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PubMed1990

Mortality of a cohort of tin miners 1941-86.

The mortality patterns of United Kingdom tin miners were examined in relation to calendar period and duration of underground work with particular attention to lung cancer and exposure to radon. Subjects were all men who had worked for at least one year between 1941 and 1984 at one of two United Kingdom tin mines and for whom a complete work history could be constructed from mine records. Standardised mortality ratios (SMRs) were calculated using national (England and Wales) rates. The pattern of SMRs in relation to potential explanatory variables was analysed using Poisson regression methods. Mortalities from lung cancer and silicosis (including silicotuberculosis) were significantly raised and showed a significant relation with duration of underground work (mortality from stomach cancer was raised in both underground and surface workers, but not significantly). Excess mortality from silica related disease declined steeply from 35% among workers first exposed before 1920 to 1% among those first exposed after 1950. Thirteen surface workers with known exposure to arsenic had high rates of lung and stomach cancer. The SMR for lung cancer showed a consistent pattern in relation to duration of underground exposure, rising from 83 (observed/expected = 8/9.6) for surface workers (without exposure to arsenic) to 447 (15/3.4) for workers with more than 30 years underground exposure. Examination of the SMR for lung cancer by total underground exposure, age, and time since last exposure gave rise to a model for the expression of risk which depends only on total exposure and time since exposure. The fitted model implies that the effect of exposure to radon in a given year has no effect on risk for 10 years, then rapidly rises to a maximum from which the excess risk then declines, halving every 4.3 years. There were no direct measurements of historic radon levels. A conservative estimate based on measurements taken since 1969 by the National Radiological Protection Board and the Mines and Quarries Inspectorate is that the annual dose to an underground worker was about 10 working level months (WLM). Given this assumption, the risk/exposure slope implied by the present data, and the model fitted to it, was somewhat lower than that given in the fourth Committee on the Biological Effects of Ionisation Radiation (BEIR IV) report (about 40% lower for lifetime exposures). The present data also imply different risks depending on the age at exposure, with relatively higher lifetime risks for exposure at older ages, and relatively lower risks for exposures at younger ages. In conclusion, there was a clear relation between exposure to radon and death from lung cancer. The relative risk of lung cancer due to exposure to radon was not constant in cessation of exposure. The lifetime excess risk of lung cancer implied by these data for 40 years exposure at the current statutory limit of four WLM a year starting at age 20, was about 8% (79 excess deaths per 1000 exposed), assuming average smoking habits among the exposed workers. Control of dust concentrations in the mines has substantially reduced--and may have eliminated--direct mortality from silica related disease.

Arsenic Poisoning↗
PubMed1999

Seizure control and mortality in epilepsy.

Mortality rates are increased among people with epilepsy, and may be highest in those with uncontrolled seizures. Because epilepsy surgery eliminates seizures in some people, we used an epilepsy surgery population to examine how seizure control influences mortality. We tested the hypothesis that patients with complete seizure relief after surgery would have a lower mortality rate than those who had persistent seizures. Three hundred ninety-three patients who had epilepsy surgery between January 1986 and January 1996 were followed after surgery to assess long-term survival; 347 had focal resection or transection, and 46 had anterior or complete corpus callosotomy. A multivariate survival analysis was performed, contrasting survival in those who had seizure recurrence with survival of those who remained seizure free. Standardized mortality ratios and 95% confidence intervals were calculated. Overall, seizure-free patients had a lower mortality rate than those with persistent seizures. This was true for the subset of patients with localized resection or multiple subpial transection. No patients died among 199 with no seizure recurrence, whereas of 194 patients with seizure recurrence, 11 died. Six of the deaths were sudden and unexplained. Most patients who died had a substantial reduction in postoperative seizure frequency. The standardized mortality ratio for patients with recurrent seizures was 4.69, and the risk of death in these patients was 1.37 in 100 person-years, whereas among patients who became seizure free, there was no difference in mortality rate compared with the age- and sex-matched population of the United States. Elimination of seizures after surgery reduces mortality rates in people with epilepsy to a level indistinguishable from that of the general population, whereas patients with recurrent seizures continue to suffer from high mortality rates. This suggests that uncontrolled seizures are a major risk factor for excess mortality in epilepsy. Achieving complete seizure control with epilepsy surgery in refractory patients reduces the risk of death, so the long-term risk of continuing medical treatment appears to be higher than the risk of epilepsy surgery in suitable candidates.

