MRSA in 15 (25%), MSSA 12 (20%), S. Epidermidis 10 (17%), Enterococci 8 (14%), multi-organism 6 (10%), gram negative 2 (3%) and VRE 1 (2%). Valves involved were mitral valve in 37 (63%), aortic valve in 10 (17%), tricuspid valve in 3 (5%) and multiple valves in 8 (13%) cases. Patient mortality was 28.8% (n = 17) during hospitalization, 37.9% (n = 22) at 30 days and 63.1% (n = 36) at 1 year. In multivariable logistic regression, the adjusted odds ratio of in-hospital mortality was 3.6-fold higher in those with IE and arteriovenous grafts (P = 0.04, 95% CI 1.04–12.27) compared to other forms of dialysis access.

Conclusion. Mortality of IE remains high, despite the availability of potent antibiotics. Patients with arteriovenous grafts who develop IE may face increased risk for in-hospital mortality, perhaps reflecting difficulty eradicating endovascular infection if a graft is involved.

Epidemiology of cerebrovascular diseases in cuba, 1970 to 2006

Introduction

Cerebrovascular diseases (CD) are a global health problem. They are the second and third causes of death in the world and in Cuba, respectively. Projections for year 2020 suggest they will continue to be among the main causes of death and disability, both in developed and developing countries. In 2006, the National Health System (NHS) presented its Public Health Projections in Cuba for Year 2015, which set the following specific goals for CD mortality reduction: overall mortality by 25%, female mortality by 30%, and hospital mortality by 30%.

Objective

Analyze CD mortality in Cuba from 1970 to 2006, before and after implementation of the National Program for Cerebrovascular Disease Prevention and Control (NPCD-PC) to obtain a better understanding of the current situation, which may serve as the basis to meet the goals set for year 2015.

Methods

CD mortality databases from the National Statistical Division of the Cuban Ministry of Public Health were used. The following variables were applied: sex, CD-related causes, and place of death. Crude and age-adjusted mortality rates were determined. Overall mortality, mortality by sex, years of potential life lost, hospital mortality, incidence, and prevalence were calculated.

Results

Crude mortality rates showed a sustained increase within the time series under study; conversely, age-adjusted rates showed a decrease in mortality during the 1970s, were stable in the 1980s and 1990s and, finally, decreased since year 2000, when the NPCD-PC program was started in the country. The male/female ratio increased slightly from the late 1990s until 2005; yet female mortality has shown a tendency to increase. Between 1993 and 2002, cerebral hemorrhage caused more deaths than the cerebral infarction; since then, this profile has reversed. CD-related years of potential life lost (YPLL) showed a decrease from 1970 to 1975, followed by a sustained increase through 1985, and a gradual decrease since 1990. Hospital mortality diminished steadily from 1990 to 1999 and has remained stable since year 2000. Even though there was greater CD incidence from 2000 to 2001, it has decreased since then. However, prevalence has increased slightly every year from 2000 to 2005.

Conclusion

Although overall mortality and female mortality rates, in particular, increased following implementation of the NPCD-PC program, age-adjusted mortality, hospital mortality, and incidence diminished during the same period. Further study is recommended to determine specific actions required to achieve CD mortality reduction goals by 2015.

Outcome and quality of life one year after percutaneous coronary interventions in octogenarians

BACKGROUND

While percutaneous coronary intervention (PCI) is increasingly being performed in octogenarians, little is known about the quality of life (QOL) one year after PCI. We assessed the one-year outcome and QOL after PCI.

METHODS

Outcome and QOL at one year were assessed in patients of 80 years and older who underwent PCI at our institution. We used the RAND-36 Health Survey to assess health-related QOL at follow-up. The EuroSCORE was used for reference risk assessment.

RESULTS

Ninety-eight patients (mean age 82.7+/-2.9 years; 60% female) underwent PCI. Acute PCI was performed in 36% of the patients. Canadian Cardiovascular Society (CCS) angina class before the procedure was class III for 28% and class IV for 64%. Of the patients, 98% were in the highest-risk group (additive EuroSCORE 6+). The overall PCI success rate was 94%. Mortality at one year was 19% (38% acute vs. 12% elective PCI). At followup, general health was rated as fairly good and better then before PCI (CCS I and II: 77%). RAND-36 scores for the mental component were better than scores for the physical component. Physical functioning (41+/-28) and role limitations caused by physical health problems (32+/-37) had the worst scores. The mental component vitality had the lowest (55+/-20) and mental health the highest (70+/-21) score. Social functioning was in general good (67+/-26).

CONCLUSION

Octogenarians have a high mortality risk following PCI, especially in acute PCI. In survivors QOL is acceptable with a better mental than physical score. In general, PCI in octogenarians has a positive effect on health perception, with less symptoms of angina pectoris. (Neth Heart J 2008;16:117-22.).

The impact of secondary particles on the association between ambient ozone and mortality

BACKGROUND

Although several previous studies have found a positive association between ambient ozone and mortality, the observed effect may be confounded by other secondary pollutants that are produced concurrently with ozone.

OBJECTIVES

We addressed the question of whether the ozone-mortality relationship is entirely a reflection of the adverse effect of ozone, or whether it is, at least in part, an effect of other secondary pollutants.

METHODS

Separate time-series models were fit to 3-6 years of data between 2000 and 2005 from 18 U.S. communities. The association between nonaccidental mortality was examined with ozone alone and with ozone after adjustment for fine particle mass, sulfate, organic carbon, or nitrate concentrations. The effect estimates from each of these models were pooled using a random-effects meta-analysis to obtain an across-community average.

RESULTS

We found a 0.89% [95% confidence interval (CI), 0.45-1.33%] increase in nonaccidental mortality with a 10-ppb increase in same-day 24-hr summertime ozone across the 18 communities. After adjustment for PM(2.5) (particulate matter with aerodynamic diameter <or= 2.5 microm) mass or nitrate, this estimate decreased slightly; but when adjusted for particle sulfate, the estimate was substantially reduced to 0.58% (95% CI, -0.33 to 1.49%).

CONCLUSIONS

Our results demonstrate that the association between ozone and mortality is confounded by particle sulfate, suggesting that some secondary particle pollutants could be responsible for part of the observed ozone effect.

Prognostic factors for mortality among patients above the 6th decade undergoing non-cardiac surgery: cares--clinical assessment and research in elderly surgical patients

PURPOSE

To ascertain perioperative morbimortality and identify prognostic factors for mortality among patients > or = 55 years who undergo non-cardiac surgery.

METHODS

A retrospective cohort of 403 patients relating to perioperative morbidity-mortality. Data were collected from a standardized protocol on gender, age, comorbidities, medications used, smoking, alcohol abuse, chronic use of benzodiazepine, nutritional status, presence of anemia, activities of daily living, American Society of Anesthesiology classification, Detsky's modified cardiac risk index--American College of Physicians, renal function evaluation, pulmonary risk according to the Torrington scale, risk of thromboembolic events, presence of malignant disease and complementary examinations.

