Predictors of development of cardiac and digestive disorders among patients with indeterminate chronic Chagas Disease

American trypanosomiasis (Chagas disease, CD) affects circa 7 million persons worldwide. While of those persons present the asymptomatic, indeterminate chronic form (ICF), many will eventually progress to cardiac or digestive disorders. We studied a nonconcurrent (retrospective) cohort of patients attending an outpatient CD clinic in Southeastern Brazil, who were admitted while presenting the ICF in the period from 1998 through 2018 and followed until 2019. The outcomes of interest were the progression to cardiac or digestive CD forms. We were also interested in analyzing the impact of Benznidazole therapy on the progression of the disease. Extensive review of medical charts and laboratory files was conducted, collecting data up to year 2019. Demographics (upon inclusion), body mass index, comorbidities (including the Charlson index) and use of Benznidazole were recorded. The outcomes were defined by abnormalities in those test that could not be attributed to other causes. Statistical analysis included univariate and multivariable Cox regression models. Among 379 subjects included in the study, 87 (22.9%) and 100 (26.4%) progressed to cardiac and digestive forms, respectively. In the final multivariable model, cardiac disorders were positively associated with previous coronary syndrome (Hazzard Ratio [HR], 2.42; 95% Confidence Interval [CI], 1.53-3.81) and negatively associated with Benznidazole therapy (HR, 0.26; 95%CI, 0.11-0.60). On the other hand, female gender was the only independent predictor of progression to digestive forms (HR, 1.56; 95%CI, 1.03-2.38). Our results point to the impact of comorbidities on progression do cardiac CD, with possible benefit of the use of Benznidazole.

Postoperative complications and mortality following emergency digestive surgery during the COVID-19 pandemic: A multicenter collaborative retrospective cohort study protocol (COVID-CIR)

ABSTRACT

Infection with the SARS-CoV-2 virus seems to contribute significantly to increased postoperative complications and mortality after emergency surgical procedures. Additionally, the fear of COVID-19 contagion delays the consultation of patients, resulting in the deterioration of their acute diseases by the time of consultation. In the specific case of urgent digestive surgery patients, both factors significantly worsen the postoperative course and prognosis. Main working hypothesis: infection by COVID-19 increases postoperative 30-day-mortality for any cause in patients submitted to emergency/urgent general or gastrointestinal surgery. Likewise, hospital collapse during the first wave of the COVID-19 pandemic increased 30-day-mortality for any cause. Hence, the main objective of this study is to estimate the cumulative incidence of mortality at 30-days-after-surgery. Secondary objectives are: to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for COVID-19-infected patients.A multicenter, observational retrospective cohort study (COVID-CIR-study) will be carried out in consecutive patients operated on for urgent digestive pathology. Two cohorts will be defined: the "pandemic" cohort, which will include all patients (classified as COVID-19-positive or -negative) operated on for emergency digestive pathology during the months of March to June 2020; and the "control" cohort, which will include all patients operated on for emergency digestive pathology during the months of March to June 2019. Information will be gathered on demographic characteristics, clinical and analytical parameters, scores on the usual prognostic scales for quality management in a General Surgery service (POSSUM, P-POSSUM and LUCENTUM scores), prognostic factors applicable to all patients, specific prognostic factors for patients infected with SARS-CoV-2, postoperative morbidity and mortality (at 30 and 90 postoperative days). The main objective is to estimate the cumulative incidence of mortality at 30 days after surgery. As secondary objectives, to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for SARS-CoV-2 infected patients.The protocol (version1.0, April 20th 2020) was approved by the local Institutional Review Board (Ethic-and-Clinical-Investigation-Committee, code PR169/20, date 05/05/20). The study findings will be submitted to peer-reviewed journals and presented at relevant national and international scientific meetings.ClinicalTrials.gov Identifier: NCT04479150 (July 21, 2020).

Circulating 25-hydroxyvitamin D concentration and cause-specific mortality in the Melbourne Collaborative Cohort Study

Vitamin D deficiency is associated with higher all-cause mortality, but associations with specific causes of death are unclear. We investigated the association between circulating 25-hydroxyvitamin D (25(OH)D) concentration and cause-specific mortality using a case-cohort study within the Melbourne Collaborative Cohort Study (MCCS). Eligibility for the case-cohort study was restricted to participants with baseline dried blood spot samples and no pre-baseline diagnosis of cancer. These analyses included participants who died (n = 2307) during a mean follow-up of 14 years and a sex-stratified random sample of eligible cohort participants ('subcohort', n = 2923). Concentration of 25(OH)D was measured using liquid chromatography-tandem mass spectrometry. Cox regression, with Barlow weights and robust standard errors to account for the case-cohort design, was used to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) for cause-specific mortality in relation to 25(OH)D concentration with adjustment for confounders. Circulating 25(OH)D concentration was inversely associated with risk of death due to cancer (HR per 25 nmol/L increment = 0.88, 95 % CI 0.78-0.99), particularly colorectal cancer (HR = 0.75, 95 % CI 0.57-0.99). Higher 25(OH)D concentrations were also associated with a lower risk of death due to diseases of the respiratory system (HR = 0.62, 95 % CI 0.43-0.88), particularly chronic obstructive pulmonary disease (HR = 0.53, 95 % CI 0.30-0.94), and diseases of the digestive system (HR = 0.44, 95 % CI 0.26-0.76). Estimates for diabetes mortality (HR = 0.64, 95 % CI 0.33-1.26) and cardiovascular disease mortality (HR = 0.90, 95 % CI 0.76-1.07) lacked precision. The findings suggest that vitamin D might be important for preventing death due to some cancers, respiratory diseases, and digestive diseases.

Years of life lost due to diseases of the digestive system in Poland according to socioeconomic factors: a cross-sectional study

OBJECTIVES

To analyse years of life lost (YLLs) due to digestive diseases in Poland according to: marital status, education, working status and place of residence.

DESIGN

A cross-sectional study.

SETTING

The study was based on a dataset containing information from death certificates of Poles who died in 2002 and in 2011.

PARTICIPANTS

The analysis covered records with codes K00-K93 according to the International Classification of Diseases and Related Health Problems, 10th Revision.

OUTCOME MEASURES

YLL values were calculated using the Standard Expected Years of Life Lost measure. For each socioeconomic variable, the rate ratio (RR) was calculated as the quotient of YLLs in the less privileged group to the more privileged group.

RESULTS

Among the categories of marital status, the smallest YLL values (per 10 000) were recorded among singles (men: 100.63 years in 2002, 121.10 years in 2011; women: 26.99, 33.33, respectively), and the most among divorced men (657.87, 689.32) and widowed women (173.97, 169.46). YLL analysis according to education level revealed the lowest values in people with higher education (men: 54.20, 57.66; women: 17.31, 18.31) and the highest in people with lower than secondary education (men: 178.85, 198.32; women: 104.95, 125.76). Being economically active was associated with a smaller YLL score (men: 39.93, 59.51; women: 10.31, 14.96) than being inactive (men: 340.54, 219.93; women: 126.86, 96.80). Urban residents had higher YLL score (men: 159.46, 174.18, women: 73.03, 78.12) than rural ones (men: 126.83, 137.11, women: 57.32, 57.56).In both sexes, RR according to education level and place of residence increased, and those according to marital status and working status decreased with time.

CONCLUSIONS

Activities aimed at reducing health inequalities in terms of YLL due to digestive diseases should be primarily addressed to inhabitants with lower than secondary education, divorced and widowed people, urban residents and those who are economically inactive.

Chronic hepatitis B virus infection and total and cause-specific mortality: a prospective cohort study of 0.5 million people

OBJECTIVES

Chronic hepatitis B virus (HBV) infection is associated with a higher risk of liver diseases. Substantial uncertainty remains, however, about the associations of HBV infection with mortality from extrahepatic causes, especially from subtypes of cardiovascular diseases. We prospectively examined the association of chronic HBV infection with total and cause-specific mortality.

