Mortality and causes of deaths of inhabitants with renal dysfunction induced by cadmium exposure of the polluted Jinzu River basin, Toyama, Japan; a 26-year follow-up

BACKGROUND

We aimed to investigate the mortality and causes of deaths of inhabitants with renal dysfunction induced by cadmium (Cd) exposure caused by heavy environmental contamination.

METHODS

We conducted a 26-year follow-up survey targeting 7529 inhabitants of the Cd-polluted Jinzu River basin and 2149 controls from non-polluted areas who participated in urinary examinations for proteinuria and glucosuria conducted in 1979 to 1984. When the residents were divided into 4 groups, no finding group, glucosuria group, proteinuria group, glucoproteinuria group, mortality risk ratios for all and specific causes of these groups in the polluted area were compared with that of controls without glucosuria and/or proteinuria after adjustments for age at baseline, smoking status, and history of hypertension using Cox's proportional hazard model.

RESULTS

The mortality risk ratios for all causes of proteinuria and glucoproteinuria in men and glucosuria, proteinuria, and glucoproteinuria in women of the polluted areas significantly increased compared with those of the controls with no urinary findings. Respiratory, renal, and cardiovascular diseases and diabetes in men, and all diseases except cerebrovascular diseases in women contributed toward an increased mortality of exposed glucoproteinuria groups, which involved chronic Cd toxicosis with renal tubular dysfunction. In women, the mortality risks for cancer of the colon and rectum, uterus and kidney and urinary tract were significantly higher in the exposed proteinuria and glucoproteinuria groups, suggesting associations between renal damage and cancer risk. In exposed women, the no finding group and glucoproteinuria group also showed increased mortality from ischemic heart diseases, indicating that all exposed women may be at risk for ischemic heart diseases. Although the control glucosuria and/or proteinuria group also showed high mortality for diabetes and renal diseases, the increased risk ratio for renal disease mortality was much higher in exposed subjects with urinary findings, particularly in women.

CONCLUSIONS

These findings indicate that inhabitants with renal effects caused by Cd exposure had a poor life prognosis over long-term observation in both genders. Particularly in women, renal tubular dysfunction indicated by glucoproteinuria may increase mortality from cancer, ischemic heart diseases, and renal diseases.

β-Blockers and All-Cause Mortality in Adults with Episodes of Acute Bronchitis: An Observational Study

BACKGROUND

Recent observational studies suggest that β-blockers may improve long-term prognosis in patients with chronic obstructive pulmonary disease (COPD). We assessed whether β-blocker use improves all-cause mortality in patients with episodes of acute bronchitis.

METHODS

An observational cohort study using data from the electronic medical records of 23 general practices in the Netherlands. The data included standardized information about daily patient contacts, diagnoses, and drug prescriptions. Cox regression was applied with time-varying treatment and covariates.

RESULTS

The study included 4,493 patients aged 45 years and older, with at least one episode of acute bronchitis between 1996 and 2006. The mean (SD) age of the patients was 66.9 (11.7) years, and 41.9% were male. During a mean (SD) follow up period of 7.7 (2.5) years, 20.4% developed COPD. In total, 22.7% had cardiovascular comorbidities, resulting in significant higher mortality rates than those without (51.7% vs. 12.0%, p<0.001). The adjusted hazard ratio of cardioselective β-blocker use for mortality was 0.62 (95% confidence interval [CI], 0.50-0.77), and 1.01 (95% CI 0.75-1.36) for non-selective ones. Some other cardiovascular drugs also reduced the risk of mortality, with adjusted HRs of 0.60 (95% CI 0.46-0.79) for calcium channel blockers, 0.88 (95% CI 0.73-1.06) for ACE inhibitors/angiotensin receptor blockers, and 0.42 (95% CI 0.31-0.57) for statins, respectively.

CONCLUSION

Cardiovascular comorbidities are common and increase the risk of mortality in adults with episodes of acute bronchitis. Cardioselective β-blockers, but also calcium channel blockers and statins may reduce mortality, possibly as a result of cardiovascular protective properties.

Respiratory tract infections after cardiac surgery: impact on hospital morbidity and mortality

AIM

Nosocomial pneumonia (NP) and tracheobronchitis after cardiac surgery are associated with worse outcomes. The aim of this study was to identify risk factors associated with NP and tracheobronchitis after cardiac surgery and to determine the impact of these infections on hospital morbidity and mortality.

METHODS

We evaluated 1600 adult patients undergoing cardiac surgery under standard cardiopulmonary bypass. Data were collected prospectively. All NP and tracheobronchitis episodes were confirmed by a semiquantitative culture of endotracheal aspirate. Logistic regression analysis was done to identify risk factors for respiratory tract infection and mortality.

RESULTS

The rate of NP was 1.2% (15.6 episodes per 1000 days of mechanical ventilation) and that of tracheobronchitis was 1.6% (21 episodes per 1000 days of mechanical ventilation). Significant independent risk factors for respiratory tract infection (pneumonia or tracheobronchitis) were: left ventricular ejection fraction < 30% (P = 0.001), chronic renal failure (P < 0.0001) and urgent surgery (P < 0.0001). Patients with NP had significantly higher mortality (42% versus 0.9%, P < 0.0001) than patients without respiratory tract infection. The median hospital length of stay was significantly longer in patients with pneumonia (42 days) and tracheobronchitis (28 days) than in patients without any respiratory tract infection (11 days, P < 0.0001).

CONCLUSION

NP after cardiac surgery is associated with severe outcomes. Independent risk markers for respiratory tract infection were left ventricular ejection fraction < 30%, chronic renal failure and urgent surgery.

[Epidemiology and development of prophylaxis of acute respiratory diseases and pneumonias in servicemen in modern conditions]

Acute diseases of respiratory organs occupy leading position among all diseases in army. In 2009 a part of total morbidity of ARD, flu, pneumonia and acute bronchitis was 45.7% from all diseases. With the start of the usage of pneumococcal vaccine in the army continuous increase of morbidity of pneumonia gave way to reduction. In postvaccinal period in patients with pneumonia, frequency of pneumococcus's effuse reduced under the increase of frequency of detection of viruses, staphylococcus and streptococcus. Considering polyaetiology of pneumonia and ARD, significancy of immune inefficiency in its developments, it is necessary to use specific prophylactic drugs with antiviral products in period of reinforce.

Natural history and life expectancy in severe alpha1-antitrypsin deficiency, Pi Z

Clinical data from 246 adult Swedish individuals with severe alpha1-antitrypsin deficiency, Pi Z, diagnosed in 1963--77, were analyzed. Primary emphysema was present in 109 cases. Of 75 Pi Z patients with other types of chronic obstructive pulmonary disease (COPD), all but 7 showed signs of emphysema. Median age at onset of dyspnoea in Pi Z smokers was 40 years, compared to 53 in non-smokers (p less than 0.001). Of the Pi Z individuals over the age of 50, 19% had a diagnosis of liver cirrhosis and 15% signs of glomerular renal damage. Of 91 deceased patients, 56 died from COPD and 12 from liver disease. A greatly reduced survival was demonstrated in Pi Z individuals, regardless of sex. Smoking Pi Z individuals had a significantly lower life expectancy than Pi Z non-smokers (p less than 0.01).