Adolescent↗
PubMed1994

Implantable cardioverter defibrillator compared with antiarrhythmic drug treatment in cardiac arrest survivors (the Cardiac Arrest Study Hamburg).

In 1987, the Cardiac Arrest Study Hamburg (CASH), a prospective, multicenter, randomized controlled study, was started in survivors of sudden cardiac death resulting from documented ventricular tachyarrhythmias. Through December 1991, 230 survivors (46 women, 184 men; mean age 57 +/- 11 years) of cardiac arrest caused by ventricular tachyarrhythmias were randomly assigned to receive either oral propafenone (56 patients), amiodarone (56 patients), or metoprolol (59 patients) or to have an implantable defibrillator (59 patients) without concomitant antiarrhythmic drugs. The primary endpoint of the study was total mortality. In March 1992, the propafenone arm of CASH was stopped because of excess mortality compared with the implantable defibrillator group. This article presents preliminary results of the comparison of implantable defibrillator therapy with propafenone therapy. A significantly higher incidence of total mortality, sudden death (12%), and cardiac arrest recurrence or sudden death (23%) was found in the propafenone group compared with the implantable defibrillator-treated patients (0%, p < 0.05). It was concluded that, in survivors of cardiac arrest, propafenone treatment is less effective than implantable defibrillator treatment.

Amiodarone↗
PubMed1998

Health and environmental benefits from air pollution reductions in Hungary.

The aim of this study was to assess the cost and benefit of the implementation of a specific energy saving program in Hungary. We have considered the possible reduced damage to public health, building materials and agricultural crops that may be obtained from reducing emissions of important air pollutants and also how the program contributes to reduced emissions of greenhouse gases. The measures are described in the National Energy Efficiency Improvement and Energy Conservation Programs (NEEIECP), elaborated by the Hungarian Ministry of Industry and Trade and accepted by the Government in 1994. The energy saving expected from the program is approximately 64 PJ/year. The benefits were estimated using monitoring data and population/recipient data from urban and rural areas in Hungary together with exposure-response functions and valuation estimates mainly from western studies. Our analysis indicates that the main benefit from reducing the concentrations of pollutants relates to public health and that reduced prevalence of chronic respiratory diseases is an important effect. Reduced premature mortality is also important and the estimated attributable risk of air pollution to excess mortality at present is approximately 6%. The estimated annual benefit of improved health conditions alone is likely to exceed the investments needed to implement the program. In addition there are significant benefits due to reduced replacement and maintenance costs for building materials (30-35 million US$ annually in Budapest only). The damage to crops due to ozone is large, but a significant improvement in Hungary depends upon concerted actions in several countries.

Agriculture↗
PubMed1988

Are hospital confinements really more dangerous for the fetus?

A large number of publications has reiterated the observation that perinatal mortality rates in Britain are higher among births in consultant units than among those occurring at home or in other units. In this paper we show that whereas these observations are themselves undeniable, the conclusion that hospital confinements are more dangerous to the fetus is probably erroneous. To illustrate the methodological difficulties, we have used as much information as possible on the delivery intentions for a national survey of 16,668 singleton births taking place in the United Kingdom in one week of April 1970. Using these data, we show that although deliveries in a consultant unit had a three times higher mortality rate than those delivered elsewhere, this was due almost entirely to the excess mortality among transfers of women originally intending to deliver elsewhere. Consideration of the place the mother was originally intending to deliver altered the picture considerably, with mortality only 38% higher among the consultant unit group. It is pointed out that if account was taken of risk factors such as past obstetric history, marital status and social class it is likely that booking for hospital delivery may well carry a lower risk of perinatal death, but that present data collection systems combined with high rates of consultant delivery are unlikely to resolve this question.