DESIGN

Population-based prospective cohort study.

SETTING

China Kadoorie Biobank in which participants from 10 geographically diverse areas across China were enrolled between 2004 and 2008.

PARTICIPANTS

475 801 participants 30-79 years of age without reporting major chronic diseases at baseline were enrolled. Hepatitis B surface antigen (HBsAg) was tested using an on-site rapid test strip at baseline.

PRIMARY AND SECONDARY OUTCOME MEASURES

Total and cause-specific mortality.

RESULTS

A total of 35 822 deaths were recorded during ~10 years of follow-up. In multivariable-adjusted analyses, compared with HBsAg-negative participants, HBsAg-positive participants had an increased risk of total mortality (HR=2.01, 95% CI: 1.91 to 2.12), which was higher in men (HR=2.16, 95% CI: 2.01 to 2.31) than in women (HR=1.74, 95% CI: 1.60 to 1.90). Presence of HBsAg was associated with increased mortality from liver cancer (1339 deaths, HR=13.95, 95% CI: 12.46 to 15.62), infections (410 deaths, HR=10.30, 95% CI: 8.21 to 12.94), digestive diseases (688 deaths, HR=6.83, 95% CI: 5.49 to 8.50), intracerebral haemorrhage (4077 deaths, HR=1.38, 95% CI: 1.14 to 1.68) and ischaemic heart diseases (4624 deaths, HR=1.31, 95% CI: 1.09 to 1.58). The positive association between HBsAg status and risk of death was stronger in participants younger than 50 years, smokers, physically active or non-hypertensive participants.

CONCLUSIONS

Among Chinese adults, chronic HBV infection was associated with increased mortality from a range of hepatic and extrahepatic diseases.

[Emergency surgery in Russian Federation (in Russian only)]

In the following article, we present the key trends in emergency surgical care in the Russian Federation between 2000 and 2017. The study used data from federal statistical observations and a survey of state medical institutions in 80 regions encompassing 99.3% of the country's population. We discovered a change in the correlation between acute abdominal diseases, particularly a significant reduction in the occurrence of acute appendicitis and perforated peptic ulcer. Reduction in the number of emergency surgeries by 27.8% annually was also observed. Mortality rate decreased in cases of strangulated hernia, acute cholecystitis and acute pancreatitis, while it is stable for bowel obstruction and acute appendicitis and increasing in perforated peptic ulcer cases. The total annual number of lethal outcomes due to acute abdominal diseases was decreased by 1900 cases. Significant changes were observed in mortality rate and minimally invasive surgeries proportions between federal districts and individual regions of the country. The range of administrative measures was proposed.

A Cohort Study of Workers Employed in a Refractory Brick Plant

A mortality study was carried out on a cohort of workers who were exposed to silica dust in a refractory brick plant. The cohort was divided into two groups: workers with and without silicosis, and their mortality was contrasted with the death rate of Genova from 1960 to 1979. Results show an increased risk for laryngeal tumors (3 obs., 0.44 exp., SMR = 682), nonmalignant respiratory disease (16 obs., 3.2 exp., SMR = 500), and cardiovascular diseases (19 obs., 11 exp., SMR = 173) among silicotics. The mortality rate for lung cancer showed an increase for the cohort of workers as a whole (11 obs., 6 exp., SMR = 183). The almost double overall mortality observed in silicotic subjects raises some doubts about the validity of other proportional mortality studies that showed no excesses for workers in these industries.

Cancer incidence and mortality risks in a large US Barrett's oesophagus cohort

OBJECTIVE

Barrett's oesophagus (BE) increases the risk of oesophageal adenocarcinoma by 10-55 times that of the general population, but no community-based cancer-specific incidence and cause-specific mortality risk estimates exist for large cohorts in the USA.

DESIGN

Within Kaiser Permanente Northern California (KPNC), we identified patients with BE diagnosed during 1995-2012. KPNC cancer registry and mortality files were used to estimate standardised incidence ratios (SIR), standardised mortality ratios (SMR) and excess absolute risks.

RESULTS

There were 8929 patients with BE providing 50 147 person-years of follow-up. Compared with the greater KPNC population, patients with BE had increased risks of any cancer (SIR=1.40, 95% CI 1.31 to 1.49), which slightly decreased after excluding oesophageal cancer. Oesophageal adenocarcinoma risk was increased 24 times, which translated into an excess absolute risk of 24 cases per 10 000 person-years. Although oesophageal adenocarcinoma risk decreased with time since BE diagnosis, oesophageal cancer mortality did not, indicating that the true risk is stable and persistent with time. Relative risks of cardia and stomach cancers were increased, but excess absolute risks were modest. Risks of colorectal, lung and prostate cancers were unaltered. All-cause mortality was slightly increased after excluding oesophageal cancer (SMR=1.24, 95% CI 1.18 to 1.31), but time-stratified analyses indicated that this was likely attributable to diagnostic bias. Cause-specific SMRs were elevated for ischaemic heart disease (SMR=1.39, 95% CI 1.18 to 1.63), respiratory system diseases (SMR=1.51, 95% CI 1.29 to 1.75) and digestive system diseases (SMR=2.20 95% CI 1.75 to 2.75).

CONCLUSIONS

Patients with BE had a persistent excess risk of oesophageal adenocarcinoma over time, although their absolute excess risks for this cancer, any cancer and overall mortality were modest.

Seasonal variations of U.S. mortality rates: Roles of solar ultraviolet-B doses, vitamin D, gene exp ression, and infections

Death rates in the U.S. show a pronounced seasonality. The broad seasonal variation shows about 25% higher death rates in winter than in summer with an additional few percent increase associated with the Christmas and New Year's holidays. A pronounced increase in death rates also starts in mid-September, shortly after the school year begins. The causes of death with large contributions to the observed seasonality include diseases of the circulatory system; the respiratory system; the digestive system; and endocrine, nutritional, and metabolic diseases. Researchers have identified several factors showing seasonal variation that could possibly explain the seasonal variations in mortality rate. These factors include seasonal variations in solar ultraviolet-B(UVB) doses and serum 25-hydroxyvitamin D [25(OH)D] concentrations, gene expression, ambient temperature and humidity, UVB effects on environmental pathogen load, environmental pollutants and allergens, and photoperiod (or length of day). The factors with the strongest support in this analysis are seasonal variations in solar UVB doses and 25(OH)D concentrations. In the U.S., population mean 25(OH)D concentrations range from 21ng/mL in March to 28ng/mL in August. Measures to ensure that all people had 25(OH)D concentrations >36ng/mL year round would probably reduce death rates significantly.

Coffee Drinking and Mortality in 10 European Countries: A Multinational Cohort Study

BACKGROUND

The relationship between coffee consumption and mortality in diverse European populations with variable coffee preparation methods is unclear.

OBJECTIVE

To examine whether coffee consumption is associated with all-cause and cause-specific mortality.

DESIGN

Prospective cohort study.

SETTING

10 European countries.

PARTICIPANTS

521 330 persons enrolled in EPIC (European Prospective Investigation into Cancer and Nutrition).

MEASUREMENTS

Hazard ratios (HRs) and 95% CIs estimated using multivariable Cox proportional hazards models. The association of coffee consumption with serum biomarkers of liver function, inflammation, and metabolic health was evaluated in the EPIC Biomarkers subcohort (n = 14 800).