Thirty-year cumulative incidence of chronic bronchitis and COPD in relation to 30-year pulmonary function and 40-year mortality: a follow-up in middle-aged rural men

PURPOSE

To describe the 30-year cumulative incidence of chronic bronchitis and COPD in relation to smoking habits. The effect of chronic bronchitis on pulmonary function and mortality was also examined.

METHODS

Middle-aged men belonging to two rural Finnish cohorts of the Seven Countries Study (n = 1,711 in 1959) were followed up for up to 40 years until 2000. Standard questionnaires were used to measure chronic bronchitis, and repeated spirometry was used to evaluate pulmonary function during the 30 years. Forty-year mortality data were examined.

RESULTS

The cumulative incidence of chronic bronchitis and COPD was 42% and 32%, respectively, in continuous smokers, compared to 26% and 14% in ex-smokers and 22% and 12% in never-smokers. During the follow-up, subjects with chronic bronchitis had on average 252 mL (95% confidence interval, 211 to 293 mL) lower forced expiratory volume than those without it. The decrease in forced expiratory volume attributable to chronic bronchitis was most pronounced in those with persistent symptoms and in smokers. In subjects with chronic bronchitis, all-cause mortality was increased by a hazard ratio of 1.30 (95% confidence interval, 1.02 to 1.65). Smokers with chronic bronchitis who decreased their daily cigarette consumption increased their median life span by 2.4 years.

CONCLUSIONS

The lifetime risk of chronic bronchitis among smokers is approximately two in five, and almost one half of smokers who have chronic bronchitis also acquire COPD. Chronic bronchitis is related to earlier death, also in never-smokers, probably partly through a rapid decline in pulmonary function.

Influenza and pneumococcal vaccination of the elderly in Taiwan

In 1998, Taiwan became the first country in Asia to provide free influenza vaccination to high-risk groups, mainly the elderly. The purpose of this study is to determine: (1) the annual mortality rate from influenza and pneumococcal-related illnesses such as pneumonia, chronic bronchitis, pulmonary emphysema and asthma and (2) the effectiveness of and adverse events associated with the influenza vaccination. In the elderly, influenza vaccination caused the annual death rate due chronic bronchitis, pulmonary emphysema, and asthma to decline steadily but had no effect on the annual pneumonia death rate. The only adverse effect of concern was vertigo (in approximately 2-3%).

Weighing social and economic determinants related to inequalities in mortality

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

Chronic bronchitis in an elderly population

BACKGROUND

in order to describe the prevalence and prognostic implications of chronic bronchitis in individuals 65 years or older we analysed data from The Copenhagen City Heart Study.

METHODS

the population was studied in 1976-1978 resurveyed in 1981-1983 and 1991-1994 and followed with regard to survival for up to 12 years. Approximately 3,700 elderly participants with a mean age of 76 years were available for analyses.

RESULTS

the prevalence of chronic bronchitis was 13.0% in women and 18.6% in men. Multiple logistic regression yielded the following predictors for chronic bronchitis: male gender (odds ratio with 95% confidence interval = 1.1 (0.9-1.3)), previous smoking odds ratio = 1.7 (1.2-2.2), present smoking odds ratio = 2.1 (2.1-3.8), previous exposure to dusts and fumes (odds ratio = 2.2 (1.7-2.7)), chest infections in childhood (odds ratio = 2.1 (1.6-2.9)), more than 6 chest infections in previous 10 years (odds ratio = 6.2 (4.1-9.2)) and alcohol consumption of more than 3 drinks a day (odds ratio = 1.8 (1.3-2.3)). Chronic bronchitis was a significant predictor of both subsequent respiratory infections and survival. After adjustment for age, smoking and lung function, a Cox regression showed that chronic bronchitis was significantly related to mortality from all causes with a hazard ratio with 95% confidence interval = 1.3 (1.1-1.4), all benign respiratory diseases (hazard ratio = 2.0 (1.6-2.7)), obstructive lung disease (hazard ratio = 2.5 (1.7-3.6)) and lung cancer (hazard ratio = 2.0 (1.4-2.9)).

CONCLUSIONS

in an elderly population, chronic bronchitis is a prevalent condition with important prognostic implications.

The pathophysiological significance of prognostic factors for fatal outcome in lower respiratory tract infections

OBJECTIVE

The aim of this study was to determine prognostic factors for outcome in patients with lower respiratory tract infections (LRTI). LRTI are an heterogeneous group of disorders, including acute bronchitis, pneumonia, superinfection of chronic bronchitis and influenza.

METHODOLOGY

A total of 616 patients with LRTI were retrospectively reviewed with regard to epidemiological, clinical, laboratory and radiographical data. Prognostic analysis included a univariate as well as a multivariate approach, in order to identify parameters associated with death.

RESULTS

The parameters found to be significantly different between survivors and non-survivors in the univariate analysis, were respiratory rate, PaO2, heart rate, systolic and diastolic blood pressure, platelet count, urea, creatinine, previous admission to the hospital in the last year and cavitations visible on the chest radiograph.

CONCLUSIONS

LRTI remain a widespread problem and have a significant impact on primary healthcare resources. The great variability seen in rates of hospital admission and lengths of stay in part reflects uncertainty among physicians in assessing the severity of the illness. According to our data, PaO2 and heart rate were most closely associated with patient death and are readily defined and available at presentation.

Life with and without disease: women experience more of both

This paper examines gender differences in life with and without six major diseases, including both mortal and morbid conditions. Disease prevalence and health behavior data are from the 1993-1995 National Health Interview Surveys for the United States. Vital registration data are the source of mortality rates used in computing life expectancy. The Sullivan method is used to estimate life lived with and without disease and risky behavior for men and women at various ages. Women live more years with each of the diseases examined, and, for arthritis, the extended years with disease are greatest. Women also live more years than men free of each of these diseases with the exception of arthritis. Gender differences in life without two health-risk behaviors are also discussed. Men spend more years of their lives overweight and have fewer years during which they see a doctor.

[Effects on health of particulate air pollution in Denmark--a quantitative assessment]

INTRODUCTION

Ambient air pollution is a risk factor for mortality and morbidity. The aim of this study was to quantify the health effects related to particulate matter (PM10) in Denmark.

MATERIALS AND METHODS

We used relative risk estimates in relation to PM10 based on the epidemiological literature. Population exposure to PM10 was calculated. Cases attributable to PM10 were estimated for mortality, cardiovascular and respiratory hospital admissions, chronic bronchitis, acute bronchitis, restricted activity days, and asthma attacks. Moreover, we attempted to estimate health-related gains from equipping all heavy-duty vehicles in Denmark with particle filters.

