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Trias-Llimós S, Barbieri M, Egidi V, Frova L, Grippo F, Meslé F, Pappagallo M, Désesquelles A. Frailty at death: An examination of multiple causes of death in four low mortality countries in 2017. DEMOGRAPHIC RESEARCH 2023; 49:13-30. [PMID: 38288270 PMCID: PMC10824539 DOI: 10.4054/demres.2023.49.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The increasing prevalence of frailty in aging populations represents a major social and public health challenge which warrants a better understanding of the contribution of frailty to the morbid process. OBJECTIVE To examine frailty-related mortality as reported on the death certificate in France, Italy, Spain and the United States in 2017. METHODS We identify frailty at death for the population aged 50 years and over in France, Italy, Spain and the United States. We estimate the proportions of deaths by sex, age group and country with specific frailty-related ICD-codes on the death certificate 1) as the underlying cause of death (UC), 2) elsewhere in Part I (sequence of diseases or conditions or events leading directly to death), and 3) anywhere in Part II (conditions that do not belong in Part I but whose presence contributed to death). RESULTS The age-standardized proportion of deaths with frailty at ages 50 and over is highest in Italy (25.0%), then in France (24.1%) and Spain (17.3%), and lowest in the United States (14.0%). Cross-country differences are smaller when frailty-related codes are either the underlying cause of the death or reported in Part II. Frailty-related mortality increases with age and is higher among females than males. Dementia is the most frequently reported frailty-related code. CONCLUSIONS Notable cross-country differences were found in the prevalence and the type of frailty-related symptoms at death even after adjusting for differential age distributions.
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Affiliation(s)
| | - Magali Barbieri
- Institut National d’Études Démographiques (France) and University of California, Berkeley (United States)
| | - Viviana Egidi
- Dipartimento di Scienze Statistiche, Sapienza Università di Roma (Italy)
| | - Luisa Frova
- Istituto nazionale di statistica – ISTAT (Italy)
| | | | - France Meslé
- Institut National d’Études Démographiques (France)
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Bishop K, Balogun S, Eynstone-Hinkins J, Moran L, Martin M, Banks E, Rao C, Joshy G. Analysis of Multiple Causes of Death: A Review of Methods and Practices. Epidemiology 2023; 34:333-344. [PMID: 36719759 PMCID: PMC10069753 DOI: 10.1097/ede.0000000000001597] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND Research and reporting of mortality indicators typically focus on a single underlying cause of death selected from multiple causes recorded on a death certificate. The need to incorporate the multiple causes in mortality statistics-reflecting increasing multimorbidity and complex causation patterns-is recognized internationally. This review aims to identify and appraise relevant analytical methods and practices related to multiple causes. METHODS We searched Medline, PubMed, Scopus, and Web of Science from their incept ion to December 2020 without language restrictions, supplemented by consultation with international experts. Eligible articles analyzed multiple causes of death from death certificates. The process identified 4,080 items of which we reviewed 434 full-text articles. RESULTS Most articles we reviewed (76%, n = 332) were published since 2001. The majority of articles examined mortality by "any- mention" of the cause of death (87%, n = 377) and assessed pairwise combinations of causes (57%, n = 245). Since 2001, applications of methods emerged to group deaths based on common cause patterns using, for example, cluster analysis (2%, n = 9), and application of multiple-cause weights to re-evaluate mortality burden (1%, n = 5). We describe multiple-cause methods applied to specific research objectives for approaches emerging recently. CONCLUSION This review confirms rapidly increasing international interest in the analysis of multiple causes of death and provides the most comprehensive overview, to our knowledge, of methods and practices to date. Available multiple-cause methods are diverse but suit a range of research objectives. With greater availability of data and technology, these could be further developed and applied across a range of settings.
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Affiliation(s)
- Karen Bishop
- From the National Centre for Epidemiology and Population Health, Australian National University
| | - Saliu Balogun
- From the National Centre for Epidemiology and Population Health, Australian National University
| | | | - Lauren Moran
- Australian Bureau of Statistics, Canberra, Australia
| | - Melonie Martin
- From the National Centre for Epidemiology and Population Health, Australian National University
| | - Emily Banks
- From the National Centre for Epidemiology and Population Health, Australian National University
| | - Chalapati Rao
- From the National Centre for Epidemiology and Population Health, Australian National University
| | - Grace Joshy
- From the National Centre for Epidemiology and Population Health, Australian National University
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Aye S, Jönsson L, Gustavsson A, Tate A, Ptacek SG, Eriksdotter M. Effect of mortality in cost‐effectiveness modeling of disease‐modifying treatment for Alzheimer's disease. ALZHEIMER'S & DEMENTIA : DIAGNOSIS, ASSESSMENT & DISEASE MONITORING 2023; 15:e12422. [PMID: 37009338 PMCID: PMC10053186 DOI: 10.1002/dad2.12422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/08/2023] [Accepted: 03/04/2023] [Indexed: 03/31/2023]
Abstract
INTRODUCTION We examined (1) the magnitude of mortality attributed to Alzheimer's disease (AD), and (2) the effect of mortality in cost‐effectiveness modeling of hypothetical disease‐modifying treatment (DMT) in AD. METHOD Data were derived from Swedish Dementia Registry (N = 39,308). Mortality was analyzed with survival analysis and multinomial logistic regression. A Markov microsimulation model was used to model the cost effectiveness of DMT using routine care as a comparator. Three scenarios were simulated: (1) indirect effect, (2) no effect on overall mortality, (3) indirect effect on AD‐related mortality. RESULTS Overall mortality increased with cognitive decline, age, male sex, number of medications used, and lower body mass index. Nearly all cause‐specific mortality was associated with cognitive decline. DMT increased survival by 0.35 years in scenario 1 and 0.14 years in scenario 3. DMT with no mortality effect is the least cost effective. DISCUSSION The results provide key mortality estimates and demonstrate influences on the cost effectiveness of DMT. Highlights We describe cause‐specific mortality in relation to disease severity in Alzheimer's disease (AD). We model different assumptions of disease‐modifying treatment (DMT) on AD survival. DMT was the least cost effective when assuming no effect on AD survival. Cost effectiveness is mainly influenced by the relative cost of staying in each disease state.