RESULTS

During a mean follow-up of 16.4 years, 41 693 deaths occurred. Compared with nonconsumers, participants in the highest quartile of coffee consumption had statistically significantly lower all-cause mortality (men: HR, 0.88 [95% CI, 0.82 to 0.95]; P for trend < 0.001; women: HR, 0.93 [CI, 0.87 to 0.98]; P for trend = 0.009). Inverse associations were also observed for digestive disease mortality for men (HR, 0.41 [CI, 0.32 to 0.54]; P for trend < 0.001) and women (HR, 0.60 [CI, 0.46 to 0.78]; P for trend < 0.001). Among women, there was a statistically significant inverse association of coffee drinking with circulatory disease mortality (HR, 0.78 [CI, 0.68 to 0.90]; P for trend < 0.001) and cerebrovascular disease mortality (HR, 0.70 [CI, 0.55 to 0.90]; P for trend = 0.002) and a positive association with ovarian cancer mortality (HR, 1.31 [CI, 1.07 to 1.61]; P for trend = 0.015). In the EPIC Biomarkers subcohort, higher coffee consumption was associated with lower serum alkaline phosphatase; alanine aminotransferase; aspartate aminotransferase; γ-glutamyltransferase; and, in women, C-reactive protein, lipoprotein(a), and glycated hemoglobin levels.

LIMITATIONS

Reverse causality may have biased the findings; however, results did not differ after exclusion of participants who died within 8 years of baseline. Coffee-drinking habits were assessed only once.

CONCLUSION

Coffee drinking was associated with reduced risk for death from various causes. This relationship did not vary by country.

PRIMARY FUNDING SOURCE

European Commission Directorate-General for Health and Consumers and International Agency for Research on Cancer.

Alcohol use disorders and associated chronic disease - a national retrospective cohort study from France

BACKGROUND

Evidence on diseases caused by or associated with alcohol use disorders (AUDs) has been based on two meta-analyses including rather dated studies. The objective of this contribution was to estimate the risks of all-cause mortality and alcohol-attributable disease categories depending on a diagnosis of AUDs in a national sample for France.

METHODS

In a national retrospective cohort study on all inpatient acute and rehabilitation care patients in Metropolitan France 2008-2012 (N = 26,356,361), AUDs and other disease categories were identified from all discharge diagnoses according to standard definitions, and we relied on in-hospital death for mortality (57.4% of all deaths).

RESULTS

704,803 (2.7%) patients identified with AUDs had a threefold higher risk of death (HR = 2.98; 95% CI: 2.96-3.00) and died on average 12.2 years younger (men: 10.4, 95% CI: 10.3-10.5; women: 13.7, 95% CI: 13.6-13.9). AUDs were associated with significantly higher risks of hospital admission for all alcohol-attributable disease categories: digestive diseases, cancers (exception: breast cancer), cardiovascular diseases, dementia, infectious diseases, and injuries. Elevated risks were highest for liver diseases that were associated with about two-third of deaths in patients with AUDs (men: 64.3%; women: 71.1%).

CONCLUSIONS

AUDs were associated with marked premature mortality and higher risks of alcohol-attributable disease categories. Our results support the urgent need of measures to reduce the burden of AUDs.

Lost life years due to premature deaths caused by diseases of the digestive system in Poland in 2013

BACKGROUND

In order to evaluate the health status of a population, besides indicators measuring the incidence of diseases and deaths, potential measures are becoming more frequently used, ie. measures that take into account life-time potential of the individuals in the population. They can particularly by applied to analyse the problem of premature mortality, which is measured by lost life years.

AIM

The aim of the study was to evaluate life years lost due to diseases of digestive system in Polish population in 2013.

MATERIALS AND METHODS

The study was based on a dataset containing 387,312 death certificates of Poles who died in 2013, provided by the Central Statistical Office in Poland. Data on deaths caused by diseases of digestive system (K00-K93 by ICD-10) were used in the study – that were 16,543 records (4.3% of all the deaths). Lost life years were assessed with the measures: SEYLL (Standard Expected Years of Life Lost), SEYLLp (Standard Expected Years of Life Lost per living person), SEYLLd (Standard Expected Years of Life Lost per death).

RESULTS

In the analysed year among men there were 9,275 deaths caused by diseases of digestive system and in women 7,268 deaths. SEYLL in the group of men amounted to 102 230.7 and in the group of women it was 53,475.5. The number of lost life years calculated per 10 000 male inhabitants was 54.9, and for 10,000 females it was 26.9. The highest share in lost life years had alcoholic liver disease (SEYLLp for men – 20.87, for women – 6.1), fibrosis and cirrhosis of the liver (SEYLLp for men- 9.7, for women- 5.6) and acute pancreatitis (SEYLLp for men – 5.3, for women – 2.1).

CONCLUSIONS

The results of the study indicate that diseases of digestive system have an important contribution to the loss of life-time potential in Polish population (6.6% of all SEYLL in 2013). The dominant role in this class of diseases played alcoholic liver disease – K70, fibrosis and cirrhosis of the liver – K74 and acute pancreatitis – K85.

Global economic consequences of selected surgical diseases: a modelling study

BACKGROUND

The surgical burden of disease is substantial, but little is known about the associated economic consequences. We estimate the global macroeconomic impact of the surgical burden of disease due to injury, neoplasm, digestive diseases, and maternal and neonatal disorders from two distinct economic perspectives.

METHODS

We obtained mortality rate estimates for each disease for the years 2000 and 2010 from the Institute of Health Metrics and Evaluation Global Burden of Disease 2010 study, and estimates of the proportion of the burden of the selected diseases that is surgical from a paper by Shrime and colleagues. We first used the value of lost output (VLO) approach, based on the WHO's Projecting the Economic Cost of Ill-Health (EPIC) model, to project annual market economy losses due to these surgical diseases during 2015-30. EPIC attempts to model how disease affects a country's projected labour force and capital stock, which in turn are related to losses in economic output, or gross domestic product (GDP). We then used the value of lost welfare (VLW) approach, which is conceptually based on the value of a statistical life and is inclusive of non-market losses, to estimate the present value of long-run welfare losses resulting from mortality and short-run welfare losses resulting from morbidity incurred during 2010. Sensitivity analyses were performed for both approaches.

FINDINGS

During 2015-30, the VLO approach projected that surgical conditions would result in losses of 1·25% of potential GDP, or $20·7 trillion (2010 US$, purchasing power parity) in the 128 countries with data available. When expressed as a proportion of potential GDP, annual GDP losses were greatest in low-income and middle-income countries, with up to a 2·5% loss in output by 2030. When total welfare losses are assessed (VLW), the present value of economic losses is estimated to be equivalent to 17% of 2010 GDP, or $14·5 trillion in the 175 countries assessed with this approach. Neoplasm and injury account for greater than 95% of total economic losses with each approach, but maternal, digestive, and neonatal disorders, which represent only 4% of losses in high-income countries with the VLW approach, contribute to 26% of losses in low-income countries.

INTERPRETATION

The macroeconomic impact of surgical disease is substantial and inequitably distributed. When paired with the growing number of favourable cost-effectiveness analyses of surgical interventions in low-income and middle-income countries, our results suggest that building surgical capacity should be a global health priority.

FUNDING

US National Institutes of Health/National Cancer Institute.

Mortality due to Chagas disease in Brazil according to a specific cause

A century after its discovery, Chagas disease (CD) is still considered a public health problem. Mortality caused by CD between 2000 and 2010 was described according to the specific underlying cause, year of occurrence, gender, age range, and region of Brazil. The standardized mortality rate decreased 32.4%, from 3.4% in 2000 to 2.3% in 2010. Most of the deaths (85.9%) occurred in male patients who were > 60 years of age caused by cardiac involvement. The mortality rate caused by cardiac involvement decreased in all regions of Brazil, except in the North region, where it increased by 1.6%. The Northeast had the smallest and the Central-West had the largest decrease. The mortality rate caused by a compromised digestive tract increased in all regions. Despite the control of transmission by vector and blood transfusions, CD should remain on the list of priority diseases for the public health service in Brazil, and surveillance actions cannot be interrupted.