RESULTS

We estimated the average population PM10 exposure to be about 22 micrograms/m3, about one third of which can be attributed to natural (not man-made) PM10. The number of cases per year attributable to the estimated exposure included about 5,000 deaths, about 5,000 hospital admissions, about 5,000 cases of chronic bronchitis, about 17,000 cases of acute bronchitis, about 200,000 asthma attacks, and about three million restricted activity days. The health-related gains from installing particle filters on all heavy-duty vehicles in Denmark are uncertain; the estimates for mortality ranged from 22 to 1,250, depending on the assumptions.

DISCUSSION

Although air pollution constitutes only a minor risk factor on the individual level, it seems to be a major public health problem. The particle characteristics responsible for the estimated health effects are not well understood. The ultrafine particle fraction may cause a much greater impact on health than indicated by the mass.

Non-malignant mortality among Norwegian silicon carbide smelter workers

OBJECTIVES

To investigate associations between exposures in the silicon carbide (SiC) industry and mortality from non-malignant diseases.

METHODS

Mortality among 2562 men, working in one of three silicon carbide smelters was investigated, giving 52,618 person-years of follow up from 1962 to 1996. Dose-response relations were investigated by internal comparisons using Poisson regression and by stratified standardised mortality ratio (SMR) analyses.

RESULTS

Mortality from all causes was significantly raised compared with the Norwegian mortalities among men, SMR=1.12, (95% confidence interval (95% CI) 1.05 to 1.20). An excess mortality from asthma, emphysema, and chronic bronchitis combined was found, SMR=2.21 (95% CI 1.61 to 2.95), increasing from 1.05 in the unexposed category to 2.64 (95% CI 1.44 to 4.43) in the upper category of exposure to total dust. The Poisson regression analysis confirmed the results from the stratified SMR analyses, and suggested that smoking did not act as a confounder. No association was found for circulatory mortality.

CONCLUSIONS

There was an increased mortality from asthma, emphysema, and chronic bronchitis combined among SiC workers exposed to dust.

Local surveillance of influenza in the United Kingdom: from sentinel general practices to sentinel cities?

Surveillance of influenza in England and Wales utilises a disparate geographical network of general practices to provide clinical data in the form of weekly consultation rates for influenza and 'influenza-like illness'. This network accurately detects and monitors seasonal influenza activity at national and supra-regional levels. Localised regional and sub-regional epidemics are less easily detected. We describe a localised epidemic of influenza affecting a deprived urban community in the North West of England that was detected by a close knit network of general practices participating in the surveillance of communicable diseases as part of a primary care health needs assessment initiative.

Mortality and causes of death in patients with monoclonal gammopathy of undetermined significance

To evaluate the mortality and causes of death in monoclonal gammopathy of undetermined significance (MGUS), we identified 1324 cases of MGUS in the period 1978-93 in North Jutland County, Denmark. Data on mortality were obtained by record linkage to the Danish Death Registry. There were 868 deaths in the MGUS cohort during 7785 years of follow-up vs. 409.6 expected, giving a standardized mortality ratio (SMR) of 2.1 (95% confidence interval 2.0-2.3). Malignant transformation was the cause of death in 97 patients vs. 4.9 expected, yielding a SMR of 20.0 (16.2-24.4), which explained about 20% of the excess mortality in the cohort. The mortality was increased for several other malignant and non-malignant causes of death during the first 4 years of follow-up. For late follow-up, 5-18 years after detection of the M-component, the overall SMR was 1.7 (1.5-1.9), and malignant transformation was the only cause of death with a substantial increase of SMR. Although malignant transformation is an important cause of death in MGUS patients, it did not entirely explain the increased mortality. MGUS patients often suffer from coexisting clinical conditions that increase the mortality, especially during the first years after detection of the M-component.

Pharmacokinetic/pharmacodynamic predictors of time to clinical resolution in patients with acute bacterial exacerbations of chronic bronchitis treated with a fluoroquinolone

Forty nine subjects with acute bacterial exacerbations of chronic bronchitis (ABECB) treated with grepafloxacin were evaluated for parameters predictive of clinical outcome. Signs and symptoms associated with ABECB were serially collected and evaluated for changes. Coughs per day, sputum volume and the percentage of sputum neutrophils were associated with clinical outcome. A by groups analysis, based on clinical success was performed using Cox regression analysis to determine factors associated with time to clinical success and time to reduction in sputum volume, coughs per day and sputum neutrophil percent. Factors evaluated included AUIC (AUC/MIC), isolate species, years and type of underlying lung disease, alcohol use, smoking history and number of ABECB within the previous 12 months. AUIC<276 (mg h/l)/mg/l (P<0.03) and or the presence of mild bronchiectasis (P<0.01) were associated with longer time to clinical success. In addition a relationship was found between AUIC>212 (mg h/l)/mg/l (P<0.01) and AUIC>576 (mg h/l)/mg/l (P<0.02) and decreasing days to sputum volume reduction and coughs per day, respectively. A diagnosis of mild bronchiectasis prolonged the time to reduce coughs per day (P<0.03) and neutrophil percentage (P<0.01). Patients with mild bronchiectasis were found to have an increase in the time to clinical success, coughs per day improvement and sputum neutrophil percent improvement. AUIC is an important PK/PD parameter predictive of successful outcome in ABECB, even in subjects with mild bronchiectasis. Grepafloxicin has been withdrawn from sale since these studies were carried out. This work is published to illustrate the relationship between pharmacodynamics and clinical efficacy and the use of AUIC as a valuable predictive parameter for fluoroquinolones.

[Predicted effect of smoking cessation of tobacco-related mortality]

INTRODUCTION

Cigarette smoking is a serious threat against public health and the most important preventable cause of death. The purpose of this study is to predict the effect on smoking-attributable mortality in Denmark by reducing the number of cigarette smokers.

MATERIALS AND METHODS

The simulation model "Prevent" is used. This model operates with the population size and death rates in 1993, data on cigarette smoking from 1973 to 1992 and relative risks for the association between cigarette smoking and lung cancer, chronic bronchitis and emphysema, ischaemic heart disease and stroke. The influence of reduced cigarette smoking on mortality due to these diseases is studied. The expected effect on a smoke-free year group is estimated and so is the effect of the implementation of targets in the Danish Government's Public Health Programme 1999-2008.

RESULTS

For the smoke-free year group death rates of ischaemic heart disease are reduced by one third for men and one half for women compared to unchanged cigarette smoking. Death rates of lung cancer, chronic bronchitis and emphysema would be approx. five times lower. If the proportion of Danish cigarette smokers could be reduced by one third over a period of ten years the reduced mortality due to lung cancer, chronic bronchitis and emphysema, ischaemic heart disease and stroke would increase the population (five mio. individuals) by 25,000 after 20 years.

DISCUSSION

Intervention against cigarette smoking, especially among young people, would massively reduce mortality from several diseases in the long term. Also in the short term mortality would be reduced substantially by reducing the number of cigarette smokers.

Employment grade differences in cause specific mortality. A 25 year follow up of civil servants from the first Whitehall study

STUDY OBJECTIVE

To test the hypothesis that the association between socioeconomic status and mortality rates cuts across the major causes of death for middle aged and elderly men.

DESIGN

25 year follow up of mortality in relation to employment grade.