Delivery, Obstetric↗
PubMed1999

Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: a matched, risk-adjusted, cohort study.

OBJECTIVE: To determine the attributable risk of death due to catheter-related septicemia (CRS) in critically ill patients when taking into account severity of illness during the intensive-care unit (ICU) stay but before CRS. DESIGN: Pairwise-matched (1:2) exposed-unexposed study. SETTING: 10-bed medical-surgical ICU and an 18-bed medical ICU. PATIENTS: Patients admitted to either ICU between January 1, 1990, and December 31, 1995, were eligible. Exposed patients were defined as patients with CRS; unexposed controls were selected according to matching variables. METHODS: Matching variables were diagnosis at ICU admission, length of central catheterization before the infection, McCabe Score, Simplified Acute Physiologic Score (SAPS) II at admission, age, and gender. Severity scores (SAPS II, Organ System Failure Score, Organ Dysfunction and Infection Score, and Logistic Organ Dysfunction System) were calculated four times for each patient: the day of ICU admission, the day of CRS onset, and 3 and 7 days before CRS. Matching was successful for 38 exposed patients. Statistical analysis was based on nonparametric tests for epidemiological data and on Cox's models for the exposed-unexposed study, with adjustment on matching variables and prognostic factors of mortality. RESULTS: CRS complicated 1.17 per 100 ICU admissions during the study period. Twenty (53%) of the CRS cases were associated with septic shock. CRS was associated with a 28% increase in SAPS II. Crude ICU mortality rates from exposed and unexposed patients were 50% and 21%, respectively. CRS remained associated with mortality even when adjusted on other prognostic factors at ICU admission (relative risk [RR], 2.01; 95% confidence interval [CI95], 1.08-3.73; P=.03). However, after adjustment on severity scores calculated between ICU admission and 1 week before CRS, the increased mortality was no longer significant (RR, 1.41; CI95, 0.76-2.61; P=.27). CONCLUSION: CRS is associated with subsequent morbidity and mortality in the ICU, even when adjusted on severity factors at ICU admission. However, after adjustment on severity factors during the ICU stay and before the event, there was only a trend toward CRS-attributable mortality. The evolution of patient severity should be taken into account when evaluating excess mortality induced by nosocomial events in ICU patients.

APACHE↗
PubMed2001

Socioeconomic inequalities in all-cause and specific-cause mortality in Australia: 1985-1987 and 1995-1997.

BACKGROUND: Socioeconomic inequalities in mortality have been repeatedly observed in Britain, the US, and Europe, and in some countries there is evidence that the differentials are widening. This study describes trends in socioeconomic mortality inequality in Australia for males and females aged 0-14, 15-24 and 25-64 years over the period 1985-1987 to 1995-1997. METHODS: Socioeconomic status (SES) was operationalized using the Index of Relative Socioeconomic Disadvantage, an area-based measure developed by the Australian Bureau of Statistics. Mortality differentials were examined using age-standardized rates, and mortality inequality was assessed using rate ratios, gini coefficients, and a measure of excess mortality. RESULTS: For both periods, and for each sex/age subgroup, death rates were highest in the most disadvantaged areas. The extent and nature of socioeconomic mortality inequality differed for males and females and for each age group: both increases and decreases in mortality inequality were observed, and for some causes, the degree of inequality remained unchanged. If it were possible to reduce death rates among the SES areas to a level equivalent to that of the least disadvantaged area, premature all-cause mortality for males in each age group would be lower by 22%, 28% and 26% respectively, and for females, 35%, 70% and 56%. CONCLUSIONS: The mortality burden in the Australian population attributable to socioeconomic inequality is large, and has profound and far-reaching implications in terms of the unnecessary loss of life, the loss of potentially economically productive members of society, and increased costs for the health care system.

Adolescent↗
PubMed1996

No persistent T lymphocyte immunosuppression or increased mortality after measles infection: a community study from Guinea-Bissau.