Laparoscopic surgery for benign and malign diseases of the digestive system: Indications, limitations, and evidence

The laparoscopic technique was introduced in gastrointestinal surgery in the mid 1980s. Since then, the development of this technique has been extraordinary. Triggered by technical innovations (stapling devices or coagulation/dissecting devices), nowadays any type of gastrointestinal resection has been successfully performed laparoscopically and can be performed laparoscopically dependent on the patient’s condition. This summary gives an overview over 30 years of laparoscopic surgery with focus on today’s indications and evidence. Main indications remain the more common procedures, e.g., appendectomy, cholecystectomy, bariatric procedures or colorectal resections. For all these indications, the laparoscopic approach has become the gold standard with less perioperative morbidity. Regarding oncological outcome there have been several high-quality randomized controlled trials which demonstrated equivalency between laparoscopic and open colorectal resections. Less common procedures like esophagectomy, oncological gastrectomy, liver and pancreatic resections can be performed successfully as well by an experienced surgeon. However, the evidence for these special indications is poor and a general recommendation cannot be given. In conclusion, laparoscopic surgery has revolutionized the field of gastrointestinal surgery by reducing perioperative morbidity without disregarding surgical principles especially in oncological surgery.

Nonalcoholic fatty liver disease is associated with benign gastrointestinal disorders

AIM: To explore associations between nonalcoholic fatty liver disease (NAFLD) and benign gastrointestinal and pancreato-biliary disorders.

METHODS: Patient demographics, diagnoses, and hospital outcomes from the 2010 Nationwide Inpatient Sample were analyzed. Chronic liver diseases were identified using International Classification of Diseases, the 9^th Revision, Clinical Modification codes. Patients with NAFLD were compared to those with other chronic liver diseases for the endpoints of total hospital charges, disease severity, and hospital mortality. Multivariable stepwise logistic regression analyses to assess for the independent association of demographic, comorbidity, and diagnosis variables with the event of NAFLD (vs other chronic liver diseases) were also performed.

RESULTS: Of 7800441 discharge records, 32347 (0.4%) and 271049 (3.5%) included diagnoses of NAFLD and other chronic liver diseases, respectively. NAFLD patients were younger (average 52.3 years vs 55.3 years), more often female (58.8% vs 41.6%), less often black (9.6% vs 18.6%), and were from higher income areas (23.7% vs 17.7%) compared to counterparts with other chronic liver diseases (all P < 0.0001). Diabetes mellitus (43.4% vs 28.9%), hypertension (56.9% vs 47.6%), morbid obesity (36.9% vs 8.0%), dyslipidemia (37.9% vs 15.6%), and the metabolic syndrome (28.75% vs 8.8%) were all more common among NAFLD patients (all P < 0.0001). The average total hospital charge ($39607 vs $51665), disease severity scores, and intra-hospital mortality (0.9% vs 6.0%) were lower among NALFD patients compared to those with other chronic liver diseases (all P < 0.0001).Compared with other chronic liver diseases, NAFLD was significantly associated with diverticular disorders [OR = 4.26 (3.89-4.67)], inflammatory bowel diseases [OR = 3.64 (3.10-4.28)], gallstone related diseases [OR = 3.59 (3.40-3.79)], and benign pancreatitis [OR = 2.95 (2.79-3.12)] on multivariable logistic regression (all P < 0.0001) when the latter disorders were the principal diagnoses on hospital discharge. Similar relationships were observed when the latter disorders were associated diagnoses on hospital discharge.

CONCLUSION: NAFLD is associated with diverticular, inflammatory bowel, gallstone, and benign pancreatitis disorders. Compared with other liver diseases, patients with NAFLD have lower hospital charges and mortality.

Premature death after self-harm: a multicentre cohort study

BACKGROUND

People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation.

METHODS

We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation.

FINDINGS

30 950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9-7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5-3·8), and occurred more in males (4·1, 3·8-4·3) than females (3·2, 2·9-3·4). Deaths due to natural causes were 2-7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5-32·2) for male patients and 30·7 years (29·5-31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7-26·0) for male patients and 25·5 years (25·2-25·8) for female patients, and for external-cause deaths was 40·2 years (40·0-40·3) and 40·0 years (39·7-40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ(2) trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease.

INTERPRETATION

Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs.

FUNDING

Department of Health Policy Research Programme.

[Formation of therapeutic group of casualties in local wars and armed conflicts]

The necessity of improvement of the therapeutic care organization in the RF Armed Forces is dictated by the existing military threats. Conflicts between states or within a single country along with inefficiency of diplomatic, social and political efforts may lead to armed conflicts or local wars. Analysis of medical support results shows the consistent prevalence of therapeutic group of casualties in the overall structure of medical losses. 35-50% of all sanitary losses is accounted for by somatic diseases. Moreover, their structure is similar to the structure of the army's peacetime morbidity rate. Respiratory diseases head the list of somatic diseases in military personnel. Next--diseases of the digestive and circulatory systems. One of the most important tasks for physicians in wartime is early diagnosis and treatment of visceral pathology in the wounded. An additional point is that the use of tactical nuclear weapons during the armed conflict or local war cannot be completely excluded. There is also a real risk of nuclear and chemical facilities damage, with consequences that are comparable to the use of nuclear or chemical weapons. Thus, in the course of armed conflict or local war, military physicians can meet all possible therapeutic spectrum of pathology: from visceral pathology of peace and wartime to combat related therapeutic pathology.

[The rate and dynamics of prevalence of diseases of digestive system in north Caucasus federal okrug and Stavropolsky kray]

The article presents the results of analysis of digestive system morbidity during last decade among adult population of Stavropolsky kray as compared with North Caucasus federal okrug and Russia in general. The analysis according classes of diseases established that in the structure ofgeneral morbidity according the appealability data first place is for diseases of respiratory organs, second place is for diseases of circulatory system, third place is for diseases of urogenital system, fourth place is for diseases of musculoskeletal system, fifth place is for traumas, intoxications and other aftermath of external causes, sixth place is for diseases of digestive system and also pregnancy, delivery and puerperal period In Stavropolsky kray, gastritis and duodenitis are registered much more infrequently as compared with corresponding morbidity increase among adult population of Russia from 2001 to 2010.

Comparison of perioperative outcomes in patients undergoing laparoscopic versus open abdominoperineal resection

BACKGROUND

The aim of this study was to retrospectively compare the outcomes of laparoscopic abdominoperineal resection (APR) and open APR.

METHODS

A multicenter, retrospective analysis was performed. The University HealthSystem Consortium database was accessed and searched for International Classification of Diseases, Ninth Revision, codes between October 2008 and January 2010. Discharge data were collected on patients undergoing laparoscopic APR and open APR.

RESULTS

Six hundred sixty-seven patients underwent laparoscopic APR, and 2,443 underwent open APR. When lower risk patient groups with minor or moderate severity of illness were compared, laparoscopic APR showed lower morbidity, reduced length of stay, reduced cost, and reduced incidence of intensive care unit admission. Comparative analysis showed no significant difference in mortality rate or 30-day readmission. When higher risk patients were compared, there were significantly reduced costs and reduced incidence of intensive care unit cases in the laparoscopic group.

CONCLUSIONS

Patients undergoing laparoscopic APR had overall superior perioperative outcomes compared with those undergoing open APR. Laparoscopic APR demonstrates excellent perioperative outcomes in appropriately selected patients.