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Affiliation(s)
- Sandar Aye
- Division of NeurogeriatricsDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetStockholmSweden
| | - Linus Jönsson
- Division of NeurogeriatricsDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetStockholmSweden
| | - Anders Gustavsson
- Division of NeurogeriatricsDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetStockholmSweden
- Quantity ResearchStockholmSweden
| | - Ashley Tate
- Division of NeurogeriatricsDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetStockholmSweden
| | - Sara Garcia Ptacek
- Division of Clinical GeriatricsDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetStockholmSweden
- Theme AgingKarolinska University HospitalHuddingeSweden
| | - Maria Eriksdotter
- Division of Clinical GeriatricsDepartment of NeurobiologyCare Sciences and SocietyKarolinska InstitutetStockholmSweden
- Theme AgingKarolinska University HospitalHuddingeSweden
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Bishop K, Moreno-Betancur M, Balogun S, Eynstone-Hinkins J, Moran L, Rao C, Banks E, Korda RJ, Gourley M, Joshy G. Quantifying cause-related mortality in Australia, incorporating multiple causes: observed patterns, trends and practical considerations. Int J Epidemiol 2022; 52:284-294. [PMID: 35984318 PMCID: PMC9908048 DOI: 10.1093/ije/dyac167] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mortality statistics using a single underlying cause of death (UC) are key health indicators. Rising multimorbidity and chronic disease mean that deaths increasingly involve multiple conditions. However, additional causes reported on death certificates are rarely integrated into mortality indicators, partly due to complexities in data and methods. This study aimed to assess trends and patterns in cause-related mortality in Australia, integrating multiple causes (MC) of death. METHODS Deaths (n = 1 773 399) in Australia (2006-17) were mapped to 136 ICD-10-based groups and MC indicators applied. Age-standardized cause-related rates (deaths/100 000) based on the UC (ASRUC) were compared with rates based on any mention of the cause (ASRAM) using rate ratios (RR = ASRAM/ASRUC) and to rates based on weighting multiple contributing causes (ASRW). RESULTS Deaths involved on average 3.4 causes in 2017; the percentage with >4 causes increased from 20.9 (2006) to 24.4 (2017). Ischaemic heart disease (ASRUC = 73.3, ASRAM = 135.8, ASRW = 63.5), dementia (ASRUC = 51.1, ASRAM = 98.1, ASRW = 52.1) and cerebrovascular diseases (ASRUC = 39.9, ASRAM = 76.7, ASRW = 33.5) ranked as leading causes by all methods. Causes with high RR included hypertension (ASRUC = 2.2, RR = 35.5), atrial fibrillation (ASRUC = 8.0, RR = 6.5) and diabetes (ASRUC = 18.5, RR = 3.5); the corresponding ASRW were 12.5, 12.6 and 24.0, respectively. Renal failure, atrial fibrillation and hypertension ranked among the 10 leading causes by ASRAM and ASRW but not by ASRUC. Practical considerations in working with MC data are discussed. CONCLUSIONS Despite the similarities in leading causes under the three methods, with integration of MC several preventable diseases emerged as leading causes. MC analyses offer a richer additional perspective for population health monitoring and policy development.