BACKGROUND: Because measles immunization is reducing overall childhood mortality in addition to mortality from acute measles infection, it has been suggested that postmeasles cases have excess mortality, possibly related to persistent immunosuppression after measles infection. After an epidemic in 1988 in Guinea-Bissau, we therefore examined T lymphocyte subsets and long term survival among measles cases and controls. METHODS: We examined 69 children < 3 years of age with a median delay of 2 months after measles infection and 71 controls who did not contract measles. The immunoalkaline method was used to determine T lymphocyte subsets. The children were followed for 5 years. RESULTS: Compared with controls, there were no significant differences in white blood cell count, absolute lymphocyte count, CD4 percentage, CD8 percentage, total CD4 count and total CD8 count, although measles cases examined > 2 months after infection had slightly higher CD4 counts than controls (P = 0.06). Adjusted for age, sex and immunization status, postmeasles cases had a mortality rate ratio of 0.50 (95% confidence interval, 0.22 to 1.16) (P = 0.11) compared with controls. CONCLUSIONS: There is no indication of persistent suppression of T cell subsets after measles infection, and postmeasles cases did not have higher mortality than uninfected community controls.

Child, Preschool↗
PubMed1981

Analysis of the 1980 heat wave in Memphis.

During the heat wave of 1980, average daily temperatures in Memphis first rose above the mean on June 25 and remained elevated for 26 consecutive days. In July, 1980, 83 heat-related deaths were recorded as compared to non in July 1979. Most of these deaths occurred in elderly, poor, black, inner-city residents. There was a statistically significant increase in total mortality rates, death from natural causes, cardiovascular mortality rates, and the rate for persons dead on arrival. Virtually all the excess mortality was in persons over the age of 60. The rise in heat-related emergency room visits occurred three days prior to the rise in heat-related deaths. Local planning for future heat waves should focus on the inner-city black elderly. Heat-related deaths and emergency room visits should be reported to public health officials.

Adolescent↗
PubMed1993

Regional organization for outcomes research.

Methods for achieving improvement in medical and surgical outcomes are often discussed, but rarely achieved. We report on a regional voluntary consortium founded in 1987 to provide information about the management of cardiovascular disease in northern New England. Members include all cardiothoracic surgeons and interventional cardiologists in the region, as well as administrators and scientists associated with the five institutions that provide advanced cardiac services in this region. The group maintains registries for coronary artery bypass grafting, coronary angioplasty, and heart valve surgery and has investigated institutional differences in mortality rates; the development and use of clinical prediction rules; the reasons for excess mortality among women undergoing bypass graft surgery; and time trends in the use of myocardial revascularization. This consortium is an inter-institutional model for the continuous improvement of medical and surgical care.

Cardiovascular Diseases↗
PubMed1993

Mortality of workers employed in shoe manufacturing.

A retrospective cohort mortality study was conducted among 7814 white shoe manufacturing workers followed from 1940 through 1982. The workers were potentially exposed to solvents (including toluene) and solvent-based adhesives. Benzene may have been present as an impurity of toluene. Mortality due to leukemia and aleukemia was not statistically significantly elevated. Statistically significant excess mortality due to cancer of the trachea, bronchus and lung was observed in the total cohort [standardized mortality ratio (SMR) 147, 95% confidence interval (95% CI) 120-180] and showed a statistically significant trend in standardized relative risk with increasing potential latency, but not with increasing duration of employment. Chronic nonmalignant respiratory disease was significantly elevated among the men (SMR 158, 95% CI 114-217) but was less than expected among the women (SMR 79), a finding suggesting a possible contribution of smoking to the mortality from respiratory cancer. However, adjustment for the potential effects of smoking did not completely eliminate the increased risk for lung cancer.

Adult↗
PubMedDate not supplied

Variation in mortality among seven hemodialysis centers as a quality indicator.