RESULTS

The mean age of the subjects was 70.8 +/- 8.1 years. The "very old" (> or =80 years) represented 14%. The mortality rate was 8.2%, and the complication rate was 15.8%. Multiple logistic regression showed that a history of coronary heart disease (OR: 3.75; p=0.02) and/or valvular heart disease (OR: 31.79; p=0.006) were predictors of mortality. The American Society of Anesthesiology classification was shown to be the best scale to mark risk (OR: 3.01; p=0.016). Nutritional status was a protective factor, in which serum albumin increases of 1 mg/dl decreased risk by 63%.

DISCUSSION

The results indicate that serum albumin, coronary heart disease, valvular heart disease and the American Society of Anesthesiology classification could be prognostic predictors for aged patients in a perioperative setting. In this sample, provided that pulmonary, cardiac and thromboembolic risks were properly controlled, they did not constitute risk factors for mortality. Furthermore, continuous effort to learn more about the preoperative assessment of elderly patients could yield intervention possibilities and minimize morbimortality.

Inpatient mortality in children with clinically diagnosed malaria as compared with microscopically confirmed malaria

BACKGROUND

Inpatient treatment for malaria without microscopic confirmation of the diagnosis occurs commonly in sub-Saharan Africa. Differences in mortality in children who are tested by microscopy for Plasmodium falciparum infection as compared with those not tested are not well characterized.

METHODS

A retrospective chart review was conducted of all children up to 15 years of age admitted to Mulago Hospital, Kampala, Uganda from January 2002 to July 2005, with a diagnosis of malaria and analyzed according to microscopy testing for P. falciparum.

RESULTS

A total of 23,342 children were treated for malaria during the study period, 991 (4.2%) of whom died. Severe malarial anemia in 7827 (33.5%) and cerebral malaria in 1912 (8.2%) were the 2 common causes of malaria-related admissions. Children who did not receive microscopy testing had a higher case fatality rate than those with a positive blood smear (7.5% versus 3.2%, P < 0.001). After adjustment for age, malaria complications, and comorbid conditions, children who did not have microscopy performed or had a negative blood smear had a higher risk of death than those with a positive blood smear [odds ratio (OR): 3.49, 95% confidence interval (CI): 2.88-4.22, P < 0.001; and OR: 1.59, 95% CI: 1.29-1.96, P < 0.001, respectively].

CONCLUSIONS

Diagnosis of malaria in the absence of microscopic confirmation is associated with significantly increased mortality in hospitalized Ugandan children. Inpatient diagnosis of malaria should be supported by microscopic or rapid diagnostic test confirmation.

General psychiatric or depressive symptoms were not predictive for mortality in a healthy elderly cohort in Southern Brazil

General psychiatric symptoms may interfere with the ability of individuals to take care of their health, to get involved with activities and develop social abilities, thereby increasing risk of death.

Egg consumption in relation to cardiovascular disease and mortality: the Physicians' Health Study

BACKGROUND

A reduction in dietary cholesterol is recommended to prevent cardiovascular disease (CVD). Although eggs are important sources of cholesterol and other nutrients, limited and inconsistent data are available on the effects of egg consumption on the risk of CVD and mortality.

OBJECTIVE

We aimed to examine the association between egg consumption and the risk of CVD and mortality.

DESIGN

In a prospective cohort study of 21,327 participants from Physicians' Health Study I, egg consumption was assessed with an abbreviated food questionnaire. Cox regression was used to estimate relative risks.

RESULTS

In an average follow-up of 20 y, 1550 new myocardial infarctions (MIs), 1342 incident strokes, and 5169 deaths occurred. Egg consumption was not associated with incident MI or stroke in a multivariate Cox regression. In contrast, adjusted hazard ratios (95% CI) for mortality were 1.0 (reference), 0.94 (0.87, 1.02), 1.03 (0.95, 1.11), 1.05 (0.93, 1.19), and 1.23 (1.11, 1.36) for the consumption of <1, 1, 2-4, 5-6, and > or = 7 eggs/wk, respectively (P for trend < 0.0001). This association was stronger among diabetic subjects, in whom the risk of death in a comparison of the highest with the lowest category of egg consumption was twofold (hazard ratio: 2.01; 95% CI: 1.26, 3.20; P for interaction = 0.09).

CONCLUSIONS

Infrequent egg consumption does not seem to influence the risk of CVD in male physicians. In addition, egg consumption was positively related to mortality, more strongly so in diabetic subjects, in the study population.

Reduction in mortality of severely injured patients in Germany

INTRODUCTION

The trauma registry of the German Society of Trauma Surgery is a multicentric prospective record of the treatment of severely injured patients.

METHODS

The present study examines the effect of a quality management system on key processes and outcomes, in hospitals included in the trauma registry. The study is based on data of 11 013 severely injured patients (injury severity score = 16) who were treated in 105 hospitals between 1993 and 2005. A variety of parameters relating to early diagnosis and treatment were considered. Outcome quality was measured by a comparison between observed and calculated mortality (revised injury severity classification).

RESULTS

During the 13 year long study period mortality could be significantly reduced from 22.8% to 18.7%. The time to initial radiological and ultrasound diagnosis was reduced, the use of computed tomography increased, the time until emergency operations in hemorrhagic shock was reduced, and damage limiting orthopedic interventions were performed more frequently.

DISCUSSION

The German Trauma Registry records processes and treatment results in severely injured patients. This information is fed back to participating hospitals. The continuous data feedback is associated with a continuous improvement of process and outcome quality in the treatment of severely injured patients.

Prediction of one-year survival in high-risk patients with acute coronary syndromes: results from the SYNERGY trial

BACKGROUND

Despite advances in pharmacologic therapy and invasive management strategies for patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), these patients still suffer substantial morbidity and mortality.

OBJECTIVE

The objective of this study was to analyze independent predictors of 1-year mortality in patients with high-risk NSTE ACS.

DESIGN AND PARTICIPANTS

A total of 9,978 patients were assigned to receive enoxaparin or unfractionated heparin (UFH) in this prospective, randomized, open-label, international trial.

MEASUREMENTS

Vital status at 1 year was collected. Univariable and multivariable predictors of 1-year mortality were identified. Three different multivariable regression models were constructed to identify: (1) predictors of 30-day mortality; (2) predictors of 1-year mortality; (3) predictors of 1-year mortality in 30-day survivors. The last model is the focus of this paper.