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Affiliation(s)
- Karen Bishop
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Margarita Moreno-Betancur
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, VIC, Australia,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Saliu Balogun
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - James Eynstone-Hinkins
- Health and Vital Statistics Section, Australian Bureau of Statistics, Canberra, ACT, Australia
| | - Lauren Moran
- Health and Vital Statistics Section, Australian Bureau of Statistics, Canberra, ACT, Australia
| | - Chalapati Rao
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Emily Banks
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Rosemary J Korda
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Michelle Gourley
- Population Health Group, Australian Institute of Health and Welfare, Canberra, ACT, Australia
| | - Grace Joshy
- Corresponding author. National Centre for Epidemiology and Population Health, College of Health and Medicine, Australian National University, 62 Mills Road, Acton ACT 2601, Australia. E-mail:
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Ulivelli M, Bezzini D, Kundisova L, Grazi I, Battaglia MA, Nante N, Rossi S. Mortality of Parkinson's disease in Italy from 1980 to 2015. Neurol Sci 2022; 43:3603-3611. [PMID: 35094172 DOI: 10.1007/s10072-021-05854-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/25/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate mortality for Parkinson's disease (PD) in Italy during a long time period (1980-2015) and to discuss the role of possible general and specific influencing factors. METHODS Based on mortality data provided by the Italian National Institute of Statistics, sex- and age-specific crude mortality rates were computed, for the whole country and for its main geographical sub-areas. Rates were standardized using both direct (annual mortality rates AMRs) and indirect (standardized mortality rates SMRs) methods. SMRs were used to evaluate geographical differences, whereas AMRs and joinpoint linear regression analysis to study mortality trends. RESULTS Considering the entire period, highest mortality rates were observed in males (AMR/100,000: 9.0 in males, 5.25 in females), in North-West and Central Italy (SMR > 100). Overall PD mortality decreased from mid-eighties onwards and then rapidly reversed the trend in the period 1998-2002, rising up to a maximum in 2015, with some differences according to sex and geographical areas. CONCLUSIONS Several factors may have contributed to the rapid inversion of decreasing trend in mortality observed in the last part of XX century. Possible explanations of this rising trend are related to the increasing burden of PD (especially in males and in certain Italian regions), caused by different factors as population aging, physiological prevalence rise due to incidence exceeding mortality, and growing exposure to environmental or occupational risk factors. In addition, the accuracy of death certificate compilation could account for geographical differences and for the temporal trend. The role of levodopa and recently introduced dopaminergic drugs is also discussed.
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Affiliation(s)
- Monica Ulivelli
- Department of Medicine, Surgery and Neuroscience, Unit of Neurology and Clinical Neurophysiology, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Daiana Bezzini
- Department of Life Sciences, University of Siena, Siena, Italy.
| | - Lucia Kundisova
- Postgradual School of Public Health, University of Siena, Siena, Italy
| | - Ilaria Grazi
- Department of Medicine, Surgery and Neuroscience, Unit of Neurology and Clinical Neurophysiology, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Mario Alberto Battaglia
- Department of Life Sciences, University of Siena, Siena, Italy.,Research Department, Italian Multiple Sclerosis Foundation, Genoa, Italy
| | - Nicola Nante
- Postgradual School of Public Health, University of Siena, Siena, Italy.,Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Simone Rossi
- Department of Medicine, Surgery and Neuroscience, Unit of Neurology and Clinical Neurophysiology, Policlinico Le Scotte, University of Siena, Siena, Italy
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Bonnet C, Cambois E, Fontaine R. Dynamiques, enjeux démographiques et socioéconomiques du vieillissement dans les pays à longévité élevée. POPULATION 2021. [DOI: 10.3917/popu.2102.0225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Gracner T, Stone PW, Agarwal M, Sorbero M, Mitchell SL, Dick AW. Advanced cognitive impairment among older nursing home residents. BMC Geriatr 2021; 21:382. [PMID: 34162335 PMCID: PMC8220753 DOI: 10.1186/s12877-021-02336-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/11/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Though work has been done studying nursing home (NH) residents with either advanced Alzheimer's disease (AD) or Alzheimer's disease related dementia (ADRD), none have distinguished between them; even though their clinical features affecting survival are different. In this study, we compared mortality risk factors and survival between NH residents with advanced AD and those with advanced ADRD. METHODS This is a retrospective observational study, in which we examined a sample of 34,493 U.S. NH residents aged 65 and over in the Minimum Data Set (2011-2013). Incident assessment of advanced disease was defined as the first MDS assessment with severe cognitive impairment (Cognitive Functional Score equals to 4) and diagnoses of AD or ADRD. Demographics, functional limitations, and comorbidities were evaluated as mortality risk factors using Cox models. Survival was characterized with Kaplan-Maier functions. RESULTS Of those with advanced cognitive impairment, 35 % had AD and 65 % ADRD. At the incident assessment of advanced disease, those with AD had better health compared to those with ADRD. Mortality risk factors were similar between groups (shortness of breath, difficulties eating, substantial weight-loss, diabetes mellitus, heart failure, chronic obstructive pulmonary disease, and pneumonia; all p < 0.01). However, stroke and difficulty with transfer (for women) were significant mortality risk factors only for those with advanced AD. Urinary tract infection, and hypertension (for women) only were mortality risk factors for those with advanced ADRD. Median survival was significantly shorter for the advanced ADRD group (194 days) compared to the advanced AD group (300 days). CONCLUSIONS There were distinct mortality and survival patterns of NH residents with advanced AD and ADRD. This may help with care planning decisions regarding therapeutic and palliative care.