SETTING

The first Whitehall study.

PARTICIPANTS

18,001 male civil servants aged 40-69 years who attended the initial screening between 1967 and 1970 and were followed up for at least 25 years.

MAIN OUTCOME MEASURE

Specific causes of death.

RESULTS

After more than 25 years of follow up of civil servants, aged 40-69 years at entry to the study, employment grade differences still exist in total mortality and for nearly all specific causes of death. Main risk factors (cholesterol, smoking, systolic blood pressure, glucose intolerance and diabetes) could only explain one third of this gradient. Comparing the older retired group with the younger pre-retirement group, the differentials in mortality remained but were less pronounced. The largest decline was seen for chronic bronchitis, gastrointestinal diseases and genitourinary diseases.

CONCLUSIONS

Differentials in mortality persist at older ages for almost all causes of death.

Management of acute inflammatory childhood stridor

BACKGROUND AND OBJECTIVE

Acute epiglottitis, bacterial tracheitis, and severe viral laryngotracheobronchitis continue to cause life-threatening airway obstruction in children. The aim of this retrospective study was to evaluate deficiencies in treatment, to clarify the role of airway endoscopy, and to identify current reasons for fatalities in these diseases.

MATERIALS AND PATIENTS

During the observation period from 1980 to 1996, we identified 61 patients treated in the pediatric intensive care unit of the University Hospital of Cologne for severe inflammatory airway obstruction.

RESULTS

Critical points in the appropriate airway management were (1) the confirmation of the admission diagnosis, (2) whether an artificial airway or rigid tracheobronchoscopy was required; and (3) appropriate timing of extubation. Since 1989 airway evaluation with flexible or small, rigid endoscopes was used to confirm the diagnosis and to determine the appropriate management. Endoscopic findings were extremely helpful to decide not to intubate and to monitor in the pediatric intensive care unit first. Three patients with acute epiglottitis died after out-of-hospital cardiorespiratory arrest.

CONCLUSION

Endoscopy should be a part of every established treatment protocol of childhood stridor. The most decisive factor to decrease mortality seems to be timely presentation to a referral center.

Trends in asthma mortality in young people in southern Brazil

BACKGROUND

Mortality from asthma increased and is now declining in some countries, but little is known about these trends in South America.

OBJECTIVE

We aimed to assess trends in mortality from asthma in southern Brazil in children and young adults.

METHODS

Death certificates of 425 people in the state of Rio Grande do Sul aged between 5 and 39 years in whom asthma was reported to be the underlying cause of death during the period 1970 to 1992 were reviewed. Population data were available in 10-year age groups. Testing for trends in mortality rates was conducted using linear and log-linear regression procedures.

RESULTS

Asthma mortality rates in the age groups 5 to 19 and 20 to 39 years ranged between 0.04 and 0.39/100,000 and 0.28 to 0.75/100,000, respectively, and were nonuniformly distributed over the study period. The mean annual increase in rate in 5- to 19-year olds was +0.01 (95% CI 0.003 to 0.016), an average annual percentage increase of +6.8% (95% CI 3% to 11%), with a total increase of 352% between 1970 and 1992. This increase was not due to a shift in labeling from bronchitis to asthma. In the 20 to 39-year age group, asthma and bronchitis mortality rates showed no trend to increase or decrease.

CONCLUSIONS

Asthma mortality in southern Brazil is low, but rose significantly between 1970 and 1992 in the 5 to 19-year age group. This trend differs from that found in other states of Brazil and several other Latin American countries. Reasons for this difference remain unclear.

Causes of death and life expectancies among dentists

The standardised mortality ratios (SMR) were obtained for dentists in Tokyo according to the causes of their deaths, in order to compare them with those for general Tokyo citizens. Furthermore, an abridged life table was prepared and those dentists' life expectancies were estimated. The materials used were 560 death certificates for male dentists issued in the 10-year period 1985-1994. The documents were kept at the Health Insurance Co-operative Society for Tokyo Dentists, run by the Tokyo Dental Association (TDA). With the general Tokyo residents as a reference population, the SMRs for dentists were significantly higher for oesophageal and colon cancers and significantly lower for heart diseases and pneumonia/bronchitis. The life expectancy for a 25-year-old dentist in Tokyo was 51.26 years. That at birth was stochastically estimated at 75.37 years, which was some one year shorter than that for an ordinary inhabitant (76.67 years), though the difference was insignificant.

Pseudomonas aeruginosa bronchopulmonary infection in patients with AIDS, with emphasis on relapsing infection

The aim of this study was to delineate the clinical and therapeutic characteristics of Pseudomonas aeruginosa bronchopulmonary infection in acquired immunodeficiency syndrome (AIDS) patients. Eighteen AIDS patients had 39 episodes of P. aeruginosa bronchopulmonary infection. Their mean CD4 cell count was 0.012+/-0.011 cells x 10(9) x L(-1) and two episodes (5.1%) occurred in neutropenic patients. Ten patients (55.5%) had 21 outbreaks of pseudomonal infection. Relapses were more frequent in patients with chronic bronchitis (80 versus 0%, p=0.03) and in those who received initial oral antibiotic therapy (100 versus 55.6%, p=0.25). Three patients died, but death was directly related to pseudomonal infection in only one patient. In a case-control study, patients with bronchopulmonary P. aeruginosa infection had a survival comparable to patients in the control group. Immunoglobulin prophylaxis was administered to three patients with relapses, without success. The two patients who had P. aeruginosa eradicated were those who began triple antiretroviral therapy and had a CD4 cell increase >0.150 cells x 10(9) x L(-1). Relapsing Pseudomonas aeruginosa bronchopulmonary infection affects patients with advanced human immunodeficiency virus infection, prior underlying lung disease, chronic bronchitis and initial oral antibiotic therapy. Immune reconstitution through triple antiretroviral therapy succeeded in eradicating Pseudomonas aeruginosa respiratory infection in two patients.

Mortality from nonmalignant respiratory diseases among male workers in Norwegian ferroalloy plants

OBJECTIVES

This study examined mortality from nonmalignant respiratory diseases among ferroalloy workers.

METHODS

The cohort comprised 14730 men employed for the first time in 1933-1990 and for at least 6 months in 1 of 12 plants. The duration of work in specific departments and exposure to amorphous silica in the ferrosilicon/silicon-metal (FeSi/Si-met) plants, estimated from a job-exposure matrix, were the main exposure variables. Deaths were observed during 1962-1990. The mortality was analyzed with the use of standardized mortality ratios (SMR) and internal comparisons of rates.

RESULTS

Overall mortality from nonmalignant respiratory diseases was not increased, but mortality from bronchitis, emphysema, and asthma combined was significantly increased among the men with at least 3 years of FeSi/Si-met furnace work (SMR 1.82, 16 deaths). A Poisson regression analysis of the mortality from these causes among 6359 employees in the FeSi/Si-met plants showed a significant increase of 0.06 per unit of amorphous silica exposure observed 10-20 years after the exposure. Six men died of pneumonia while still employed in a ferromanganese/silicomanganese (FeMn/SiMn) plant. No corresponding deaths occurred among employees in FeSi/Si-met plants. Only 2 deaths from pneumoconiosis were observed in the total cohort.