RESULTS

Overall, 9,922 (99.4%) of patients had 1-year follow-up. Of the 56 patients (37 UFH-assigned and 19 enoxaparin-assigned) without 1-year data, 11 patients were excluded because of withdrawal of consent, and 45 could not be located. One-year mortality was 7.5% (7.7% enoxaparin-assigned patients; 7.3% UFH-assigned patients; P = 0.4). In patients surviving 30 days after enrollment, independent predictors of 1-year mortality included factors known at baseline such as increased age, male sex, decreased weight, having ever smoked, decreased creatinine clearance, ST-segment depression, history of diabetes, history of angina, congestive heart failure, coronary artery bypass grafting, increased heart rate, rales, increased hematocrit, lowered hemoglobin, and higher platelet count. Factors predictive of mortality during the hospitalization and 30-day follow-up period were decreased weight at 30 days from baseline, atrial fibrillation, decreased nadir platelet, no use of beta-blockers and statins up to 30 days, and not receiving an intervention (c-index = 0.82).

CONCLUSIONS

Easily determined baseline clinical characteristics can be used to predict 1-year mortality with reasonable discriminative power. These models corroborate prior work in a contemporary aggressively managed population. A model to predict 1-year mortality in patients surviving at least 30 days may be quite helpful to healthcare providers in setting expectations and goals with patients after ACS.

Temporal variation in the association between benzene and leukemia mortality

BACKGROUND

Benzene is a human carcinogen. Exposure to benzene occurs in occupational and environmental settings.

OBJECTIVE

I evaluated variation in benzene-related leukemia with age at exposure and time since exposure.

METHODS

I evaluated data from a cohort of 1,845 rubber hydrochloride workers. Benzene exposure-leukemia mortality trends were estimated by applying proportional hazards regression methods. Temporal variation in the impact of benzene on leukemia rates was assessed via exposure time windows and fitting of a multistage cancer model.

RESULTS

The association between leukemia mortality and benzene exposures was of greatest magnitude in the 10 years immediately after exposure [relative rate (RR) at 10 ppm-years = 1.19; 95% confidence interval (CI), 1.10-1.29]; the association was of smaller magnitude in the period 10 to < 20 years after exposure (RR at 10 ppm-years = 1.05; 95% CI, 0.97-1.13); and there was no evidence of association > or = 20 years after exposure. Leukemia was more strongly associated with benzene exposures accrued at > or = 45 years of age (RR at 10 ppm-years = 1.11; 95% CI, 1.04-1.17) than with exposures accrued at younger ages (RR at 10 ppm-years = 1.01; 95% CI, 0.92-1.09). Jointly, these temporal effects can be efficiently modeled as a multistage process in which benzene exposure affects the penultimate stage in disease induction.

CONCLUSIONS

Further attention should be given to evaluating the susceptibility of older workers to benzene-induced leukemia.

Child mortality inequalities and linkage with sanitation facilities in Bangladesh

Principal component analysis (PCA) was applied to assets and other household data, collected as part of the Bangladesh Demographic and Health Survey (BDHS) in 2004, to rank individuals according to a household socioeconomic index and to investigate whether this predicts access to the sanitation system or outcomes. PCA was used for determining wealth indices for 11,440 women in 10,500 households in Bangladesh. The index was based on the presence or absence of items from a list of 13 specific household assets and three housing characteristics. PCA revealed 35 components, of which the first component accounted for 18% of the total variance. Ownership of assets and housing features contributed almost equally to the variance in the first component. In this study, ownership of latrines was examined as an example of sanitation-intervention access, and rates of mortality of neonates, infant, and children aged less than five years (under-five mortality) as examples of health outcomes. The analysis demonstrated significant gradients in both access and outcome measures across the wealth quintiles. The findings call for more attention to approaches for reducing health inequalities. These could include reforms in the health sector to provide more equitable allocation of resources, improvement in the quality of health services offered to the poor, and redesigning interventions and their delivery to ensure that they are more pro-poor.

Alcohol dependence, mortality, and chronic health conditions in a rural population in Korea

To determine the effects of excessive drinking and alcohol dependency on mortality and chronic health problems in a rural community in South Korea, this study represents a nested case-control study. In 1998, we conducted the Alcohol Dependence Survey (ADS), a population survey of a village in Korea. To measure the effects of alcohol on chronic health conditions and mortality over time, in 2004, we identified 290 adults from the ADS sample (N=1,058) for follow-up. Of those selected, 145 were adults who had alcohol problems, either alcohol dependence as assessed in the ADS by the Severity of Alcohol Dependence Questionnaire (N=59), or excessive drinking without dependency (N=86). Further 145 nondrinkers were identified, matching those with alcohol problems in age and sex. We revisited the village in 2004 and completed personal interviews with them. In multivariate logistic regressions, the rates of mortality and morbidity of chronic health conditions were three times greater for alcohol dependents compared with the rate for nondrinkers. Importantly, however, excessive drinking without dependency was not associated with the rates of either mortality or morbidity. Future investigations would benefit by attending more specifically to measures for alcohol dependence as well as measures for alcohol consumption.

Body mass index, dementia, and mortality in the elderly

OBJECTIVES

To explore the association between body mass index and mortality in the elderly taking the diagnosis of dementia into account.

DESIGN

Cohort study.

SETTING

cohort study of aging in Medicare recipients in New York City.

PARTICIPANTS

1,452 elderly individuals 65 years and older of both genders.

MEASUREMENTS

We used proportional hazards regression for longitudinal multivariate analyses relating body mass index (BMI) and weight change to all-cause mortality.

RESULTS

There were 479 deaths during 9,974 person-years of follow-up. There were 210 cases of prevalent dementia at baseline, and 209 cases of incident dementia during follow-up. Among 1,372 persons with BMI information, the lowest quartile of BMI was associated with a higher mortality risk compared to the second quartile (HR=1.5; 95% CI: 1.1,2.0) after adjustment for age, gender, education, ethnic group, smoking, cancer, and dementia. When persons with dementia were excluded, both the lowest (HR=1.9; 95% CI=.3,2.6) and highest (HR=1.6; 95% CI: 1.1,2.3) quartiles of BMI were related to higher mortality. Weight loss was related to a higher mortality risk (HR=1.5; 95% CI: 1.2,1.9) but this association was attenuated when persons with short follow-up or persons with dementia were excluded.

CONCLUSION

The presence of dementia does not explain the association between low BMI and higher mortality in the elderly. However, dementia may explain the association between weight loss and higher mortality.

HbA1c measured in stored erythrocytes and mortality rate among middle-aged and older women

AIMS/HYPOTHESIS

Diabetes is known to increase mortality rate, but the degree to which mild hyperglycaemia may be associated with the risk of death is uncertain. We examined the association between HbA1c measured in stored erythrocytes and mortality rate in women with and without diabetes.

METHODS

We conducted a cohort study of 27,210 women>or=45 years old with no history of cardiovascular disease or cancer who participated in the Women's Health Study, a randomised trial of vitamin E and aspirin.