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Affiliation(s)
- Tadeja Gracner
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA.
| | - Patricia W Stone
- Center for Health Policy, Columbia University School of Nursing, 560 W. 168th St, New York, NY, 10032, USA
| | - Mansi Agarwal
- Washington University School of Medicine, 660 S Euclid Ave, St.Louis, MO, 63110, USA
| | - Mark Sorbero
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Susan L Mitchell
- Hebrew Senior Life Marcus Institute for Aging Research, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andrew W Dick
- RAND Corporation, 20 Park Plaza #920, Boston, MA, 02116, USA
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Akbar U, McQueen RB, Bemski J, Carter J, Goy ER, Kutner J, Johnson MJ, Miyasaki JM, Kluger B. Prognostic predictors relevant to end-of-life palliative care in Parkinson's disease and related disorders: a systematic review. J Neurol Neurosurg Psychiatry 2021; 92:jnnp-2020-323939. [PMID: 33789923 PMCID: PMC8142437 DOI: 10.1136/jnnp-2020-323939] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 11/22/2022]
Abstract
Parkinson's disease and related disorders (PDRD) are the second most common neurodegenerative disease and a leading cause of death. However, patients with PDRD receive less end-of-life palliative care (hospice) than other illnesses, including other neurologic illnesses. Identification of predictors of PDRD mortality may aid in increasing appropriate and timely referrals. To systematically review the literature for causes of death and predictors of mortality in PDRD to provide guidance regarding hospice/end-of-life palliative care referrals. We searched MEDLINE, PubMed, EMBASE and CINAHL databases (1970-2020) of original quantitative research using patient-level, provider-level or caregiver-level data from medical records, administrative data or survey responses associated with mortality, prognosis or cause of death in PDRD. Findings were reviewed by an International Working Group on PD and Palliative Care supported by the Parkinson's Foundation. Of 1183 research articles, 42 studies met our inclusion criteria. We found four main domains of factors associated with mortality in PDRD: (1) demographic and clinical markers (age, sex, body mass index and comorbid illnesses), (2) motor dysfunction and global disability, (3) falls and infections and (4) non-motor symptoms. We provide suggestions for consideration of timing of hospice/end-of-life palliative care referrals. Several clinical features of advancing disease may be useful in triggering end-of-life palliative/hospice referral. Prognostic studies focused on identifying when people with PDRD are nearing their final months of life are limited. There is further need for research in this area as well as policies that support need-based palliative care for the duration of PDRD.
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Affiliation(s)
- Umer Akbar
- Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | | | - Julienne Bemski
- Department of Neurology, University of Colorado, Denver, Colorado, USA
| | - Julie Carter
- Department of Neurology, University of Colorado, Denver, Colorado, USA
| | - Elizabeth R Goy
- Department of Neurology, Portland VA Medical Center, Portland, Oregon, USA
| | - Jean Kutner
- Department of Neurology, University of Colorado, Denver, Colorado, USA
| | - Miriam J Johnson
- Department of Palliative Medicine, Hull York Medical School, Hull, Kingston upon Hull, UK
| | - Janis M Miyasaki
- Department of Neurology, University of Alberta, Edmonton, Alberta, Canada
| | - Benzi Kluger
- Department of Neurology, University of Rochester, Rochester, New York, USA
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Einfluss methodischer Veränderungen auf die unikausale Todesursachenstatistik und Potenziale einer multikausalen Datengrundlage. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:1476-1484. [DOI: 10.1007/s00103-019-03048-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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10
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Oliveri S, Ferrari F, Manfrinati A, Pravettoni G. A Systematic Review of the Psychological Implications of Genetic Testing: A Comparative Analysis Among Cardiovascular, Neurodegenerative and Cancer Diseases. Front Genet 2018; 9:624. [PMID: 30619456 PMCID: PMC6295518 DOI: 10.3389/fgene.2018.00624] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/23/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Genetic testing is performed for different purposes, such as identifying carriers, predicting a disease onset in presymptomatic individuals or confirming a diagnosis. However, these tests may have notable psychological effects, such as generating anxiety and depression. These effects may depend on people's perception of risk, severity, and controllability of the disease; and the availability of treatments. To date, there are no reports that analyze these factors specifically, and their role in influencing genetic test users' experience. Methods: We performed a systematic review of the psychological implication of undergoing genetic testing for cardiovascular, neurodegenerative and cancer diseases. Articles were searched on PubMed, Google Scholar, and PsychInfo. Results: 47 studies were included, 9 concerning cardiovascular disease, 18 neurodegenerative disorders, and 20 for cancer disease. According to the reviewed studies, people experience no significant increase in distress and anxiety, or adverse impacts on quality of life, except the Huntington disease, which is characterized by depressive symptoms, suicidal ideations, and hopelessness in gene carriers. People tend to consider genetic tests as valid information to take important preventive decisions. Genetic risk for cardiovascular disease is perceived to be manageable; genetic analysis for some neurodegenerative diseases (e.g., Alzheimer) or cancer (breast cancer in particular) is considered useful because the problem could be addressed in advance with preventive behaviors. Conclusions: Genetic tests should be proposed along with proper psychological support and counseling focused on users' genetic health literacy; perception of risk, beliefs about disease controllability, in order to foster fruitful medical decisions.