CONCLUSIONS

Among employees in FeSi/Si-met plants increased mortality from bronchitis, emphysema, and asthma may be associated with previous exposure to amorphous silica. Deaths from pneumonia among FeMn/SiMn workers may be associated with manganese exposure.

Asthma statistics in The Netherlands 1980-94

Concern about the rising asthma mortality and morbidity in several countries in the 1980s, and the consequent development of international guidelines for diagnosis and management of asthma, gave reason to evaluate national mortality and hospital admission data from the Netherlands for asthma [International Classification of Diseases (ICD) 493] over the period 1980-94, as well as for chronic obstructive pulmonary disease (COPD) (ICD 490-2, 496) and acute bronchi(oli)tis (ICD 466), according to age (0-4, 5-34, 35-64 and > or = 65 years). Rates per million population per year were calculated and time trend analyses were performed. Hospital admissions for asthma showed a decrease in all age groups except in age group 0-4 years. In this age group, an increase was found which continued in the 1990s. Hospital admissions also increased for COPD and acute bronchi(oli)tis in the age group 0-4 years. These increases, however, had no impact on the respiratory mortality, which remained stable and even fell for acute bronchi(oli)tis. Asthma mortality showed a large decline in the 1990s in age group > or = 65 years in both sexes, and also fell, to a lesser extent, in age group 35-64 years. In both age groups, rising COPD trends were found in hospital admissions and mortality, except in males aged 35-64 years, in whom trends fell in the last decade. In age group 5-34 years, asthma mortality declined over the whole study period, whilst the other respiratory trends were stable. It is concluded that asthma statistics in the Netherlands indicate favourable development, except for the age group 0-4 years. In this age group, morbidity from asthma and from other reactive airway disorders is still of great concern.

Mortality rates for respiratory disorders in Italy (1979-1990)

Trends in mortality rates for respiratory disorders were investigated in Italy from 1979 to 1990, using data from the Italian Central Statistical Institute (ISTAT). Mortality from lung cancer increased in all age groups, except for those aged 45-64 yrs after 1985. Respiratory diseases showed a consistent reduction; in particular, mortality from emphysema decreased slowly, and mortality from chronic bronchitis showed a significant reduction in all age groups. However, mortality from asthma increased markedly in all age groups up to 1985, and then levelled off and slightly decreased, although remaining at a higher level than in the 1970s. In 1990, data stratified for age group and gender indicated a higher mortality rate in males, that tended to be age-dependent, with the highest rate ratio male/female in those aged 65-74 yrs. Overall, these data indicate a trend to increased mortality from lung cancer and asthma in Italy in the 1980s.

Follow up study of moderate alcohol intake and mortality among middle aged men in Shanghai, China

OBJECTIVE

To assess the risk of death associated with various patterns of alcohol intake.

DESIGN

Prospective study of mortality in relation to alcohol consumption at recruitment, with active annual follow up.

SETTING

Four small, geographically defined communities in Shanghai, China.

SUBJECTS

18,244 men aged 45-64 years enrolled in a prospective study of diet and cancer during January 1986 to September 1989.

MAIN OUTCOME MEASURE

All cause mortality.

RESULTS

By 28 February 1995, 1198 deaths (including 498 from cancer, 269 from stroke, and 104 from ischaemic heart disease) had been identified. Compared with lifelong non-drinkers, those who consumed 1-14 drinks a week had a 19% reduction in overall mortality (relative risk 0.81; 95% confidence interval 0.70 to 0.94) after age, level of education, and cigarette smoking were adjusted for. This protective effect was not restricted to any specific type of alcoholic drink. Although light to moderate drinking (28 or fewer drinks per week) was associated with a 36% reduction in death from ischaemic heart disease (0.64; 0.41 to 0.998), it had no effect on death from stroke, which is the leading cause of death in this population. As expected, heavy drinking (29 or more drinks per week) was significantly associated with increased risks of death from cancer of the upper aerodigestive tract, hepatic cirrhosis, and stroke.

CONCLUSIONS

Regular consumption of small amounts of alcohol is associated with lower overall mortality including death from ischaemic heart disease in middle aged Chinese men. The type of alcoholic drink does not affect this association.

The beginnings of chronic airflow obstruction

Recent follow-up studies have provided convincing evidence that the foundations of chronic airflow obstruction (CAO) are laid in utero and early childhood. Men born in Hertfordshire and Derbyshire, England, were more likely to have impaired lung function at 60-70 years of age if they had been lighter at birth and if they had had lower respiratory tract infection (LRTI) in the first 2 years of life. Furthermore, they were more likely to have died from chronic obstructive pulmonary disease if they had been lighter at 1 year of age. These findings suggest that impairment of pulmonary growth in utero and early childhood, as a consequence of undernutrition and LRTI, plays an important part in the development of CAO in late adult life. This may be of particular importance for the future respiratory health of developing nations as the additive effects of smoking take hold.

[Mortality in non-specific respiratory tract inflammation and bronchial obstructive diseases in relation to the environment in the Czech Republic]

BACKGROUND

Despite antibiotic treatment the mortality from inflammations of the airways is still high in our country and worldwide. The objective of the present work is a review of the mortality from respiratory diseases with regard to their prevalence, in relation to gender in the whole Czech Republic and in different regions, in Prague and in southern and northern Bohemia.

METHODS AND RESULTS

During the last years the order of mortality from respiratory diseases is as follows: lung cancer, chronic bronchitis and pneumonia, whereby in men the first place is held by lung cancer, in women by pneumonia. In 1992-1994 in the Czech Republic the relative mortality rate from acute bronchitis (bronchiolitis). pneumonia and influenza combined was 24.8, 20.7 and 20.6/100,000 population. In Prague the increment of this mortality was as follows: in 1993-13.5/100,000, in 1994-14.8/100,000. A marked increase was recorded in southern Bohemia (from 16.9 to 26.0) but a drop in northern Bohemia (from 14.5 to 12.2/100,000 population). In 1992 and 1993 in the Czech Republic the number of deaths from diseases associated with respiratory infections -influenza, pneumonia, acute bronchitis (bronchiolitis) and diseases associated with bronchial obstruction (chronic bronchitis, bronchial asthma and pulmonary emphysema) was balanced. In 1994 there was a marked drop in the mortality from diseases with bronchial obstruction as compared with 1993-N 2104/679. In 1994, as compared with 1992 and 1993, the mortality relation in these two groups was reversed and in 1994 mortality from respiratory infections predominates markedly over mortality from obstructions. In Prague infections predominate 1.6 times, in northern Bohemia 1.5 times and in southern Bohemia as much as 3.8 times.

CONCLUSIONS

In the Czech Republic the mortality from acute bronchitis (bronchiolitis), pneumonia and influenza combined was in 1993 and 1994 20.7 and 20.6 per 100 000 population. In 1994 the mortality from diseases associated with bronchial obstruction declined markedly, while the mortality from respiratory infections increased in southern Bohemia.