RESULTS

Over a median of 10 years of follow-up, 706 women died. Proportional hazards models adjusted for age, smoking, hypertension, blood lipids, exercise, postmenopausal hormone use, multivitamin use and C-reactive protein were used to estimate the relative risk of mortality. Among women without a diagnosis of diabetes and HbA1c<5.60%, those in the top quintile (HbA1c 5.19-5.59%) had a relative risk of mortality of 1.28 (95% CI 0.98-1.69, p value for linear trend=0.14) compared with those with HbA1c 2.27-4.79%. Women with HbA1c 5.60-5.99% and no diagnosis of diabetes had a 54% increased risk of mortality (95% CI 1-136%) compared with those with HbA1c 2.27-4.79%. HbA1c was significantly associated with mortality across the range 4.50-7.00% (p value for linear trend=0.02); a test of deviation from linearity was not statistically significant (p=0.67). Diabetic women had more than twice the mortality risk of non-diabetic women.

CONCLUSIONS/INTERPRETATION

This study provides further evidence that chronic mild hyperglycaemia, even in the absence of diagnosed diabetes, is associated with increased risk of mortality. ClinicalTrials.gov ID no.: NCT00000479.

Long-term effects of traffic-related air pollution on mortality in a Dutch cohort (NLCS-AIR study)

BACKGROUND

Several studies have found an effect on mortality of between-city contrasts in long-term exposure to air pollution. The effect of within-city contrasts is still poorly understood.

OBJECTIVES

We studied the association between long-term exposure to traffic-related air pollution and mortality in a Dutch cohort.

METHODS

We used data from an ongoing cohort study on diet and cancer with 120,852 subjects who were followed from 1987 to 1996. Exposure to black smoke (BS), nitrogen dioxide, sulfur dioxide, and particulate matter < or = 2.5 microm (PM(2.5)), as well as various exposure variables related to traffic, were estimated at the home address. We conducted Cox analyses in the full cohort adjusting for age, sex, smoking, and area-level socioeconomic status.

RESULTS

Traffic intensity on the nearest road was independently associated with mortality. Relative risks (95% confidence intervals) for a 10-microg/m(3) increase in BS concentrations (difference between 5th and 95th percentile) were 1.05 (1.00-1.11) for natural cause, 1.04 (0.95-1.13) for cardiovascular, 1.22 (0.99-1.50) for respiratory, 1.03 (0.88-1.20) for lung cancer, and 1.04 (0.97-1.12) for mortality other than cardiovascular, respiratory, or lung cancer. Results were similar for NO(2) and PM(2.5), but no associations were found for SO(2).

CONCLUSIONS

Traffic-related air pollution and several traffic exposure variables were associated with mortality in the full cohort. Relative risks were generally small. Associations between natural-cause and respiratory mortality were statistically significant for NO(2) and BS. These results add to the evidence that long-term exposure to ambient air pollution is associated with increased mortality.

Prognostic importance of anaemia in HIV type-1-infected patients starting antiretroviral therapy: collaborative analysis of prospective cohort studies

BACKGROUND

In HIV type-1-infected patients starting highly active antiretroviral therapy (HAART), the prognostic value of haemoglobin when starting HAART, and of changes in haemoglobin levels, are not well defined.

METHODS

We combined data from 10 prospective studies of 12,100 previously untreated individuals (25% women). A total of 4,222 patients (35%) were anaemic: 131 patients (1.1%) had severe (<8.0 g/dl), 1,120 (9%) had moderate (male 8.0-<11.0 g/dl and female 8.0- < 10.0 g/dl) and 2,971 (25%) had mild (male 11.0- < 13.0 g/ dl and female 10.0- < 12.0 g/dl) anaemia. We separately analysed progression to AIDS or death from baseline and from 6 months using Weibull models, adjusting for CD4+ T-cell count, age, sex and other variables.

RESULTS

During 48,420 person-years of follow-up 1,448 patients developed at least one AIDS event and 857 patients died. Anaemia at baseline was independently associated with higher mortality: the adjusted hazard ratio (95% confidence interval) for mild anaemia was 1.42 (1.17-1.73), for moderate anaemia 2.56 (2.07-3.18) and for severe anaemia 5.26 (3.55-7.81). Corresponding figures for progression to AIDS were 1.60 (1.37-1.86), 2.00 (1.66-2.40) and 2.24 (1.46-3.42). At 6 months the prevalence of anaemia declined to 26%. Baseline anaemia continued to predict mortality (and to a lesser extent progression to AIDS) in patients with normal haemoglobin or mild anaemia at 6 months.

CONCLUSIONS

Anaemia at the start of HAART is an important factor for short- and long-term prognosis, including in patients whose haemoglobin levels improved or normalized during the first 6 months of HAART.

Body mass index is inversely related to mortality in elderly subjects

PURPOSE

To study the long-term effect of being overweight on mortality in very elderly subjects.

METHODS

The medical records of 470 inpatients (226 males) with a mean age of 81.5 +/- 7 years and hospitalized in an acute geriatric ward between 1999 and 2000 were reviewed for this study. Body mass index (BMI) at admission day was subdivided into quartiles: <22, 22-25, 25.01-28, and > or =28 kg/m(2). Patients were followed-up until August 31, 2004. Mortality data were taken from death certificates.

RESULTS

During a mean follow-up of 3.46 +/- 1.87 years (median 4.2 years [range 1.6 to 5.34 years]), 248 patients died. Those who died had lower baseline BMI than those who survived (24.1 +/- 4.2 vs 26.3 +/- 4.6 kg/m(2); p < .0001). The age-adjusted mortality rate decreased from 24 to 9.6 per 100 patient-years from the highest to lowest BMI quartile (p < .001). BMI was associated with all-cause and cause-specific mortality even after controlling for sex. A multivariate Cox proportional hazards model identified that even after controlling for male gender, age, renal failure, and diabetes mellitus, which increased the risk of all-cause mortality, elevated BMI decreased the all-cause mortality risk.

CONCLUSIONS

In very elderly subjects, elevated BMI was associated with reduced mortality risk.

Self-reported diabetes mellitus and risk of mortality from all causes, cardiovascular disease, and cancer in Takayama: a population-based prospective cohort study in Japan

BACKGROUND

Diabetes mellitus has been reported to be a major risk factor for cardiovascular disease (CVD), and higher risk of CVD among women than that among men has been observed in many studies. Further, the association of diabetes with increasing risk of cancer has also been reported. Well-designed studies conducted among men and women in the general Japanese population remain scarce.

METHODS

Our cohort consisted of 13355 men and 15724 women residing in Takayama, Japan, in 1992. At the baseline, the subjects reported diabetes in a questionnaire. Any deaths occurring in the cohort until 1999 were noted by using data from the Office of the National Vital Statistics. The risk of mortality was separately assessed for men and women by using a Cox proportional hazard model after adjusting for age; smoking status; body mass index (BMI); physical activity; years of education; history of hypertension; and intake of total energy, vegetables, fat, and alcohol.