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Affiliation(s)
- Serena Oliveri
- Department of Oncology and Hematoncology, Interdisciplinary Research Center on Decision Making Processes, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
| | - Federica Ferrari
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
| | - Andrea Manfrinati
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
| | - Gabriella Pravettoni
- Department of Oncology and Hematoncology, Interdisciplinary Research Center on Decision Making Processes, University of Milan, Milan, Italy
- Applied Research Division for Cognitive and Psychological Science, IEO Istituto Europeo di Oncologia, Milan, Italy
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Insights on dying, dementia and death certificates. Arch Public Health 2018; 76:16. [PMID: 29545947 PMCID: PMC5846233 DOI: 10.1186/s13690-018-0263-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022] Open
Abstract
For our master thesis in medicine, we aimed to determine how many deaths were caused by and with dementia in 2014 and we compared our results with figures from abroad. The mortality rates of 2014 in Flanders were used to determine the amount of deaths related to dementia. These figures are collected by Vlaams Agentschap Zorg & Gezondheid (VAZG) and coded per ICD-10 classification. Of all deaths in Flanders in 2014, 6.60% were caused by dementia and 4.29% were caused by another condition, while also suffering from dementia. Data from abroad are ambiguous. While working on our thesis about “death & dementia”, we questioned the reliability of mortality statistics. Possible explanations could be; the complexity of completing death certificates correctly and the challenges involved in properly constructing a chain of causes of death. The accuracy of mortality data can be improved by training and redrafting death certificates.
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Schwarzinger M, Pollock BG, Hasan OSM, Dufouil C, Rehm J. Contribution of alcohol use disorders to the burden of dementia in France 2008-13: a nationwide retrospective cohort study. LANCET PUBLIC HEALTH 2018; 3:e124-e132. [PMID: 29475810 DOI: 10.1016/s2468-2667(18)30022-7] [Citation(s) in RCA: 168] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/23/2018] [Accepted: 01/30/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Dementia is a prevalent condition, affecting 5-7% of people aged 60 years and older, and a leading cause of disability in people aged 60 years and older globally. We aimed to examine the association between alcohol use disorders and dementia risk, with an emphasis on early-onset dementia (<65 years). METHODS We analysed a nationwide retrospective cohort of all adult (≥20 years) patients admitted to hospital in metropolitan France between 2008 and 2013. The primary exposure was alcohol use disorders and the main outcome was dementia, both defined by International Classification of Diseases, tenth revision discharge diagnosis codes. Characteristics of early-onset dementia were studied among prevalent cases in 2008-13. Associations of alcohol use disorders and other risk factors with dementia onset were analysed in multivariate Cox models among patients admitted to hospital in 2011-13 with no record of dementia in 2008-10. FINDINGS Of 31 624 156 adults discharged from French hospitals between 2008 and 2013, 1 109 343 were diagnosed with dementia and were included in the analyses. Of the 57 353 (5·2%) cases of early-onset dementia, most were either alcohol-related by definition (22 338 [38·9%]) or had an additional diagnosis of alcohol use disorders (10 115 [17·6%]). Alcohol use disorders were the strongest modifiable risk factor for dementia onset, with an adjusted hazard ratio of 3·34 (95% CI 3·28-3·41) for women and 3·36 (3·31-3·41) for men. Alcohol use disorders remained associated with dementia onset for both sexes (adjusted hazard ratios >1·7) in sensitivity analyses on dementia case definition (including Alzheimer's disease) or older study populations. Also, alcohol use disorders were significantly associated with all other risk factors for dementia onset (all p<0·0001). INTERPRETATION Alcohol use disorders were a major risk factor for onset of all types of dementia, and especially early-onset dementia. Thus, screening for heavy drinking should be part of regular medical care, with intervention or treatment being offered when necessary. Additionally, other alcohol policies should be considered to reduce heavy drinking in the general population. FUNDING None.
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Affiliation(s)
- Michaël Schwarzinger
- Translational Health Economics Network, Paris, France; Infection Antimicrobials Modeling and Evolution, UMR 1137, INSERM-Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
| | - Bruce G Pollock
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Omer S M Hasan
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Carole Dufouil
- INSERM, University of Bordeaux, Centre INSERM U1219-Bordeaux Population Health, ISPED-Bordeaux School of Public Health, Bordeaux, France; Bordeaux University Hospital, Public Health Department, Medical Information Service, Bordeaux, France
| | - Jürgen Rehm
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Institute for Clinical Psychology and Psychotherapy, Technical University Dresden, Dresden, Germany
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Wunsch G, Gourbin C. Mortality, morbidity and health in developed societies: a review of data sources. GENUS 2018; 74:2. [PMID: 29398718 PMCID: PMC5787574 DOI: 10.1186/s41118-018-0027-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 01/11/2018] [Indexed: 12/26/2022] Open
Abstract
The purpose of this paper is to review the major sources of data on mortality, morbidity and health in Europe and in other developed regions in order to examine their potential for analysing mortality and morbidity levels and trends. The review is primarily focused on routinely collected information covering a whole country. No attempt is made to draw up an inventory of sources by country; the paper deals instead with the pros and cons of each source for mortality and morbidity studies in demography. While each source considered separately can already yield useful, though partial, results, record linkage among data sources can significantly improve the analysis. Record linkage can also lead to the detection of possible causal associations that could eventually be confirmed. More generally, Big Data can reveal changing mortality and morbidity trends and patterns that could lead to preventive measures being taken rather than more costly curative ones.