[Global burden of mortality in Italian polluted sites]

SENTIERI Project has assessed the overall mortality profile in all the IPSs combined, and performed IPS-specific analyses. The epidemiological evidence of the causal association between cause of death and exposure was classified into one of these three categories: Sufficient (S), Limited (L) and Inadequate (I). The procedures and results of the evidence evaluation have been presented in a 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI. Mortality for causes of death with a priori Sufficient or Limited evidence of association with the environmental exposure exceeds the expected figures, with a SMR of 115.8 for men (90%CI 114.4-117.2; 2 439 extra deaths) and 114.4 for women (90% CI 112.4-116.5; 1 069 extra deaths). These excesses are also observed when analysis is extended to all the causes of death (i.e. with no restriction to the ones with a priori Sufficient or Limited evidence): for a total of 403 692 deaths (men and women combined), an excess of 9 969 deaths is observed, with an average of around 1 200 extra deaths per year. Most of these excesses are observed in IPSs located in Southern and Central Italy. The distribution of the causes of deaths shows that the excesses are not evenly distributed: cancer mortality accounts for 30%of all deaths, but is 43.2%of the excess deaths (4 309 cases of 9 969). Conversely, the percentage of excesses in non cancer causes, 19%, is lower than their share of total mortality (42%). Consistently with previous studies, the results suggest that the health status of populations living in the IPSs is worse than what regional averages show. Compared to previous studies, the analysis of the causes selected in SENTIERI, on the basis of a priori Sufficient or Limited evidence of association with the environmental exposures, provides additional information on their role, though some limitations, due to methodology and data used, should be considered.

[Mortality results in SENTIERI Project]

SENTIERI Project (Mortality study of residents in Italian polluted sites) studies mortality of residents in 44 sites of national interest for environmental remediation (Italian polluted sites, IPS). The epidemiological evidence of the causal association between causes of death and exposures was a priori classified into one of these three categories: Sufficient (S), Limited (L) and Inadequate (I). In these sites various environmental exposures are present. Asbestos (or asbestiform fibres as in Biancavilla) has been the motivation for defining six sites as IPSs (Balangero, Emarese, Casale Monferrato, Broni, Bari-Fibronit, Biancavilla). In five of these, increases in malignant neoplasm or pleura mortality are detected; in four of them, results are consistent in both genders. In six other sites (Pitelli, Massa Carrara, Aree del Litorale Vesuviano, Tito, "Aree industriali della Val Basento", Priolo), where other sources of environmental pollution in addition to asbestos are reported, mortality from malignant neoplasm of pleura is increased in both genders in Pitelli, Massa Carrara, Priolo, "Litorale vesuviano". In the time span 1995-2002, a total of 416 extra cases of malignant neoplasm of pleura are detected in the twelve asbestos-polluted sites. Asbestos and pleural neoplasm represent an unique case. Unlike mesothelioma, most causes of death analyzed in SENTIERI have multifactorial etiology; furthermore, in most IPSs multiple sources of different pollutants are present, sometimes concurrently with air pollution from urban areas: in these cases, drawing conclusions on the association between environmental exposures and specific health outcomes might be complicated. Notwithstanding these difficulties, in a number of cases an etiological role could be attributed to some environmental exposures. The attribution could be possible on the basis of increases observed in both genders and in different age classes, and the exclusion of a major role of occupational exposures was thus allowed. For example, a role of emissions from refineries and petrochemical plants was hypothesized for the observed increases in mortality from lung cancer and respiratory diseases in Gela and Porto Torres; a role of emissions from metal industries was suggested to explain increased mortality from respiratory diseases in Taranto and in Sulcis-Iglesiente-Guspinese. An etiological role of air pollution in the raise in congenital anomalies and perinatal disorders was suggested in Falconara Marittima, Massa-Carrara, Milazzo and Porto Torres. A causal role of heavy metals, PAH's and halogenated compounds was suspected for mortality from renal failure in Massa Carrara, Piombino, Orbetello, "Basso bacino del fiume Chienti" and Sulcis-Iglesiente-Guspinese. In Trento-Nord, Grado and Marano, and "Basso bacino del fiume Chienti" increases in neurological diseases, for which an etiological role of lead, mercury and organohalogenated solvents is possible, were reported. The increase for non-Hodgkin lymphomas in Brescia was associated with the widespread PCB pollution. Mortality for causes of death with a priori Sufficient or Limited evidence of association with the environmental exposure exceeds the expected figures, with a SMR of 115.8% for men (90% IC 114.4-117.2; 2 439 extra deaths) and 114.4% for women (90% CI 112.4-116.5; 1 069 extra deaths). These excesses are also observed when analysis is extended to all the causes of death (i.e. with no restriction to the ones with a priori Sufficient or Limited evidence): for a total of 403 692 deaths (both men and women), an excess of 9 969 deaths is observed, with an average of about 1 200 extra deaths per year. Most of these excesses are observed in IPSs located in Southern and Central Italy. The procedures and results of the evidence evaluation are presented in a 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI.

Human mortality seasonality in Castile-León, Spain, between 1980 and 1998: the influence of temperature, pressure and humidity

This study was carried out in the region of Castile and Leon, Spain, from 1980 to 1998 and analyzes the relationship between the number of monthly deaths caused by cardiovascular, respiratory and digestive diseases and three meteorological variables: temperature, pressure and humidity. One of the innovations in this study is the application of principal component analysis in a way that differs from its usual application: one single series representing the whole region was constructed for each meteorological variable from the series of eight weather stations. Annual and seasonal mortality trends were also studied. Cardiovascular diseases are the leading cause of death in Castile and Leon. The mortality related to cardiovascular, respiratory and digestive systems shows a statistically significant rising trend across the study period (an annual increase of 6, 16 and 4 per thousand, respectively). The pressure at which mortality is lowest is approximately the same for all causes of death (about 915 hPa), but temperature values vary greatly (16.8-19.7 degrees C for the mean, 10.9-18.1 degrees C for the minimum, and 24.1-27.2 degrees C for the maximum temperature). The most comfortable temperatures for patients with cardiovascular diseases (16.8 degrees C) are apparently lower than those for patients with respiratory diseases (18.1 degrees C), which are, in turn, lower than in the case of diseases of the digestive system (19.7 degrees C). Finally, the optimal humidity for patients with respiratory diseases is the lowest (24%) among the diseases, and the highest (51%) corresponds to diseases of the digestive system, while the optimal relative humidity for the cardiovascular system is 45%.

[The impact of controllable factors on mortality due to diseases of digestive system in Tverskaya oblast]

The article deals with the assessment of the impact of various social, biological and medical factors on the level of mortality of diseases of digestive organs in hospitals of certain districts of Tverskaya oblast. The controllable factors are determined impacting on the level of mortality of digestive system pathology and depending mainly of organization and quality of medical care at various stages of patient monitoring. The expertise technique was applied to evaluate the tactics of carried out treatment and the causes of diagnostics errors entailing preventable death and possibility of preventing lethal outcome. The study results can be used by health administrations and medical institutions to develop target programs reducing the preventable mortality of population. Another direction ? to impact specific causes of death in various subjects of the Russian Federation considering territorial characteristics of local health services and resource support of health care system in particular region.

Impact of abdominal complications on outcome after mechanical circulatory support

BACKGROUND

Mechanical circulatory support (MCS) is life sustaining for patients with end-stage heart failure. Most devices require abdominal wall transgression, creating a potential for abdominal complications. The incidence and impact of these relatively underreported complications are unknown.

METHODS

A retrospective review was performed on 179 patients who received MCS therapy from 1999 to 2008. Abdominal complications were grouped as abdominal wall, gastrointestinal tract, and solid organ.

RESULTS

Ninety-eight patients (55%) experienced 157 abdominal complications. These involved the abdominal wall in 69 (44%), the gastrointestinal tract in 52 (33%), and the solid organs in 36 (23%). Surgical intervention was required in 36% of patients with abdominal wall complications, 19% of patients with gastrointestinal tract complications, and 14% of patients with solid organ complications. Multivariate analysis identified diabetes mellitus (p < 0.001), emergent device placement (p = 0.019), and preimplant mechanical ventilation (p = 0.045) as independent risk factors for developing an abdominal complication. Kaplan-Meier survival while receiving MCS was significantly reduced for patients with abdominal complications versus those without (p = 0.0142). Multivariate analysis identified only solid organ abdominal complications (p = 0.001) as an independent risk factor for death while receiving device support.