RESULTS

Diabetes significantly increased the risk of mortality from all causes [hazard ratio (HR): 1.35, 95% confidence interval (CI): 1.11-1.64] and from coronary heart disease (CHD) (HR: 2.96, 95% CI: 1.59-5.50) among men, and that from all causes (HR: 1.74, 95% CI: 1.34-2.26) and cancer (HR: 1.88, 95% CI: 1.16-3.05) among women. Diabetes was not significantly associated with mortality from CHD among women.

CONCLUSION

The findings suggest that diabetes increases the risk of mortality from CVD among men and that from cancer among women. The absence of increased risk of mortality from CHD among women may suggest a particular pattern in the Japanese population.

Application of potential outcomes to an intentional weight loss latent variable problem

Studies that explore the link between weight loss among obese individuals and mortality have met with mixed results. One possible explanation is that total weight loss may have contributions from weight loss that is intentional and weight loss that is unintentional. The latter may be due to some underlying condition that has a deleterious effect on subsequent mortality. Some studies have then focused on subjects who intend to lose weight. However, in a population there is no guarantee that weight loss among these individuals is due only to their intention. This paper extends the work of Coffey et al., (2005) who treated intentional weight loss as a latent variable. In particular, the problem is reformulated using potential outcomes. This formulation more clearly identifies a nonestimable correlation that arises because of the latent variable, and it allows for the incorporation of covariate information that can tighten estimable bounds for this correlation. We show in a data set from an experiment on mice that substantial tightening of bounds is possible with a covariate that is predictive of weight loss. These bounds can then, in turn, be used to estimate bounds on a causal parameter in a linear model.

Method for moderation: measuring lifetime risk of alcohol-attributable mortality as a basis for drinking guidelines

The objective of this paper was to determine separately the lifetime risk of drinking alcohol for chronic disease and acute injury outcomes as a basis for setting general population drinking guidelines for Australia. Relative risk data for different levels of average consumption of alcohol were combined with age, sex, and disease-specific risks of dying from an alcohol-attributable chronic disease. For injury, combinations of the number of drinks per occasion and frequency of drinking occasions were combined to model lifetime risk of death for different drinking pattern scenarios. A lifetime risk of injury death of 1 in 100 is reached for consumption levels of about three drinks daily per week for women, and three drinks five times a week for men. For chronic disease death, lifetime risk increases by about 10% with each 10-gram (one drink) increase in daily average alcohol consumption, although risks are higher for women than men, particularly at higher average consumption levels. Lifetime risks for injury and chronic disease combine to overall risk of alcohol-attributable mortality. In terms of guidelines, if a lifetime risk standard of 1 in 100 is set, then the implications of the analysis presented here are that both men and women should not exceed a volume of two drinks a day for chronic disease mortality, and for occasional drinking three or four drinks seem tolerable.

Effect of risperidone on serum lipids and cerebrovascular mortality among elderly dementia patients with associated behavioral disturbances

Background. Concern exists about safety of risperidone in glucose and lipid metabolism as well as cerebrovascular mortality. Our aim is to evaluate the safety of low-dose risperidone in elderly dementia patients with associated behavioral disturbances on glucose, serum lipids and cerebrovascular mortality. Material and methods. Thirty-one patients entered the study. Fasting glucose, total cholesterol, LDL, HDL, BMI, waist circumference, and triglycerides were measured at baseline and after 3 months. Mortality was reported after 6 months of starting the study. Risk factors for cerebrovascular disease were reported. A control group with 30 subjects was included. Results. Eighteen women and 13 men were included. Mean age was 80.6 years. After analyzing the different variables no significant differences between baseline and after 3 months of follow-up were found. During the study seven (22.58%) patients died, one from stroke. The most frequent associated cerebrovascular risk factors were smoking history, valvular heart disease and atrial fibrillation. Conclusion. In our study, low-dose risperidone administered in patients with behavioral symptoms associated dementia does not affect significantly the lipid profile, fasting glucose, BMI or waist circumference and is not associated with an increased risk for cerebrovascular mortality.

Does the effect of PM10 on mortality depend on PM nickel and vanadium content? A reanalysis of the NMMAPS data

BACKGROUND

Lack of knowledge regarding particulate matter (PM) characteristics associated with toxicity is a crucial research gap. Short-term effects of PM can vary by location, possibly reflecting regional differences in mixtures. A report by Lippmann et al. [Lippmann et al., Environ Health Perspect 114:1662-1669 (2006)] analyzed mortality effect estimates from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS) for 1987-1994. They found that average concentrations of nickel or vanadium in PM2.5 (PM with aerodynamic diameter < 2.5 microm) positively modified the lag-1 day association between PM10 and all-cause mortality.

OBJECTIVE

We reestimated the relationship between county-specific lag-1 PM10 (PM with aerodynamic diameter < 10 microm) effects on mortality and county-specific nickel or vanadium PM2.5 average concentrations using 1987-2000 effect estimates. We explored whether such modification is sensitive to outliers.

METHODS

We estimated long-term average county-level nickel and vanadium PM2.5 concentrations for 2000-2005 for 72 U.S. counties representing 69 communities. We fitted Bayesian hierarchical regression models to investigate whether county-specific short-term effects of PM10 on mortality are modified by long-term county-specific nickel or vanadium PM2.5 concentrations. We conducted sensitivity analyses by excluding individual communities and considering log-transformed data.

RESULTS

Our results were consistent with those of Lippmann et al. However, we found that when counties included in the NMMAPS New York community were excluded from the sensitivity analysis, the evidence of effect modification of nickel or vanadium on the short-term effects of PM10 mortality was much weaker and no longer statistically significant.

CONCLUSIONS

Our analysis does not contradict the hypothesis that nickel or vanadium may increase the risk of PM to human health, but it highlights the sensitivity of findings to particularly influential observations.

Diabetes, depression, and death: a randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT)

OBJECTIVE

We sought to test our a priori hypothesis that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared with depressed patients with diabetes in usual-care practices.

RESEARCH DESIGN AND METHODS

We used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), with patient recruitment from May 1999 to August 2001, supplemented with a search of the National Death Index. Twenty primary care practices participated from the greater metropolitan areas of New York City, New York; Philadelphia, Pennsylvania; and Pittsburgh, Pennsylvania. In all, 584 participants identified though a two-stage, age-stratified (aged 60-74 or >or=75 years) depression screening of randomly sampled patients and classified as depressed with complete information on diabetes status are included in these analyses. Of the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years.

RESULTS

After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the intervention category were less likely to have died during the 5-year follow-up interval than depressed diabetic patients in usual care after accounting for baseline differences among patients (adjusted hazard ratio 0.49 [95% CI 0.24-0.98]).

CONCLUSIONS

Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than depressed patients with diabetes in usual-care practices.

Screening of older community-dwelling people at risk for death and hospitalization: the Assistenza Socio-Sanitaria in Italia project

OBJECTIVES

To develop and validate mortality and hospitalization prognostic tools based upon information readily available to primary care physicians (PCPs).