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Affiliation(s)
- Guillaume Wunsch
- Centre for Demographic Research, Catholic University of Louvain, Place Montesquieu 1/L2.08.03, B-1348 Louvain-la-Neuve, Belgium
| | - Catherine Gourbin
- Centre for Demographic Research, Catholic University of Louvain, Place Montesquieu 1/L2.08.03, B-1348 Louvain-la-Neuve, Belgium
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15
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Niu H, Alvarez-Alvarez I, Guillen-Grima F, Al-Rahamneh MJ, Aguinaga-Ontoso I. Trends of mortality from Alzheimer's disease in the European Union, 1994-2013. Eur J Neurol 2017; 24:858-866. [DOI: 10.1111/ene.13302] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 03/23/2017] [Indexed: 11/30/2022]
Affiliation(s)
- H. Niu
- Department of Health Sciences; Public University of Navarre; Pamplona Navarre
| | - I. Alvarez-Alvarez
- Department of Health Sciences; Public University of Navarre; Pamplona Navarre
| | - F. Guillen-Grima
- Department of Health Sciences; Public University of Navarre; Pamplona Navarre
- Navarre's Institute for Health Research (IDISNA); Pamplona Navarre
- Preventive Medicine; University of Navarre Clinic; Pamplona Navarre Spain
| | - M. J. Al-Rahamneh
- Department of Health Sciences; Public University of Navarre; Pamplona Navarre
| | - I. Aguinaga-Ontoso
- Department of Health Sciences; Public University of Navarre; Pamplona Navarre
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Grande E, Zucchetto A, Suligoi B, Grippo F, Pappagallo M, Virdone S, Camoni L, Taborelli M, Regine V, Serraino D, Frova L. Multiple cause-of-death data among people with AIDS in Italy: a nationwide cross-sectional study. Popul Health Metr 2017; 15:19. [PMID: 28521797 PMCID: PMC5437492 DOI: 10.1186/s12963-017-0135-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 05/04/2017] [Indexed: 12/12/2022] Open
Abstract
Background Multiple cause-of-death (MCOD) data allow analyzing the contribution to mortality of conditions reported on the death certificate that are not selected as the underlying cause of death. Using MCOD data, this study aimed to fully describe the cause-specific mortality of people with AIDS (PWA) compared to people without AIDS. Methods We conducted a nationwide investigation based on death certificates of 2,515 Italian PWA and 123,224 people without AIDS who had died between 2006 and 2010. The conditions most frequently associated with PWA mortality, compared to people without AIDS, were identified using an age-standardized proportion ratio (ASPR) calculated as the ratio between the age-standardized proportion of a specific cause among PWA and the same proportion among people without AIDS. Results The most frequently reported conditions at death among PWA were infectious/parasitic diseases (52%), digestive (36%), respiratory (33%), and circulatory (32%) system diseases, and neoplasms (29%). All AIDS-defining conditions resulted highly associated (ASPR significantly greater than unity) with PWA deaths. Significant associations also emerged for leishmaniasis (ASPR = 188.0), encephalitis/myelitis/encephalomyelitis (ASPR = 14.3), dementia (ASPR = 13.1), chronic viral hepatitis (ASPR = 13.1), liver fibrosis/cirrhosis (ASPR = 4.4), pneumonia (ASPR = 4.4), anal (ASPR = 12.1) and liver (ASPR = 1.9) cancers, and Hodgkin’s disease (ASPR = 3.1). Conclusions Study findings identified the contribution of several non-AIDS-defining conditions on PWA mortality, emphasizing the need of preventive public health interventions targeting this population.
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Affiliation(s)
- Enrico Grande
- Servizio Sistema integrato salute, assistenza, previdenza e giustizia, Istituto Nazionale di Statistica, Viale Liegi 13, 00198, Rome, Italy
| | - Antonella Zucchetto
- Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Via Gallini 2, 33081, Aviano, PN, Italy
| | - Barbara Suligoi
- Centro Operativo AIDS, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Francesco Grippo
- Servizio Sistema integrato salute, assistenza, previdenza e giustizia, Istituto Nazionale di Statistica, Viale Liegi 13, 00198, Rome, Italy
| | - Marilena Pappagallo
- Servizio Sistema integrato salute, assistenza, previdenza e giustizia, Istituto Nazionale di Statistica, Viale Liegi 13, 00198, Rome, Italy
| | - Saverio Virdone
- Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Via Gallini 2, 33081, Aviano, PN, Italy
| | - Laura Camoni
- Centro Operativo AIDS, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Martina Taborelli
- Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Via Gallini 2, 33081, Aviano, PN, Italy
| | - Vincenza Regine
- Centro Operativo AIDS, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161, Rome, Italy
| | - Diego Serraino
- Unit of Cancer Epidemiology, CRO Aviano National Cancer Institute, Via Gallini 2, 33081, Aviano, PN, Italy.