CONCLUSIONS

Abdominal complications are common in patients supported with MCS devices and significantly reduce survival. Surgical intervention is more frequently required for complications related to the abdominal wall compared with other complications. Patients with significant comorbidities (diabetes mellitus, respiratory failure) requiring urgent or emergent device placement are at higher risk for the development of abdominal complications with an attendant reduction in device-related survival.

Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial

CONTEXT

Polymyxin B fiber column is a medical device designed to reduce blood endotoxin levels in sepsis. Gram-negative-induced abdominal sepsis is likely associated with high circulating endotoxin. Reducing circulating endotoxin levels with polymyxin B hemoperfusion could potentially improve patient clinical outcomes.

OBJECTIVE

To determine whether polymyxin B hemoperfusion added to conventional medical therapy improves clinical outcomes (mean arterial pressure [MAP], vasopressor requirement, oxygenation, organ dysfunction) and mortality compared with conventional therapy alone.

DESIGN, SETTING, AND PATIENTS

A prospective, multicenter, randomized controlled trial (Early Use of Polymyxin B Hemoperfusion in Abdominal Sepsis [EUPHAS]) conducted at 10 Italian tertiary care intensive care units between December 2004 and December 2007. Sixty-four patients were enrolled with severe sepsis or septic shock who underwent emergency surgery for intra-abdominal infection.

INTERVENTION

Patients were randomized to either conventional therapy (n=30) or conventional therapy plus 2 sessions of polymyxin B hemoperfusion (n=34).

MAIN OUTCOME MEASURES

Primary outcome was change in MAP and vasopressor requirement, and secondary outcomes were PaO(2)/FIO(2) (fraction of inspired oxygen) ratio, change in organ dysfunction measured using Sequential Organ Failure Assessment (SOFA) scores, and 28-day mortality.

RESULTS

MAP increased (76 to 84 mm Hg; P = .001) and vasopressor requirement decreased (inotropic score, 29.9 to 6.8; P < .001) at 72 hours in the polymyxin B group but not in the conventional therapy group (MAP, 74 to 77 mm Hg; P = .37; inotropic score, 28.6 to 22.4; P = .14). The PaO(2)/FIO(2) ratio increased slightly (235 to 264; P = .049) in the polymyxin B group but not in the conventional therapy group (217 to 228; P = .79). SOFA scores improved in the polymyxin B group but not in the conventional therapy group (change in SOFA, -3.4 vs -0.1; P < .001), and 28-day mortality was 32% (11/34 patients) in the polymyxin B group and 53% (16/30 patients) in the conventional therapy group (unadjusted hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.20-0.94; adjusted HR, 0.36; 95% CI, 0.16-0.80).

CONCLUSION

In this preliminary study, polymyxin B hemoperfusion added to conventional therapy significantly improved hemodynamics and organ dysfunction and reduced 28-day mortality in a targeted population with severe sepsis and/or septic shock from intra-abdominal gram-negative infections.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00629382.

Mortality profiles in a country facing epidemiological transition: an analysis of registered data

BACKGROUND

Sub-national analyses of causes of death and time-trends help to define public health policy priorities. They are particularly important in countries undergoing epidemiological transition like Peru. There are no studies exploring Peruvian national and regional characteristics of such epidemiological transition. We aimed to describe Peru's national and regional mortality profiles between 1996 and 2000.

METHODS

Registered mortality data for the study period were corrected for under-registration following standardized methods. Main causes of death by age group and by geographical region were determined. Departmental mortality profiles were constructed to evaluate mortality transition, using 1996 data as baseline. Annual cumulative slopes for the period 1996-2000 were estimated for each department and region.

RESULTS

For the study period non-communicable diseases explained more than half of all causes of death, communicable diseases more than one third, and injuries 10.8% of all deaths. Lima accounted for 32% of total population and 20% of total deaths. The Andean region, with 38% of Peru's population, accounted for half of all country deaths. Departmental mortality predominance shifted from communicable diseases in 1996 towards non-communicable diseases and injuries in 2000. Maternal and perinatal conditions, and nutritional deficiencies and nutritional anaemia declined markedly in all departments and regions. Infectious diseases decreased in all regions except Lima. In all regions acute respiratory infections are a leading cause of death, but their proportion ranged from 9.3% in Lima and Callao to 15.3% in the Andean region. Tuberculosis and injuries ranked high in Lima and the Andean region.

CONCLUSION

Peruvian mortality shows a double burden of communicable and non-communicable, with increasing importance of non-communicable diseases and injuries. This challenges national and sub-national health system performance and policy making.

Adult height and the risk of mortality in South Korean women

To evaluate the association between adult height as a surrogate marker of childhood circumstances and the risk of mortality, 344,519 South Korean women aged 40-64 years categorized into six height groups were prospectively followed for mortality between 1994 and 2004. In Cox proportional hazards regression with adjustment for behavioral and biologic risk factors, there was an inverse association between height and total mortality; mortality risk decreased 7% for each 5-cm increment in height. The association did not materially change after adjustment for behavioral factors and adulthood socioeconomic factors or after full adjustment for all available covariates. When height-associated risks of death from specific causes were evaluated in a fully adjusted analysis, a 5-cm increment in height was associated with lower risks of death from respiratory diseases, stroke, diabetes mellitus, and external causes (hazard ratios were 0.84 (95% confidence interval (CI): 0.74, 0.96), 0.84 (95% CI: 0.80, 0.88), 0.87 (95% CI: 0.80, 0.96), and 0.88 (95% CI: 0.83, 0.94), respectively) and with a higher risk of death from cancer (hazard ratio = 1.05, 95% CI: 1.02, 1.09). Given that adult height reflects early-life conditions, the independent associations between height and mortality from all causes and specific causes support the view that early-life circumstances significantly influence health outcomes in adulthood.

[Current guidelines for the treatment of intra-abdominal infections]

Intra-abdominal infections (IAIs) are a frequent cause of mobility and mortality. These infections can be caused by a wide variety of microorganisms, including both aerobes and anaerobes, and are often polymicrobial. Several studies observed that mortality depends on initiating early appropriate antimicrobial therapy. Moreover, the inappropriate choice of initial antibiotic therapy result in a longer hospital stay and higher costs of hospitalization compared with appropriate initial antibiotic therapy. The aim of current review is that of summarize the recommendations of several guidelines on the management of IAIs.

Periodontitis and premature death: a 16-year longitudinal study in a Swedish urban population

BACKGROUND AND OBJECTIVE

Growing experimental evidence implicates chronic inflammation/infection due to periodontal diseases as a risk factor for death. The objective was to evaluate the role of periodontitis in premature death in a prospective study.

METHODS

The causes of death in 3273 randomly-selected subjects, aged 30-40 years, from 1985 to 2001 were registered. At baseline, 1676 individuals underwent a clinical oral examination (Group A) and 1597 did not (Group B). Mortality and causes of death from 1985 to 2001 were recorded according to ICD-9-10.

RESULTS

In Groups A (clinically examined group) and B, a total of 110 subjects had died: 40 subjects in Group A, and 70 in Group B. In Group A significant differences were present at baseline between survivors and persons who later died, with respect to dental plaque, calculus, gingival inflammation and number of missing molars in subjects with periodontitis (p < 0.001). The multiple logistic regression analysis results of the relationship between being dead (dependent variable) and several independent variables identified periodontitis with any missing molars as a principal independent predictor of death.

CONCLUSIONS

Young individuals with periodontitis and missing molars seem to be at increased risk for premature death by life-threatening diseases, such as neoplasms, and diseases of the circulatory and digestive systems.