[Deaths from asthma, bronchitis and pulmonary heart disease in Warsaw in the years 1993-1994]

By the regular checking the death certificates in the municipal offices in 7 districts of Warsaw, the morality rate from asthma has been established as 2.98/100.000, from chronic bronchitis as 8.71/100.000 and from pulmonary heart disease as 6.27/100.000. During one year of this survey only 15 deaths (4.7%) from these diseases were below age of 50.67% of patients died in hospitals and 22 (7%) died suddenly (at home). In general, deaths reported as the results of COLD were only 1.59% of the total number of deaths in Warsaw (21.530). 6.9% of all death certificates were without clinical diagnosis (Number 798 of ICD)-described as "natural death", "death before doctor's arrival" or "noncriminal death". Authors discuss the problem of over- and under-diagnosis of asthma as the cause of death, the historical background of asthma mortality and also put the question of the righteousness of regard the pulmonary heart disease as the primary cause of death.

Asthma deaths in Washington State, 1980-1989: geographic and demographic distributions

BACKGROUND

Asthma prevalence and mortality rates have been increasing for the past two decades for reasons that are not definitively known. Few studies of asthma mortality rates have concentrated on subnational regions, such as individual states.

OBJECTIVE

To determine geographic and demographic patterns of asthma mortality in Washington State during 1980 through 1989 and to compare aggregated data with patterns of chronic bronchitis mortality.

METHODS

Age-adjusted mortality rates for asthma and chronic bronchitis were calculated from 1980 through 1989 for all age groups. Rates were then disaggregated by county, gender, age, and race. Rates were calculated from death certificates listed by the Washington State Center for Health Statistics as either asthma (ICD9-493) or chronic bronchitis (ICD9-490 and 491) and census data.

RESULTS

During the period 1980-1989, age-adjusted mortality rates for asthma increased by 15% while those for bronchitis decreased by 43%. There was no consistent geographic pattern in the increase, though one county with a very small population had the highest rate of increase. Female asthma mortality rates increased during the decade, while male asthma mortality rates and both male and female bronchitis rates decreased. Two populations demonstrated pronounced increases in asthma mortality rates: females between ages 40 and 69 years and non-whites.

CONCLUSIONS

While increased asthma mortality rates have been noted elsewhere for non-whites, this is the first study to demonstrate elevated mortality rates for middle aged women. The explanation for this remains a mystery.

Mortality in Danish fishermen

This cohort study investigated mortality patterns in Danish commercial fishermen between 1970 and 1985, compared to all economically active men. The population census in 1970 in Denmark was the source of information on individual occupation, age and economic status. Computerised linkage with the Danish Mortality Register gave information about deceased persons' date and cause of death. Standarised mortality ratio (SMR) for all causes among crew members was 1.50; 95% confidence intervals (95% CI) 1.34-1.65) highest in the age group 20-34 years (SMR = 2.09, 95% CI 1.68-2.58). The increased SMR among fishermen was primarity due to deaths by accident other than road accidents (SMR = 5.76, 95% CI = 3.09-7.46), ischemic heart disease (SMR = 1.27, 95% CI, 1.01-1.57) and causes without information (SMR = 6.44 95% CI 4.31-9.27). SMR due to bronchitis and emphysema among 35-64 years old crew members was 1.96, 95% CI 1.01-3.45. Among skippers, the SMR for all causes was 1.12, 95% CI 1.03-1.20). The study confirms earlier findings of a high mortality among fishermen, especially due to accidents, and a slightly increased risk of dying from cancer, respiratory and cardiovascular diseases.

Community-acquired lower respiratory tract infection in the elderly: a community-based study of incidence and outcome

BACKGROUND

We studied the incidence, characteristics, and survival of elderly patients from a defined community who had pneumonia or bronchitis (lower respiratory tract infection).

METHODS

This study was a population-based retrospective cohort study of residents of Rochester, Minnesota, aged 65 years or older with a first episode of pneumonia or bronchitis during the calendar year 1987.

RESULTS

Overall age- and sex-adjusted incidence rates for an initial episode in a calendar year were 5452 per 100,000: 2420 per 100,000 (95 percent confidence interval, 2056 to 2783 per 100,000) for bronchitis and 3032 per 100,000 (95 percent confidence interval, 2639 to 3425 per 100,000) for pneumonia. After exclusion of eight cases diagnosed at autopsy, the overall 30-day mortality was 10.7 percent. Patients with pneumonia had lower survival than expected for the Minnesota white population (log-rank statistic = 117.38, P < 0.0001). The observed survival of patients with bronchitis was also significantly less than expected (log-rank statistic = 6.25, P = 0.012).

CONCLUSION

Lower respiratory tract infections are common in the elderly. Most patients in this study were not hospitalized, and atypical presentations were not observed. Early mortality (30 days) was high. Among elderly patients with either pneumonia or bronchitis, the survival was lower than expected. This study confirmed the need for population-based studies, because more than two-thirds of patients would have been missed if only hospitalized patients were included.

Lower respiratory tract infections following cardiac arrest and cardiopulmonary resuscitation

All episodes of lower respiratory tract infection that developed among 96 patients surviving for > 24 hours after cardiac arrest were prospectively studied over an 18-month period. Pneumonia developed in 23 (24.0%) of patients after a mean of 7 days (SD, +/- 6.2 days). The development of four superinfections raised the cumulative incidence to 28.1%. Purulent tracheobronchitis was diagnosed in three instances. The causative agent of pneumonia was identified in 18 episodes, three of which were polymicrobial. Gram-positive cocci represented 57.1% of isolates, and Staphylococcus aureus--the most frequently isolated microorganism in this population--accounted for two-thirds of all gram-positive cocci. Pseudomonas aeruginosa was isolated in six episodes, five of which were associated with previous antibiotic use. Nine (39.1%) of the 23 patients in the group with pneumonia died, but only one of these deaths was considered to be directly related to pneumonia. In conclusion, pneumonia is a common complication of patients surviving cardiac arrest, but, with adequate treatment, its influence on outcome is marginal. Gram-positive cocci are the predominant pathogens, although infection with P. aeruginosa should be considered among patients receiving antibiotics.

The long-term antimicrobial prophylaxis of chronic bronchitis exacerbations

Infectious exacerbations are the major cause of mortality in patients with chronic bronchitis, particularly in elderly subjects. Considering that the preventive use of antibiotics has provided no clear-cut evidence of real efficacy, it has become quite common to use treatments potentially able to stimulate the immune system for prevention of exacerbations of chronic bronchitis. This treatment, based on the oral administration of bacterial extracts, should, at least in theory, stimulate the immune defenses and reduce the incidence of recurring respiratory tract infections. Although during the last few years a good effort to define better the real efficacy and role played by bacterial extracts in chronic bronchitis has been made, their clinical effectiveness is still the subject of debate and the results of some clinical trials are controversial. Particularly, its mechanism of action remains poorly understood, although a huge effort has been made in this direction.