| | - Luisa Frova
- Servizio Sistema integrato salute, assistenza, previdenza e giustizia, Istituto Nazionale di Statistica, Viale Liegi 13, 00198, Rome, Italy
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Fedeli U, Schievano E. Increase in Parkinson's disease-related mortality among males in Northern Italy. Parkinsonism Relat Disord 2017; 40:47-50. [PMID: 28416129 DOI: 10.1016/j.parkreldis.2017.04.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 03/20/2017] [Accepted: 04/09/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND According to standard mortality statistics based on the underlying cause of death (UCOD), mortality from Parkinson's disease (PD) is increasing in most European countries. However, mortality trends are better investigated taking into account all the diseases reported in the death certificate (multiple causes of death approach, MCOD). METHODS All deaths of residents in the Veneto Region (Northern Italy) aged≥45 years with any mention of PD were extracted from 2008 to 2015. The Annual Percent Change (APC) in age-standardized mortality rates was computed both for PD as the UCOD, and by MCOD. The association with common chronic comorbidities and acute complications was investigated by log-binomial regression. The frequency of the mention of PD in death certificates was investigated through linkage with an archive of patients with a previous clinical diagnosis of the disease. RESULTS PD was reported in 2.1% of all deaths, rising from 1.9% in 2008 to 2.4% in 2015. Among males, age-standardized rates increased over time both in analyses based on the UCOD (APC +4.1%; Confidence Interval +1.5%,+6.7%), and on MCOD (APC +2.2%; +0.2,+4.2%). Among females time trends were not significant. Mention of PD was associated with that of dementia/Alzheimer and acute infectious diseases. Among known PD patients, the disease was reported only in 60.2% of death certificates. CONCLUSIONS Mortality associated to PD is steeply increasing among males in Northern Italy; further investigations on time trends for PD, both through all available electronic health archives and clinical studies, should be set as a priority for epidemiological research.
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Affiliation(s)
- Ugo Fedeli
- Epidemiological Department, Veneto Region, Italy.
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Piffaretti C, Moreno-Betancur M, Lamarche-Vadel A, Rey G. Quantifying cause-related mortality by weighting multiple causes of death. Bull World Health Organ 2016; 94:870-879. [PMID: 27994280 PMCID: PMC5153928 DOI: 10.2471/blt.16.172189] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 07/06/2016] [Accepted: 07/25/2016] [Indexed: 01/31/2023] Open
Abstract
Objective To investigate a new approach to calculating cause-related standardized mortality rates that involves assigning weights to each cause of death reported on death certificates. Methods We derived cause-related standardized mortality rates from death certificate data for France in 2010 using: (i) the classic method, which considered only the underlying cause of death; and (ii) three novel multiple-cause-of-death weighting methods, which assigned weights to multiple causes of death mentioned on death certificates: the first two multiple-cause-of-death methods assigned non-zero weights to all causes mentioned and the third assigned non-zero weights to only the underlying cause and other contributing causes that were not part of the main morbid process. As the sum of the weights for each death certificate was 1, each death had an equal influence on mortality estimates and the total number of deaths was unchanged. Mortality rates derived using the different methods were compared. Findings On average, 3.4 causes per death were listed on each certificate. The standardized mortality rate calculated using the third multiple-cause-of-death weighting method was more than 20% higher than that calculated using the classic method for five disease categories: skin diseases, mental disorders, endocrine and nutritional diseases, blood diseases and genitourinary diseases. Moreover, this method highlighted the mortality burden associated with certain diseases in specific age groups. Conclusion A multiple-cause-of-death weighting approach to calculating cause-related standardized mortality rates from death certificate data identified conditions that contributed more to mortality than indicated by the classic method. This new approach holds promise for identifying underrecognized contributors to mortality.
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Affiliation(s)
- Clara Piffaretti
- CépiDc-Inserm, Epidemiology Centre on Medical Causes of Death, 80, rue du Général Leclerc, 94276 le Kremlin-Bicêtre, Cedex, France
| | - Margarita Moreno-Betancur
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Agathe Lamarche-Vadel
- CépiDc-Inserm, Epidemiology Centre on Medical Causes of Death, 80, rue du Général Leclerc, 94276 le Kremlin-Bicêtre, Cedex, France
| | - Grégoire Rey
- CépiDc-Inserm, Epidemiology Centre on Medical Causes of Death, 80, rue du Général Leclerc, 94276 le Kremlin-Bicêtre, Cedex, France
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Perera G, Stewart R, Higginson IJ, Sleeman KE. Reporting of clinically diagnosed dementia on death certificates: retrospective cohort study. Age Ageing 2016; 45:668-73. [PMID: 27146301 PMCID: PMC5027637 DOI: 10.1093/ageing/afw077] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/23/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND mortality statistics are a frequently used source of information on deaths in dementia but are limited by concerns over accuracy. OBJECTIVE to investigate the frequency with which clinically diagnosed dementia is recorded on death certificates, including predictive factors. METHODS a retrospective cohort study assembled using a large mental healthcare database in South London, linked to Office for National Statistics mortality data. People with a clinical diagnosis of dementia, aged 65 or older, who died between 2006 and 2013 were included. The main outcome was death certificate recording of dementia. RESULTS in total, 7,115 people were identified. Dementia was recorded on 3,815 (53.6%) death certificates. Frequency of dementia recording increased from 39.9% (2006) to 63.0% (2013) (odds ratio (OR) per year increment 1.11, 95% CI 1.07-1.15). Recording of dementia was more likely if people were older (OR per year increment 1.02, 95% CI 1.01-1.03), and for those who died in care homes (OR 1.89, 95% CI 1.50-2.40) or hospitals (OR 1.14, 95% CI 1.03-1.46) compared with home, and less likely for people with less severe cognitive impairment (OR 0.95, 95% CI 0.94-0.96), and if the diagnosis was Lewy body (OR 0.30, 95% CI 0.15-0.62) or vascular dementia (OR 0.79, 95% CI 0.68-0.93) compared with Alzheimer's disease. CONCLUSIONS changes in certification practices may have contributed to the rise in recorded prevalence of dementia from mortality data. However, mortality data still considerably underestimate the population burden of dementia. Potential biases affecting recording of dementia need to be taken into account when interpreting mortality data.