OBJECTIVES: To identify patient attributes that were associated with increased mortality; variables that were associated with process of care that were correlated with mortality; and outlier centers after adjustment for patient attributes. DESIGN: Standard interviews were conducted by trained nurses with all patients. Detailed information regarding primary renal diagnosis, comorbidity, and results of laboratory tests were obtained from the medical charts. The vital status of the patients was obtained from the records of each of the centers. We used the Cox hazard method to identify variables that correlated with a 1-year mortality. Centers with observed mortality exceeding the 95% confidence interval (CI95) of the expected probability of death were marked as outliers. SETTING: Seven dialysis centers located in large teaching hospitals in Israel. PATIENTS: The current study included patients > 16 years of age who had undergone hemodialysis > 4 weeks prior to the day of data collection. RESULTS: The study included 564 patients. Significant differences were found in patient demographics and process variables among the centers. The following variables correlated with mortality; diabetes (odds ratio [OR], 2.03; CI95, 1.28-3.21); ischemic heart disease (OR, 2.2; CI95, 1.39-3.49); each year of age (OR, 1.04; CI95, 1.02-1.06); each 1 g% of albumin (OR, 0.51; CI95, 0.30-0.86). The average observed mortality in all centers was 17.4%. After adjustment for casemix, one center showed excess mortality (24% observed compared to 15% expected after adjustment for patient attributes; CI95, 6.2-23.7). CONCLUSIONS: The ability to compare mortality rates among dialysis centers to detect possible quality outliers depends on thorough consideration of patient attributes and random variation.

Adolescent↗
PubMed1987

Use of public pension scheme and industrial statistics data for supplement of company records in Denmark and influence on cohort mortality pattern.

Completeness of company records is a crucial point in interpretation of follow-up studies of industrial cohorts. The Employers Quarterly Reports on Earnings (EQRE) are valuable for control of company records in the United States. The public Supplementary Pension Scheme (ATP) and the industrial statistics questionnaires are of equal value in Denmark. The authors report on a cohort study from a chemical plant, where cohort members were identified from company records, which were checked against ATP and industrial statistics data. The mortality analysis shows employees known only from the ATP data to have an excess mortality, relative risk (RR) = 1.45. Inclusion in the cohort of these additional employees only changed the relative risk in overall mortality from 1.01 to 1.04, but turned out to be decisive in the study of a rare disease.

Chemical Industry↗
PubMed1995

Electrocardiographic changes in patients with intrathoracic sarcoidosis: influence on prognosis.

A retrospective evaluation of 244 electrocardiograms obtained at rest at time of diagnosis from a population of 254 patients with intrathoracic sarcoidosis was carried out. Thirty-five (14%) were abnormal. Sinus tachycardia was present in 17 (7%), the rest encompassing various degrees of right-sided bundle branch, atrioventricular first degree block, ventricular extrasystolia and ST-depression. At follow-up after a median time of 27 years we found a significantly higher mortality risk in the group with ECG-changes compared to those without. Excess mortality was increased when comparing patients with tachycardia to those without. However, when adjusted for FEV1, the risk of death was not significantly different between the two groups.

Adolescent↗
PubMed1990

Mortality of cellulose fiber production workers.

Mortality was studied among 1271 employees of a cellulose fiber production plant in Rock Hill, South Carolina, in the United States. Each subject was employed for at least three months between 1 January 1954 and 1 January 1977 in jobs that entailed exposure to the highest concentrations of methylene chloride. In the cohort 122 deaths were identified through 1 September 1986, and mortality rates for the cohort were compared with mortality rates for York County, South Carolina. Deficit mortality was observed for cancers of the respiratory system, breast, and pancreas and from ischemic heart disease. Excess mortality was observed for cancers of the buccal cavity and pharynx and the liver and biliary tract, and for melanoma as well. The largest relative excess was for liver and biliary tract cancers. There were only four deaths in this category; however, three of the four deaths were cancer of the biliary tract (3 observed, 0.15 expected, standardized mortality ratio 20).

Biliary Tract Neoplasms↗
PubMed1993

Fiberglass or silica exposure and increased nephritis or ESRD (end-stage renal disease).