Epidemiology of lower respiratory tract infections

The aim of this review is to focus on the epidemiology of lower respiratory tract infections, the etiology, prognosis and risk factors, dividing these problems into the following issues: global impact of these afflictions, community-acquired pneumonia, hospital acquired pneumonia, respiratory infections in surgery, acute bronchitis and exacerbations of chronic bronchitis. Every year about 5 million people die of acute respiratory infections. Among these, pneumonia represents the most frequent cause of mortality, hospitalization and medical consultation. Several factors (age, underlying disease, environment) influence mortality, morbidity and also microbial etiology. The authors also refer to recent data on the most frequently identified antibiotic resistance of respiratory pathogens. The knowledge of such different clinico-epidemiological situations is essential to physicians for an effective approach to treatment of pneumonia and bronchitis.

Contrasting geographical distribution of mortality from pneumoconiosis and chronic bronchitis and emphysema in British coal miners

To explore whether the characteristics of coal mine dust that predispose to chronic airways obstruction are the same as those associated with pneumoconiosis, mortality from the two disease was compared in coal miners in 22 counties of England and Wales during 1979-80 and 1982-90. The proportional mortality ratios (PMRs) for coal workers' pneumoconiosis varied from 135 (95% confidence interval (95% CI) 16-488) in Leicestershire to 3825 (95% CI 1538-7881) in South Glamorgan. The PMRs for chronic bronchitis and emphysema were consistently higher than those in other occupations, but showed much less geographical variation and did not correlate geographically with those for pneumoconiosis. These findings indicate that the pathogenetic mechanisms by which coal mine dust causes chronic bronchitis and emphysema depend on different features of the dust from those producing pneumoconiosis. Also, they suggest that current social security regulations in Britain, which require evidence of pneumoconiosis as a condition of compensation for chronic bronchitis and emphysema in coal miners, may discriminate unfairly against claimants from some regions.

Endobronchial inflammation following Pseudomonas aeruginosa infection in resistant and susceptible strains of mice

The early endobronchial inflammation induced by Pseudomonas aeruginosa infection varies in resistant and susceptible strains of mice. Mice of the DBA/2 strain are severely afflicted by the infection, with a high bacterial burden accumulating rapidly following inoculation and a high mortality rate occurring. Mice of the BALB/c strain are resistant to infection and clear the bacteria within 3 to 7 days. Infection of (BALB/c x DBA/2)F1 hybrid mice showed that the resistance to lung P. aeruginosa infection is inherited as a dominant trait. Mice of the A/J and C57BL/6 strains were found to have an intermediate phenotype to Pseudomonas aeruginosa infection when compared with BALB/c and DBA/2 strains. The decrease in the bacterial load seen early after infection coincided with a steady and strong recruitment of inflammatory cells to the bronchoalveolar spaces of mice of the resistant BALB/c strain. On the other hand, the recruitment of inflammatory cells to the lungs of mice of the susceptible DBA/2 strain was deficient, resulting in the failure to control bacterial multiplication. Chemotactic factors, proinflammatory cytokines, and the number and function of recruited inflammatory cells may play major roles in the determination of the genetic resistance to lung infection with P. aeruginosa in a normal immunocompetent host.

[Why do farmers die more often from lung diseases?]

During the period 1988-1992 deaths from lung diseases were more frequent among the farming population according to Swiss mortality data. The age-standardized proportional mortality rate (PMR) is 127 for all the lung diseases (ICD-8 460-519), 140 for bronchitis and asthma (ICD-8 490-493), 137 for asthma alone (ICD-8 493) and 841 for pneumoconiosis due to organic dust (ICD-8 516.1 + .2). Stock-farmers showed a mortality pattern for chronic obstructive pulmonary disease opposite to that of vegetable farmers and wine-growers. This increased mortality among farmers is paradoxical in the light of the more frequent tolerance for aeroallergens among the children of farmers, the conservative style of housing and living as well as received ideas about working in natural and therefore healthy air. Insufficient knowledge of the multifactorial risks of natural pathogenic organic substances and of dangerous work are just as important for the pathogenesis of these diseases and deaths as the changed social and cultural values with the consequences on insurance policy. These factors affect optimal prophylaxis (limitation of air pollution, safety measures, job change and measures in order to achieve adequate social security).

Acute infective exacerbations of chronic bronchitis

Patients with an acute infective exacerbation of chronic bronchitis (AECB) (n = 471) were enrolled into a computer-based general-practice study to determine whether features of past history, presenting symptoms, or findings on examination were predictive of failure to recover. The median age was 68, 56.3% were male, and 82% were current or ex-smokers. All had daily sputum production and 57.5% had moderate or severe airflow obstruction. During the AECB 11.5% were pyrexial, and 80.7% had abnormal auscultatory findings; about half had moderate to severe increases in dyspnoea and airflow obstruction, and the majority had increases in sputum volume and/or purulence. The median number of AECBs in the previous year was three, and one-third of patients had cardiopulmonary disease. The only factors significantly (p < 0.05) predicting failure to recover from an AECB were historical. Neither clinical features at presentation nor antibiotic treatment affected recovery. Coexistent cardiopulmonary disease was a risk factor for returning with a chest problem and for being referred to hospital. The number of chest infections in the previous 12 months was a risk factor for returning with a chest problem. The higher the number of chest infections, the higher the odds of returning with a chest problem. The best combination predicting return with a chest problem was history of cardiopulmonary disease and more than four previous AECBs in the last 12 months. The sensitivity was 75% and specificity 47%.

Mortality and causes of death in patients with diabetes mellitus in Japan

Although the mortality rate of diabetes mellitus in Japan is much lower than the rates in Western countries, an increasing trend has been evident over the last 40 years as a whole. However, the trend shows variations with age; there is an apparent decreasing trend in subjects of 0-35 years of age at death, while there is a remarkable increasing trend in subjects of 75 years of age and over. It appears that the increase in diabetes mortality is largely due to an elevation in the mortality rate in aged subjects and an increase in the size of the aged population in this country. A population-based study of causes of death, carried out in Osaka Prefecture for the period 1960-1989, indicates a remarkable increase in the age at death and significant changes in the causes of death of diabetic patients. Diseases of the circulatory system were found to be the major causes of death other than diabetes, and, among them, a rapid increase in the frequency of disease of the heart was observed. As a cause of death, tuberculosis decreased sharply, while malignant neoplasms, ischemic heart disease, and pneumonia and bronchitis increased during the same period. Among malignant neoplasms, an increase in neoplasm of the liver was marked.