Mortality from diseases other than cancer following low doses of ionizing radiation: results from the 15-Country Study of nuclear industry workers

BACKGROUND

Ionizing radiation at very high (radio-therapeutic) dose levels can cause diseases other than cancer, particularly heart diseases. There is increasing evidence that doses of the order of a few sievert (Sv) may also increase the risk of non-cancer diseases. It is not known, however, whether such effects also occur following the lower doses and dose rates of public health concern.

METHODS

We used data from an international (15-country) nuclear workers cohort study to evaluate whether mortality from diseases other than cancer is related to low doses of external ionizing radiation. Analyses included 275 312 workers with adequate information on socioeconomic status, over 4 million person-years of follow-up and an average cumulative radiation dose of 20.7 mSv; 11 255 workers had died of non-cancer diseases.

RESULTS

The excess relative risk (ERR) per Sv was 0.24 [95% CI (confidence intervals) -0.23, 0.78] for mortality from all non-cancer diseases and 0.09 (95% CI -0.43, 0.70) for circulatory diseases. Higher risk estimates were observed for mortality from respiratory and digestive diseases, but confidence intervals included zero. Increased risks were observed among the younger workers (attained age <50 years, identified post hoc) for all groupings of non-cancer causes of death, including external causes. It is unclear therefore whether these findings reflect real effects of radiation, random variation or residual confounding.

CONCLUSIONS

The most informative low-dose radiation study to date provides little evidence for a relationship between mortality from non-malignant diseases and radiation dose. However, we cannot rule out risks per unit dose of the same order of magnitude as found in studies at higher doses.

Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery

BACKGROUND

Hypothermia is common in the operating theatre and may increase susceptibility to postoperative complications. Intraoperative systemic warming has been shown to improve outcomes of surgery. This study aimed to examine the effects of additional perioperative systemic warming on postoperative morbidity.

METHODS

All patients admitted for elective major abdominal surgery and fulfilling the inclusion criteria were randomized into control or warming groups. Both groups were warmed during surgery, but patients in the warming group were additionally warmed 2 h before and after surgery using a conductive carbon polymer mattress.

RESULTS

The trial recruited 103 patients (56 in the control group, 47 in the warming group). Both groups were well matched for age, sex and clinical state. Patients in the warming group had lower blood loss (median 200 (range 5-1000) ml versus median 400 (range 50-2300) ml in the control group; P = 0.011) and complication rates (15 (32 per cent) of 47 versus 30 (54 per cent) of 56 in the control group; P = 0.027). There were three deaths; two in the control group (P = 0.566).

CONCLUSION

Extending systemic warming to the perioperative period had additional beneficial effects, with minimal additional cost and patient discomfort.

Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients

BACKGROUND

Studies of risk factors after pancreatoduodenectomy are few: some concern restricted populations and others are based on administrative data.

METHODS

Multicenter clinical data were collected for 300 patients undergoing pancreatoduodenectomy to determine (by univariate and multivariate analysis) preoperative and intraoperative risk factors for mortality and intra-abdominal complications (IACs), including pancreatic fistula. Fourteen factors including the center and volume effect were analyzed.

RESULTS

In univariate analysis, mortality was increased with age 70 years or more, extended resection(s), and volume and center effects. IACs occurred more often with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, extended resection(s), and the center effect. Pancreatic fistula was more frequent with main pancreatic duct diameter of 3 mm or less, normal parenchyma texture, and the center effect. In multivariate analysis, independent risk factor(s) for mortality were age greater than 70 years (odds ratio [OR], 3; 95% confidence interval [CI], 1.3-8) and extended resection (OR, 5; 95% CI, 1.2-22), risk factors for IACs were extended resection (OR, 5; 95% CI, 1.2-22) and main pancreatic duct diameter of 3 mm or less (OR, 2; 95% CI, 1.1-3), and the risk factor for pancreatic fistula was main pancreatic duct diameter of 3 mm or less (OR, 2.5; 95% CI, 1.2-4.6).

CONCLUSIONS

Age more than 70 years, extended resections, and main pancreatic duct diameter less than 3 mm are independent risk factors that should be considered in indications for and techniques of pancreatoduodenectomy.

Causes of Death Following 1 Year Postinjury Among Individuals With Traumatic Brain Injury

OBJECTIVE

To investigate causes of death in individuals with traumatic brain injury (TBI).

DESIGN

Retrospective cohort study.

SETTING

Utilized data from the TBI Model Systems National Database, the Social Security Death Index, death certificates, and the US population age-race-gender-cause-specific mortality rates for 1994.

PATIENTS

Two thousand one hundred forty individuals with TBI completing inpatient rehabilitation in 1 of 15 National Institute on Disability and Rehabilitation Research-funded TBI Model Systems of Care between 1988 and 2001, and surviving past 1 year postinjury.

MAIN OUTCOME MEASURES

Primary cause of death based on the International Classification of Diseases--9th Revision--Clinical Modification-coded death certificates.

RESULTS

Individuals with TBI were about 37 times more likely to die of seizures, 12 times more likely to die of septicemia, 4 times more likely to die of pneumonia, and about 3 times more likely to die of other respiratory conditions (excluding pneumonia), digestive conditions, and all external causes of injury/poisoning than were individuals in the general population of similar age, gender, and race.

CONCLUSION

Long-term follow-up of individuals with TBI should increase vigilance for, and prevention of, diagnoses frequently causing death (circulatory disorders) and diagnoses with a high relative risk of causing death in this population (seizures, septicemia, respiratory and digestive conditions, and external causes of injury).

[Newborn emergencies in the Pediatric Surgery Service of CHU Donka]

DRANK: The goal of this work is to determine the factors of surgical mortality in period neonatal and to emphasize the difficulties of the assumption of responsibility.

MATERIALS AND METHODS

Retrospective study of 222 cases over 10 years from January 1992 to December 00 realized in the service of Paediatric surgery of the National Hospital Donka. We studied the age of the patients to the first consultation according to whether it is received before or after the 6th day of birth, the socio-economic level was appreciated according to the mode of dwelling, accessibility with drinking water and electricity, the diet, associated malformations, the postoperative results.

RESULTS

In 10 years (January 1992 at December 2001), we recorded 222 surgical cases of newborn emergency interesting the digestive tract (27.48%), the abdominal wall (37.39%), the parts urogenital (2.25%) and neurological (32.88%). We noted a male prevalence of 64.41% and surgical newborn mortality was 29.28%. The delay with the consultation, poverty on the one hand and the lack of the means of reanimation, the insufficiency of qualified personnel, were the principal factors of risk in our series.

CONCLUSION

The surgical newborn urgencies gather affections which require an immediate and adequate assumption of responsibility. The early diagnosis is a requirement; it must be done in the room of childbirth. The childbirth in residence, the ignorance of these affections by much of experts involves the delay with the consultation. The insufficiency of personnel qualified in paediatric surgery and infantile anaesthesia-reanimation, the poverty of the parents who must deal with the medical expenses of the new-born babies are as many factors which delay the time of intervention. The training of the specialists in paediatric anaesthesia-reanimation, the formation continues agents of health on all the levels on the tracking of the newborn urgencies, the creation of the centers of reanimation, the motivation of the personnel looking after in these structures and the intervention of the medical O.N.G. will be major assets to improve the assumption of responsibility and to decrease the death rate.

Pilot study of using GIS to visualize health status distribution: case study of Songjiang District, Shanghai

The aim of this study was to investigate the geographic variation in mortality indicators in Songjiang District of Shanghai under rapid change with urbanization. Geographic Information System (GIS) was used to visualize the distributions of health status and to test the extent of spatial auto-correlation in the indictors. In 2001, total crude mortality was 687/100,000 for the district; the rates for the townships (N=15) in the district ranged from 444/100,000 to 805/100,000. GIS maps indicated that the mortality was higher in the marginal areas of the district. Significant positive auto-correlations were found in total crude mortality rates, death rate for infectious diseases, and death rates for digestive diseases. The measures that consider intra-region inequality in health needs will be required in the regions under urbanization.