DESIGN

Population-based cohort study. Baseline predictors were patient demographics, a seven-item questionnaire on functional status and general health, use of five or more drugs, and previous hospitalization.

SETTING

Community-based study.

PARTICIPANTS

Prognostic indexes were developed in 2,470 subjects and validated in 2,926 subjects, all community-dwelling, aged 65 and older, and randomly sampled from the rosters of 98 PCPs in Florence, Italy.

MEASUREMENTS

Fifteen-month mortality and hospitalization.

RESULTS

Two scores were derived from logistic regression models and used to stratify participants into four groups. With Model 1, based upon the seven-item questionnaire, mortality rate ranged from 0.8% in the lowest-risk group (0-1 point) to 9.4% in the highest risk group (> or = 3 points), and hospitalization rate ranged from 12.4% to 29.3%; area under the receiver operating characteristic curves (AUC) was 0.75 and 0.60, respectively. With Model 2, considering also drug use and previous hospitalization, mortality and hospitalization rates ranged from 0.3% to 8.2% and from 8.1% to 29.7%, for the lowest-risk to the highest-risk group; the AUC increased significantly only for hospitalization (0.67).

CONCLUSION

Prediction of death and hospitalization in older community-dwelling people can be easily obtained with two indexes using information promptly available to PCPs. These tools might be useful for guiding clinical care and targeting interventions to reduce the need for hospital care in older persons.

The association between self-rated health and mortality in different socioeconomic groups in the GAZEL cohort study

OBJECTIVES

Self-rated health (SRH) is considered a valid measure of health status as it has been shown to predict mortality in several studies. We examine whether SRH predicts mortality equally well in different socioeconomic groups.

METHODS

Data (14 879 men and 5525 women) are drawn from GAZEL, a prospective cohort study of French public utility workers. Data on SRH and the socioeconomic measures (education, occupational position and income) were taken from the baseline questionnaire (1989), when the average age of individuals was 44.2 years (SD = 3.5). Mortality follow-up was available for a mean of 17.2 years and analysed over the first 10 years and over the entire follow-up period. Associations between SRH and mortality were assessed using Cox regression models using the relative index of inequality (RII) to summarize associations.

RESULTS

The RII for the association between SRH and mortality over the first 10 years was 6.78 [95% confidence interval (CI) = 3.33-13.81] in the lowest occupational group and 2.10 (95% CI = 0.97-4.54) in the highest. For income, the RIIs were 8.82 (95% CI = 4.70-16.54) for the lowest and 1.80 (95% CI = 0.86-3.80) for the highest groups respectively. Findings over the full follow-up period were similar. The association between SRH and mortality was weaker in the high occupation and income groups, both in the short and the long term. The results for education were similar but generally weaker than for the other socioeconomic measures.

CONCLUSIONS

The predictive ability of SRH for mortality weakens with increasing socioeconomic advantage among middle-aged individuals. Thus SRH appears not to measure 'true' health status in a similar way across socioeconomic categories.

Biliary tract infection and bacteraemia: presentation, structural abnormalities, causative organisms and clinical outcomes

BACKGROUND

Biliary tract infection is a common cause of bacteraemia and is associated with high morbidity and mortality. Few papers describe blood culture isolates, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.

AIMS

To determine the proportion of bacteraemias caused by biliary tract infection and to describe patient demographics, underlying structural abnormalities and clinical outcomes in patients with bacteraemia.

DESIGN

Prospective cohort study.

METHODS

Biliary tract infection that caused bacteraemia was defined as a compatible clinical syndrome and a blood culture isolate consistent with ascending cholangitis. Patients aged 16 years and over were included in the study. From June 2003 to May 2005, demographic and clinical data were collected prospectively on all adult patients with bacteraemia. Radiological and endoscopic retrograde cholangiopancreatography findings were collected retrospectively.

RESULTS

In 49 patients, the biliary tract was the site of infection for 39/592 (6.6%) community-acquired and 19/466 (4.1%) hospital-acquired episodes of bacteraemia. Three patients had mixed bacteraemias, and four had recurrent bacteraemia. The proportion of patients presenting with a structural abnormality was 34/49 (69%), and, of these structural abnormalities, 18/34 (53%) were pre-existing or newly diagnosed malignancies. Gram-negative organisms caused 55/58 (95%) episodes of bacteraemia. The most common Gram-negative organisms were Escherichia coli (34/55; 62%) and Klebsiella pneumoniae (14/55; 26%). Of the E coli isolates, 6/34 (18%) were extended spectrum beta-lactamase producers or multiply drug resistant. Thirty-day mortality was 7/49 (14%). There was no difference in time taken to administer an effective antibiotic to survivors and non-survivors (0.86 vs 1.05 days, respectively, p = 0.92). Of the seven who died, four died from septic shock within 48 h of admission caused by "susceptible" Gram-negative organisms. Two others died from disseminated malignancy.

CONCLUSIONS

The proportion of bacteraemias caused by biliary tract infection was 5.5%. The most common infecting organisms were E coli and K pneumoniae. There was a strong association with choledocholithiasis and malignancies, both pre-existing and newly diagnosed. Death was uncommon but when it occurred was often caused by septic shock within 48 h of presentation.

Mortality rate in veterans with multiple chronic conditions

BACKGROUND

Among patients with multiple chronic conditions, there is increasing appreciation of the complex interrelatedness of diseases. Previous studies have focused on the prevalence and economic burden associated with multiple chronic conditions, much less is known about the mortality rate associated with specific combinations of multiple diseases.

OBJECTIVE

Measure the mortality rate in combinations of 11 chronic conditions.

DESIGN

Cohort study of veteran health care users.

PARTICIPANTS

Veterans between 55 and 64 years that used Veterans Health Administration health care services between October 1999 and September 2000.

MEASUREMENTS

Patients were identified as having one or more of the following: COPD, diabetes, hypertension, rheumatoid arthritis, osteoarthritis, asthma, depression, ischemic heart disease, dementia, stroke, and cancer. Mutually exclusive combinations of disease based on these conditions were created, and 5-year mortality rates were determined.

RESULTS

There were 741,847 persons included. The number in each group by a count of conditions was: none = 217,944 (29.34%); 1 = 221,111 (29.8%); 2 = 175,228 (23.6%); 3 = 86,447 (11.7%); and 4+ = 41,117 (5.5%). The 5-year mortality rate by the number of conditions was: none = 4.1%; 1 = 6.0%; 2 = 7.8%; 3 = 11.2%; 4+ = 16.7%. Among combinations with the same number of conditions, there was significant variability in mortality rates.

CONCLUSIONS

Patients with multiple chronic conditions have higher mortality rates. Because there was significant variation in mortality across clusters with the same number of conditions, when studying patients with multiple coexisting illnesses, it is important to understand not only that several conditions may be present but that specific conditions can differentially impact the risk of mortality.