Changes in causes of death in diabetic patients based on death certificates during a 30-year period in Osaka District, Japan, with special reference to cancer mortality

As reported previously, we have conducted studies on causes of death among diabetic patients during the 25-year period, from 1960 to 1984, in Osaka District, Japan. We have now added the most recent 5-year data, for 1985-1989, and analyzed changes in causes of death during the entire 30-year period as a whole. The subjects studied were those for whom a total of 32,222 death certificates had been filed in Osaka Prefecture, from 1960 to 1989, with diabetes mentioned either as the underlying cause or as a contributory condition. The relative number of death certificates mentioning diabetes as the underlying cause, which had been decreasing during the 25-year study period, showed a further decrease, reaching the lowest value, 33.4%, for the period 1985-1989. The mean age at death exceeded 70 years for all causes of death, showing a continuous increasing trend. An increase in disease of the heart and a decrease in cerebrovascular disease were observed, making the difference between the two causes greater since 1980-1984. Malignant neoplasms, ischemic heart disease, and pneumonia and bronchitis also showed steady increases. The O/E ratios (ratio of observed/expected number of deaths) for cirrhosis of the liver and tuberculosis were markedly increased, while that for malignant neoplasms was only about 0.5, suggesting extreme underestimation of the number of diabetic cases with cancer. Among malignant neoplasms, an increasing trend in liver cancer was remarkable and was associated with a relatively high O/E ratio.

[Relationship between air pollution and mortality in Dongcheng and Xicheng Districts, Beijing]

Relationship between air pollution and mortality in 1989 was studied in two residential areas in Beijing (Dongcheng District and Xicheng District). The daily number of death was regressed on the logarithmic air levels of sulphur dioxide (SO2) and/or total suspended particulate (TSP) on the same day with Poisson regression method. A highly significant association was found between logarithmic levels of air SO2 and daily number of death adjusted for the influence of temperature and humidity. The stronger effects of them were seen on the death caused by chronic bronchitis, chronic obstructive pulmonary disease and cor pulmonale.

Occupational dust exposure and chronic obstructive pulmonary disease. A systematic overview of the evidence

The object of this study was to assess the relationship between occupational dust exposure and chronic obstructive pulmonary disease (COPD). Studies were identified using MEDLINE (January 1966 to July 1991), SCISEARCH, manual review of reference lists, and personal contact with more than 30 international experts. Studies of COPD, lung function, emphysema, chronic bronchitis, or mortality in workers exposed to nonorganic dust were retrieved. Studies were included if dust exposure was measured quantitatively, and a quantitative relationship between dust exposure and one of the outcomes of interest was calculated while controlling at least for smoking and age. Methodological rigor was assessed, and data regarding the study populations, prognostic factors, and outcomes were extracted independently by two reviewers. Thirteen reports derived from four cohorts of workers met our inclusion criteria. Three of the cohorts were of coal miners and one was of gold miners. All of the studies found a statistically significant association between loss of lung function and cumulative respirable dust exposure. It was estimated that 80 (95% CI, 34 to 137) of 1,000 nonsmoking coal miners with a cumulative respirable dust exposure of 122.5 gh/m3 (considered equivalent to 35 years of work with a mean respirable dust level of 2 mg/m3) could be expected to develop a clinically important (> 20%) loss of FEV1 attributable to dust. Among 1,000 smoking miners the comparable estimate was 66 (95% CI, 49 to 84). The risk of a clinically important loss of lung function attributable to dust among nonsmoking gold miners was estimated to be three times as large as for coal miners at less than one fifth of the cumulative respirable dust exposure (21.3 gh/m3), the maximal exposure observed among the cohort of gold miners. We conclude that occupational dust is an important cause of COPD, and the risk appears to be greater for gold miners than for coal miners. One possible explanation of the greater risk among gold miners is the higher silica content in gold mine dust.

Economics of a reduction in smoking: case study from Heartbeat Wales

STUDY OBJECTIVE

This study aims to apply economic principles and techniques in evaluating a health promotion programme.

DESIGN

This study is an economic appraisal of the Heartbeat Wales no smoking intervention programme. The costs incurred over the four year period 1985-89 have been identified and estimates have been made of the likely future impact of the reduced smoking prevalence within Wales in terms of reduced morbidity and displaced mortality in three disease groups--coronary heart disease, lung cancer, and chronic bronchitis.

SETTING

Wales, UK.

RESULTS

The net present value of benefits is considerably greater than costs in terms of both the NHS and the economy as a whole in Wales. In addition, the net costs per life year saved shows that the programme generates additional working life years at relatively low cost. Because not all the benefits can be fully attributed to the programme 'impact rates' ranging from 100 to 10% have been applied to the level of benefits. The evidence suggests that even if only 10% of the benefits could be attributed to the programme there is still a positive net present value of benefits. The relative efficiency of this programme has not been considered here.

CONCLUSION

Large scale benefits to the NHS and the economy as a whole can be derived from reductions in smoking.

[The information value of epidemiological research in chronic nonspecific lung diseases]

Results of the study indicate that in several countries there occurred during 1971-1980 a reduction of mortality of the male population at the age of 1-4 years. In those over 65 years of age this index was inconsistent. Results indicate a definite dependence of mortality on age.

Labelling shift from acute bronchitis may be contributing to the recent rise in asthma mortality in the 5-34 age group

To test the hypothesis that labelling shift from acute bronchitis to asthma may be contributing to the rise in deaths from asthma in the U.K., we studied mortality rates for males, females and both sexes combined for all ages and for the 5-34 age group, from published mortality tables from 1950 to 1985. The 5-34 age group mortality from asthma showed the 1960s peak and a more gradual increase from 1975. Mortality (all ages) from acute bronchitis showed a decline over the period, but in the 5-34 age group mortality was remarkably stable from 1950-1974 with a mean rate of 2.61 per million (95% confidence intervals, 2.44-2.78). From 1975 to 1985 the rate declined linearly to 0.75 per million. The number of acute bronchitis deaths 'saved' over this period was 366 compared to the number of excess asthma deaths during the same period (taking the 1974 rate as baseline) of 514. These findings lend support to the hypothesis that, in the 5-34 age group, labelling shift from acute bronchitis to asthma may be a contributing factor to the recent rise in asthma mortality. They also raise the question whether different factors contributing to the rise in asthma may have proportionately different weights of effect according to the age of the patients involved.

[Evolution of mortality from principal chronic diseases in Spain 1975-1988]

BACKGROUND

Most mortality in developed countries is attributable to chronic non transmittable diseases, many of which are theoretically susceptible to prevention. The tendency of mortality by the principal chronic diseases in Spain is reviewed with different prevention strategies of the same being discussed.

METHODS

The 9 chronic diseases which presented the highest mortality rate in Spain in 1988 are included. The rates of mortality, adjusted by age/year in males and females was calculated from the data of deaths by age, sex and cause of death from death statistics. Moreover, the percentage of the mean annual change of these during the periods 1975-1981 and 1982-1988 have also been calculated.

RESULTS

Except for mortality by malignant tumor of the colon and rectum, malignant lung tumor in males and malignant breast tumors in women, which had an increase, the remaining diseases in the adjusted mortality rate by age decreased between 1975-1988.

CONCLUSIONS

Among the diseases in which the rate of mortality has increased there is only that of malignant lung tumors for which one factor has consistently been identified as responsible for this increase, that being smoking. The possible influence of the control of arterial hypertension in the decrease in mortality of cerebrovascular disease must be emphasized. Moreover, the impact which the ninth review of the International Disease Classification had in the reduction in mortality by chronic bronchitis, emphysema and asthma must also be pointed out.