The U.S. multiplant cohort mortality study of workers producing manufactured mineral fibers is finding increasing mortality from nephritis and/or nephrosis. We examine other data sets to see if similar effects can be identified. In a case-referent study among Michigan patients with end-stage renal disease (ESRD), men with exposures to silica have elevated odds ratio for ESRD. In a California occupational mortality study based on 1979-81 data, a number of the construction trades, farmers, and farm laborers show excess mortality for renal disease. The highest mortality ratio is found in the category including insulation workers. This ratio remains significantly elevated when adjusted for estimated exposures to smoking, alcohol, and for socio-economic status. California mortality data from 20 years earlier (1959-61) fail to show much excess renal disease in construction workers, but do for farmers. In Singapore, granite workers with a long-term exposure to silica have excess excretion of albumin and similar compounds compared to less exposed controls, leading to the presumption that silica exposure can lead to silica nephrotoxicity. Balkan nephropathy has been associated with consumption of well water high in silica. In the Negev of Israel, dust storms are a vehicle for increasing respiratory uptake of silica. The Beduin, thought to be a population with maximal exposures, have higher rates of ESRD than do Jews in the age groups over 60 years. Although high blood concentrations of silica are found in persons with renal failure, the close association with elevated creatinine has been interpreted as evidence that the buildup of silica is due to renal failure, rather than vice-versa.(ABSTRACT TRUNCATED AT 250 WORDS)

Cohort Studies↗
PubMed1995

Mortality after prostatectomy: selection and surgical approach.

Observational studies have found higher long-term mortality after transurethral prostatectomy (TURP) than after open prostatectomy (OP) and that this difference remained after statistical adjustment for comorbidity. This higher mortality has been attributed to the transurethral procedure itself. This association is reassessed here. Time-sequenced hospital and death records were analysed for 13,815 men undergoing prostatectomy (not for cancer) during the years 1963-85. TURP had a lower 30-day case-fatality rate than had OP, a similar 90-day rate, but TURP had a higher one-year rate. By inference, any excess mortality after TURP must begin shortly after the first postoperative month. However, plotting mortality expressed as SMRs, for the three years after operation showed no increase in long-term mortality after TURP, nor was there any concomitant increase in one-year death rates after prostatectomy as TURP replaced OP. Long-term mortality after TURP was close to that expected from background population rates: after SMR for TURP, for the second and third postoperative years, was 100 (95% CI 93-107). In contrast, long-term mortality after OP was lower than expected from population rates with a corresponding SMR of 79 (95% CI 71-88). The apparent excess in long-term mortality after TURP is unlikely to be caused by the operation itself. It is more likely to reflect relatively low long-term mortality in OP patients as a consequence of OP patients having been relatively fitter than those having TURP.

Aged↗
PubMed2005

Relationship between HbA(1)c and mortality in a Japanese population.

AIM/HYPOTHESIS: HbA(1)c concentrations are known to be associated with all-cause excess mortality risk in Caucasians. However, the relationship has not been clarified well in the Japanese. In addition, studies of the relationship between HbA(1)c and mortality from malignant neoplasms are scarce. METHODS: HbA(1)c was measured for 3,710 people of a cohort composed of A-bomb survivors and controls. At baseline they were divided into five groups: a normal HbA(1)c group of 1,143 individuals with HbA(1)c of <5.5%, a slightly high but normal HbA(1)c group of 1,341 individuals with HbA(1)c > or =5.5% to <6.0%, a slightly high HbA(1)c group of 589 individuals with HbA(1)c > or =6.0% to <6.5%, a high HbA(1)c group of 259 individuals with HbA(1)c > or =6.5%, and a group of 378 individuals known to have type 2 diabetes. Using a Cox proportional hazards model, hazard ratios based on comparisons with the normal HbA(1)c group were obtained. RESULTS: During the observation period there were 754 deaths. For all-cause and cardiovascular disease mortality, a significant increase of the hazard ratio was observed for the slightly high HbA(1)c group. A similar increase in malignant neoplasm-related mortality was observed for both the high HbA(1)c group and the diabetes group. CONCLUSIONS/INTERPRETATION: Our results suggest that individuals in the Japanese population with HbA(1)c levels of 6% or more might have increased mortality risk. The results indicate that HbA(1)c measurements should be sought even for people who have not been diagnosed with diabetes.

Aged↗