Analysis of sex, age and disease factors contributing to prolonged life expectancy at birth, in cases of malignant neoplasms in Japan

BACKGROUND

This study aimed to examine the contribution made by the change in mortality from malignant neoplasms to the life expectancy at birth, observed during the years 1965-1995 in Japan.

METHODS

We used data on the population and number of deaths by cause, age and sex in 1965, 1975, 1985 and 1995. The contribution of different ages and causes of death to the change in life expectancy were examined with the method developed by Pollard.

RESULTS

We found that, among all causes, the decrease of mortality from stomach cancer led to the greatest improvement in life expectancy for both sexes. On the other hand, negative contributions were seen with cancers of many sites, such as cancer of the intestine, liver and lung for males, and cancer of the intestine, gallbladder, lung and breast for females. Recently, the contributing years of all cancers have been negative because of the increase in mortality from malignant neoplasms. In addition, increase of death from malignant neoplasms in middle-aged and elderly people negatively influenced the life expectancy at birth.

CONCLUSIONS

Female cancer influenced the improvement in life expectancy at birth. Cancer for males, however, contributed little to improvement of life expectancy at birth except for a little prolongation of life expectancy at birth during the years 1965-1975. To develop a public health policy, the contributing years to life expectancy at birth can be a useful indication in evaluating the impact of death from various diseases. It is necessary to analyze the contribution made by various causes of death to the changes of life expectancy at birth.

Outcome of convulsive status epilepticus: a review

The outcome of CSE in childhood depends mainly upon the cause but length of seizure may also be important

Short-term effects of carbon monoxide on mortality: an analysis within the APHEA project

OBJECTIVES

We investigated the short-term effects of carbon monoxide on total and cardiovascular mortality in 19 European cities participating in the APHEA-2 (Air Pollution and Health: A European Approach) project.

METHODS

We examined the association using hierarchical models implemented in two stages. In the first stage, data from each city were analyzed separately, whereas in the second stage the city-specific air pollution estimates were regressed on city-specific covariates to obtain overall estimates and to explore sources of possible heterogeneity. We evaluated the sensitivity of our results by applying different degrees of smoothing for seasonality control in the city-specific analysis.

RESULTS

We found significant associations of CO with total and cardiovascular mortality. A 1-mg/m(3) increase in the 2-day mean of CO levels was associated with a 1.20% [95% confidence interval (CI), 0.63-1.77%] increase in total deaths and a 1.25% (95% CI, 0.30-2.21%) increase in cardiovascular deaths. There was indication of confounding with black smoke and nitrogen dioxide, but the pollutant-adjusted effect of CO on mortality remained at least marginally statistically significant. The effect of CO on total and cardiovascular mortality was observed mainly in western and southern European cities and was larger when the standardized mortality rate was lower.

CONCLUSIONS

The results of this large study are consistent with an independent effect of CO on mortality. The heterogeneity found in the effect estimates among cities may be explained partly by specific city characteristics.

Excess mortality following hip fracture: the role of underlying health status

We evaluated the long-term excess mortality associated with hip fracture, using prospectively collected data on pre-fracture health and function from a nationally representative sample of U.S. elders. Although mortality was elevated for the first six months following hip fracture, we found no evidence of long-term excess mortality.

INTRODUCTION

The long-term excess mortality associated with hip fracture remains controversial.

METHODS

To assess the association between hip fracture and mortality, we used prospectively collected data on pre-fracture health and function from a representative sample of U.S. elders in the Medicare Current Beneficiary Survey (MCBS) to perform survival analyses with time-varying covariates.

RESULTS

Among 25,178 MCBS participants followed for a median duration of 3.8 years, 730 sustained a hip fracture during follow-up. Both early (within 6 months) and subsequent mortality showed significant elevations in models adjusted only for age, sex and race. With additional adjustment for pre-fracture health status, functional impairments, comorbid conditions and socioeconomic status, however, increased mortality was limited to the first six months after fracture (hazard ratio [HR]: 6.28, 95% CI: 4.82, 8.19). No increased mortality was evident during subsequent follow-up (HR: 1.04, 95% CI: 0.88, 1.23). Hip-fracture-attributable population mortality ranged from 0.5% at age 65 among men to 6% at age 85 among women.

CONCLUSIONS

Hip fracture was associated with substantially increased mortality, but much of the short-term risk and all of the long-term risk was explained by the greater frailty of those experiencing hip fracture.

Mental ability across childhood in relation to risk factors for premature mortality in adult life: the 1970 British Cohort Study

OBJECTIVE

To examine the relation of scores on tests of mental ability across childhood with established risk factors for premature mortality at the age of 30 years.

METHODS

A prospective cohort study based on members of the British Cohort Study born in Great Britain in 1970 who had complete data on IQ scores at five (N = 8203) or 10 (N = 8171) years of age and risk factors at age 30 years.

RESULTS

In sex-adjusted analyses, higher IQ score at age 10 years was associated with a reduced prevalence of current smoking (OR(per 1 SD advantage in IQ) 0.84; 95% CI 0.80, 0.88), overweight (0.88; 0.84, 0.92), obesity (0.84; 0.79, 0.92), and hypertension (0.90; 0.83, 0.98), and an increased likelihood of having given up smoking by the age of 30 years (1.25; 1.18, 1.24). These gradients were attenuated after adjustment for markers of socioeconomic circumstances across the life course, particularly education. There was no apparent relationship between IQ and diabetes. Essentially the same pattern of association was evident when the predictive value of IQ scores at five years of age was examined.

CONCLUSIONS

The mental ability-risk factor gradients reported in the present study may offer some insights into the apparent link between low pre-adult mental ability and premature mortality.

Potential confounding of particulate matter on the short-term association between ozone and mortality in multisite time-series studies

BACKGROUND

A critical question regarding the association between short-term exposure to ozone and mortality is the extent to which this relationship is confounded by ambient exposure to particles.

OBJECTIVES

We investigated whether particulate matter < 10 and < 2.5 microm in aerodynamic diameter (PM(10) and PM(2.5)) is a confounder of the ozone and mortality association using data for 98 U.S. urban communities from 1987 to 2000.

METHODS

We a) estimated correlations between daily ozone and daily PM concentrations stratified by ozone or PM levels; b) included PM as a covariate in time-series models; and c) included PM as a covariate as in d), but within a subset approach considering only days with ozone below a specified value.

RESULTS

Analysis was hindered by data availability. In the 93 communities with PM(10) data, only 25.0% of study days had data on both ozone and PM(10). In the 91 communities with PM(2.5) data, only 9.2% of days in the study period had data on ozone and PM(2.5). Neither PM measure was highly correlated with ozone at any level of ozone or PM. National and community-specific effect estimates of the short-term effects of ozone on mortality were robust to inclusion of PM(10) or PM(2.5) in time-series models. The robustness remains even at low ozone levels (< 10 ppb) using a subset approach.