[Occupation and mortality in the Brazilian Navy]

OBJECTIVE

To describe the distribution of mortality due to digestive tract, genitourinary and nervous system diseases according to occupation among Brazilian Navy servicemen.

METHODS

This was an exploratory study of proportional mortality among male servicemen in the Brazilian Navy who died between 1991 and 1995. The study population comprises the entire contingent of servicemen during this same time period. Data were obtained from death certificates submitted in order to obtain dependents' pensions, and from the corresponding occupational histories of these individuals. Basic causes of death were coded in accordance with the International Classification of Diseases (9th Revision).

RESULTS

Servicemen presented increased proportional mortality for liver diseases related to alcohol consumption (age-adjusted proportional mortality ratio, PMRadj=2.03; 95% confidence interval, CI: 1.26-3.00), pancreatitis (PMRadj=2.03; 95% CI: 1.06-3.38), digestive hemorrhage (PMRadj=1.61; 95% CI: 1.10-2.23), chronic kidney diseases (PMRadj=2.82; 95% CI: 1.98-3.84), Parkinson's disease (PMRadj=3.00; 95% CI: 1.27-5.72) and degenerative brain diseases (PMRadj=2.88; 95% CI: 1.14-5.70), in relation to the reference population. A statistically non-significant association was observed between radar operators (PMR=6.50; 95% CI: 1.43-29.56) and nervous system diseases was observed.

CONCLUSIONS

The results indicate the existence of possible occupational risk factors in the working environment of the Brazilian Navy, and the need for studies using quantitative measurement of such exposure.

Seasonal changes in mortality rates from main causes of death in Japan

BACKGROUND

It is well recognized that the season of the year exerts an influence on some diseases and causes of death such as coronary heart diseases, stroke, infectious diseases and so on.

METHODS

We evaluated the influence of seasonal changes on diseases and causes of death in Japan using the Japan Vital Statistics from 1970 to 1999 and recorded weather data (mean temperature), by a Fourier decomposition in a log linear regression model.

RESULTS

Major influences of seasonal change with the highest rates in winter were seen on the following: the overall causes of death; infectious and parasitic diseases including tuberculosis; respiratory disease, including pneumonia and influenza; heart and cerebrovascular diseases; diabetes; and digestive diseases and accidents. Two peaks were seen in suicides, a large peak in April and a small peak in autumn. Cancer and homicides were little or not at all influenced by seasonality. There was no major difference in changes between the years studied, except for respiratory disease and tuberculosis, which showed a clear reduction in the seasonality effect from 1970 to 1999.

CONCLUSIONS

To reduce the overall mortality rate and to prolong life expectancy in Japan, measures must be taken to reduce those mortality rates associated with seasonal differences, especially those causes of death which show a strong correlation with seasonal change: respiratory, heart, cerebrovascular, diabetes and infectious diseases.

Digestive and liver diseases statistics, 2004

BACKGROUND & AIMS

Digestive and liver diseases are associated with substantial morbidity and mortality in the United States. Statistics about the incidence, prevalence, mortality, and resource utilization of digestive and liver diseases in the United States may be cumbersome to obtain because they are scattered in multiple sources. These data may be useful for policy makers, grant applicants, and authors.

METHODS

Data on the most common gastrointestinal and liver diseases were collected from large publicly available national databases. Information was collected on inpatient and outpatient gastrointestinal complaints and diagnoses, gastrointestinal cancers, and deaths from common liver diseases.

RESULTS

The leading gastrointestinal complaint prompting an outpatient visit is abdominal pain, with 12.2 million annual visits, followed by diarrhea, nausea, and vomiting. Abdominal pain is the leading outpatient gastrointestinal diagnosis, accounting for 5.2 million visits annually, followed by gastroesophageal reflux disease, with 4.5 million visits. Gallstone disease is the most common inpatient diagnosis, with 262,411 hospitalizations and a median inpatient charge of USD$11,584. Colorectal cancer is the most common gastrointestinal cause of death and is the most common gastrointestinal cancer, with an incidence of 54 per 100,000. Among gastrointestinal cancers, primary liver cancer had the highest increase in incidence from 1992 to 2000.

CONCLUSIONS

Gastrointestinal and liver diseases are associated with significant outpatient and inpatient healthcare utilization. Following trends in utilization is important for determining allocation of resources for health care and research.

[Causes of death in a cohort of EDF-GDF employees: comparison between occupational medicine and official statistics data]

BACKGROUND

In an epidemiological study, medical causes of death may be obtained from different sources. In a study on French gas and electricity company (EDF-GDF) workers, they were obtained from the national INSERM database. Additionally, the causes collected by the EDF-GDF occupational physicians were available for a subset of 1,330 deaths, which occurred between 1989 and 1994. The data from the two sources were compared with each other, in order to assess whether they were globally equivalent, and the potential impact of their differences on the results of epidemiological analyses.

METHODS

Concordance rates between causes of death in the INSERM and EDF-GDF physicians databases were calculated according to the International Classification of Diseases (ICD) ninth revision codes and for various causes groups. Causes of death records were also examined in order to clarify the observed divergences. SMRs were computed in order to evaluate the consequences of using each database in epidemiological analyses. Finally, some SMRs were computed with the two sources and compared with each other.

RESULTS

INSERM and EDF-GDF physicians causes belonged to the same causes group in 81% of cases, but the exact cause was different for more than half of them. The concordance rate was high for the deaths by AIDS and by cancer, and low for deaths by respiratory system and digestive system diseases. More causes of death were coded as "unknown" in EDF-GDF physicians data than in INSERM data. The SMRs varied widely depending on whether the INSERM or EDF-GDF physicians causes of death databases were used.

CONCLUSIONS

Causes of death recorded in the INSERM and EDF-GDF physicians databases are very different. Therefore, using the national mortality rates computed by INSERM with the EDF-GDF physicians causes of death to calculate SMRs is not valid, and it is observed that they may be very different from those computed with INSERM data. In a general way, it should be better to use the INSERM database, which is a common source, in order to generate results comparable with other studies. However, this database has its own limitations, and it may be better, in particular situations and for internal analyses, to use another source if it seems to be a better one.

Social inequalities in mortality in a retrospective cohort of civil servants in Barcelona

BACKGROUND

The objective of this study is to describe the inequalities in mortality by occupational category and sex in a retrospective cohort of civil servants working in the city council of Barcelona (Spain).

METHODS

The cohort was followed for the period 1984-1993. There were 11 647 men and 9001 women. Age-adjusted hazard ratios (HR) of death for occupational categories and manual versus non-manual groups and 95% CI were derived from Cox proportional hazards models.

RESULTS

For total deaths in males, compared with high-level professionals, auxiliary workers (HR = 1.30, 95% CI: 0.96-1.77), skilled manual workers (HR = 1.29, 95% CI: 0.95-1.77), unskilled manual workers (HR = 1.46, 95% CI: 1.07-1.98) and police and fire manual workers (HR = 1.42, 95% CI: 1.08-1.87) had higher risk of death. Among women, for all causes of mortality, only police manual workers had higher mortality (HR = 5.63, 95% CI: 1.89-16.7) whereas auxiliary workers had the lowest HR (HR = 0.51, 95% CI: 0.25-1.05). The HR comparing manual and non-manual categories for all causes of death was 1.29 for males (95% CI: 1.09-1.52) and 1.07 for females (95% CI: 0.77-1.49). Among males, whereas manual workers had lower cardiovascular mortality (HR = 0.85, 95% CI: 0.63-1.15), cancer mortality was higher in the manual category. No association between manual category and mortality was found among women.

CONCLUSIONS

This study provides an analysis of social inequalities in mortality in a cohort from a Southern European urban area.