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Affiliation(s)
- Gayan Perera
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Robert Stewart
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Irene J Higginson
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK
| | - Katherine E Sleeman
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, UK
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Subjective wellbeing and longevity: Findings from a 22-year cohort study. J Psychosom Res 2016; 85:28-34. [PMID: 27212667 DOI: 10.1016/j.jpsychores.2016.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 04/15/2016] [Accepted: 04/16/2016] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The health implications of positive affect (PA) are still a matter of debate. The present study examined the longitudinal relationships between subjective wellbeing (SWB) components (i.e., Life satisfaction, PA and negative affect (NA)) and all-cause mortality in older adults. METHODS Discrete-time survival analysis within the structural equation modeling framework was applied to data from the PAQUID Cohort (n=3777, baseline age 62-101years) including ten time periods spanning 22years. Time-invariant (age, gender, baseline life satisfaction, diabetes mellitus and hypercholesterolemia status) and lagged time-varying (PA, NA, dementia, functional status and self-rated health) predictors were included sequentially in the analyses. RESULTS When included together in the model, only PA among the SWB components showed a significant association with longevity, which persisted (OR=.962, 95% CI=.938, .986) even after adjustment for the interaction between PA and NA, and after additional adjustment for prior medical conditions, functional status and self-rated health. CONCLUSIONS In congruence with positive psychology, PA proved to be an independent protective factor regardless of variations in NA, which did not seem to be a mortality risk factor.
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Mazuy M, Barbieri M, Breton D, d’Albis H. L’évolution démographique récente de la France et ses tendances depuis 70 ans. POPULATION 2015. [DOI: 10.3917/popu.1503.0417] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Zou JX, Wang MJ, Lei XJ, Chen XG. 3.0 T MRI arterial spin labeling and magnetic resonance spectroscopy technology in the application of Alzheimer's disease. Exp Gerontol 2014; 60:31-6. [PMID: 25220149 DOI: 10.1016/j.exger.2014.09.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 09/11/2014] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to investigate the changes in the cerebral blood flow (CBF) and spectrum variables in the posterior cingulate region of patients with AD under the detection of arterial spin labeling (ASL) and magnetic resonance spectroscopy (MRS). A total of 20 AD patients (8 males and 12 females; mean age, 64.84±8.82 years) and 20 healthy controls (9 males and 11 females; mean age, 64.94±7.93 years) were included in this study for analysis. All images were obtained using a 3.0-T MR imager and an 8-channel head array receiving coil. MRS measurements were conducted exploring variables of metabolite ratios. Statistical analyses were conducted with the SPSS 11.0 statistical software package. Findings in the present study revealed a significant difference in the mean MMSE scores between the AD group and the healthy control group (16.21±4.01 vs. 27.35±1.01, P<0.01). Compared with the healthy control group, CBF in the bilateral frontal region showed a significant decrease in the AD group (right frontal: 83.5±7.2 vs. 110±11.5, P<0.05; left frontal: 85.6±8.1 vs. 108.7±12.2, P<0.05, respectively), and a similar association was also observed in the TL, TPJ, parietal, and hippocampal regions (all P<0.05). MRS imaging in the posterior cingulate region showed a significant reduction in the NAA/Cr ratio in the AD group (1.43±0.1 vs. 1.49±0.0, P<0.05). Additionally, we found that the MI/Cr and Cho/Cr ratios were higher than normal controls in patients with AD (all P<0.05). Our results suggested that 3D ASL detection combined with MRS in studying AD could show the regional hypo-perfusion with the decrease of CBF and the abnormal metabolic changes of the posterior cingulate cortex.
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Affiliation(s)
- Jian-Xun Zou
- Department of Radiology, Lishui People's Hospital, Lishui 323000, PR China.
| | - Ming-Jie Wang
- Department of Radiology, Lishui People's Hospital, Lishui 323000, PR China
| | - Xin-Jun Lei
- Department of Radiology, Lishui People's Hospital, Lishui 323000, PR China
| | - Xu-Gao Chen
- Department of Radiology, Lishui People's Hospital, Lishui 323000, PR China
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