CONCLUSIONS

Results provide evidence that neither PM(10) nor PM(2.5) is a likely confounder of observed ozone and mortality relationships. Further investigation is needed to investigate potential confounding of the short-term effects of ozone on mortality by PM chemical composition.

Nested case-control study on associations between lung function, smoking and mortality in Japanese population

OBJECTIVES

Only a few long-term follow-up studies with a focus on the association between lung function and mortality in the Japanese population have been undertaken. In this study, we examined the associations of lung function, smoking and the results of allergy skin tests with mortality in a longitudinal study of the Japanese population.

METHODS

Baseline measurements were performed on residents of Fukui, Japan in 1972, and a follow-up survey was conducted in 2002. By employing a nested case-control design, 596 cases (deaths) and 596 age and sex-matched controls (survivals) were selected. Lung function was assessed using forced vital capacity (FVC) expressed as the normal percent predicted (FVC %pred) and the ratio of forced expiratory volume in 1 second (FEV(1)) to FVC (FEV(1)/FVC). Allergy skin tests were performed with extracts of house dust, candidia and mixed fungal samples (bronchomycosis). The Brinkman index was used to assess smoking intensity. The Cox proportional hazards model was used to evaluate whether lung function was associated with mortality after adjustment for other potential confounding variables.

RESULTS

Those categorized into the first- or second-lowest quartile of FVC %pred had a higher mortality [hazard ratios (HRs) and 95% confidence intervals (CIs): 2.01 (1.26-3.19) and 1.84 (1.11-3.05)], respectively. On top of these, heavy smoking (BI≥400) was associated with a higher mortality [HR and 95% CI: 1.73 (1.18-2.53)]. There were only weak of associations between the results of allergy skin tests and mortality.

CONCLUSIONS

These results suggest that FVC %pred of lung function and smoking can serve as long-term independent predictors of mortality.

Effects of nurse home visiting on maternal and child functioning: age-9 follow-up of a randomized trial

OBJECTIVE

Our goal was to test the effect of prenatal and infancy home visits by nurses on mothers' fertility and children's functioning 7 years after the program ended at child age 2.

METHODS

We conducted a randomized, controlled trial in a public system of obstetric and pediatric care. A total of 743 primarily black women <29 weeks' gestation, with previous live births and at least 2 sociodemographic risk characteristics (unmarried, <12 years of education, unemployed), were randomly assigned to receive nurse home visits or comparison services. Primary outcomes consisted of intervals between births of first and second children and number of children born per year; mothers' stability of relationships with partners and relationships with the biological father of the child; mothers' use of welfare, food stamps, and Medicaid; mothers' use of substances; mothers' arrests and incarcerations; and children's academic achievement, school conduct, and mental disorders. Secondary outcomes were the sequelae of subsequent pregnancies, women's employment, experience of domestic violence, and children's mortality.

RESULTS

Nurse-visited women had longer intervals between births of first and second children, fewer cumulative subsequent births per year, and longer relationships with current partners. From birth through child age 9, nurse-visited women used welfare and food stamps for fewer months. Nurse-visited children born to mothers with low psychological resources, compared with control-group counterparts, had better grade-point averages and achievement test scores in math and reading in grades 1 through 3. Nurse-visited children, as a trend, were less likely to die from birth through age 9, an effect accounted for by deaths that were attributable to potentially preventable causes.

CONCLUSIONS

By child age 9, the program reduced women's rates of subsequent births, increased the intervals between the births of first and second children, increased the stability of their relationships with partners, facilitated children's academic adjustment to elementary school, and seems to have reduced childhood mortality from preventable causes.

Joint effect of cigarette smoking and alcohol consumption on mortality

OBJECTIVE

To evaluate the joint effect of cigarette smoking and alcohol consumption on mortality.

METHODS

A population-based cohort of 66,743 Chinese men aged 30-89 in Shanghai, China recruited from 1996 to 2000. Lifestyle data were collected using structured questionnaires. As of November 2004, follow-up for the vital status of 64,515 men was completed and death information was further confirmed through record linkage with the Shanghai Vital Statistics Registry. Associations were evaluated by Cox regression analyses.

RESULTS

2514 deaths (982 from cancers, 776 from cardiovascular diseases (CVD)) were identified during 297,396 person-years of follow-up. Compared to never-smokers, both former and current smokers had significantly elevated mortality from any cause, CVD, and cancer; risk increased with amount of smoking. Intake of 1-7 drinks/week was associated with reduced risk of death, particularly CVD death (hazard ratio (HR): 0.7, 95% confidence interval (CI): 0.5, 1.0), whereas intake of >42 drinks/week was related to increased mortality, particularly cancer-related death (HR: 1.7, 95% CI: 1.1, 2.5). The HR for total mortality associated with moderate alcohol consumption increased from 0.8 (95% CI: 0.6, 1.0) for non-smokers to 1.0 (0.9, 1.2) for moderate smokers and 1.4 (95% CI: 1.2, 1.7) for heavy smokers. Heavy drinkers and heavy smokers had the highest mortality (HR: 1.9, 95% CI: 1.6, 2.4).

CONCLUSIONS

Light and moderate alcohol consumption reduced mortality from CVD. This beneficial effect, however, was offset by cigarette smoking.

Serum zinc and pneumonia in nursing home elderly

BACKGROUND

Zinc plays an important role in immune function. The association between serum zinc and pneumonia in the elderly has not been studied.

OBJECTIVE

The objective was to determine whether serum zinc concentrations in nursing home elderly are associated with the incidence and duration of pneumonia, total and duration of antibiotic use, and pneumonia-associated and all-cause mortality.

DESIGN

This observational study was conducted in residents from 33 nursing homes in Boston, MA, who participated in a 1-y randomized, double-blind, and placebo-controlled vitamin E supplementation trial; all were given daily doses of 50% of the recommended dietary allowance of essential vitamins and minerals, including zinc. Participants with baseline (n = 578) or final (n = 420) serum zinc concentrations were categorized as having low (<70 microg/dL) or normal (>or=70 microg/dL) serum zinc concentrations. Outcome measures included the incidence and number of days with pneumonia, number of new antibiotic prescriptions, days of antibiotic use, death due to pneumonia, and all-cause mortality.

RESULTS

Compared with subjects with low zinc concentrations, subjects with normal final serum zinc concentrations had a lower incidence of pneumonia, fewer (by almost 50%) new antibiotic prescriptions, a shorter duration of pneumonia, and fewer days of antibiotic use (3.9 d compared with 2.6 d) (P <or= 0.004 for all). Normal baseline serum zinc concentrations were associated with a reduction in all-cause mortality (P = 0.049).

CONCLUSION

Normal serum zinc concentrations in nursing home elderly are associated with a decreased incidence and duration of pneumonia, a decreased number of new antibiotic prescriptions, and a decrease in the days of antibiotic use. Zinc supplementation to maintain normal serum zinc concentrations in the elderly may help reduce the incidence of pneumonia and associated morbidity.