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PubMed1999

The impact of particulate matter on daily mortality in Bangkok, Thailand.

Several studies conducted in U.S. cities report an association between acute exposures to particulate matter (PM), usually measured as PM10, and mortality. Evidence of high concentrations of PM10 in Eastern Europe and in large metropolitan areas outside of the United States, such as Mexico City and Bangkok, underscores the need to determine whether these same associations occur outside of the United States. In addition, conducting studies of mortality and air pollution in regions that have distinctly different seasonal patterns than those of the United States provides an effective opportunity to assess the potentially confounding aspects of seasonality. Over the last few years, daily measures of ambient PM10 have been collected in Bangkok, a tropical city of over 6 million people. In this metropolitan area, PM10 consists largely of fine particles generated from diesel- and gasoline-powered automobiles, and from two-stroke motorcycle engines. Our analysis involved the examination of the relationship between PM10 and daily mortality for 1992 through 1995. In addition to counts of daily natural mortality (total mortality net of accidents, homicides, and suicides), the data were compiled to assess both cardiovascular and respiratory mortality, and natural mortality by age group. A multivariate Poisson regression model was used to explain daily mortality while controlling for several covariates including temperature, humidity, day of the week, season, and time. The analysis indicated a statistically significant association between PM10 and all of the alternative measures of mortality. The results suggest a 10-microgram/m3 change in daily PM10 is associated with a 1-2% increase in natural mortality, a 1-2% increase in cardiovascular mortality, and a 3-6% increase in respiratory mortality. These relative risks are generally consistent with or greater than those reported in most studies undertaken in the United States.

Adolescent↗
PubMed2003

A decline in adult mortality, ages 45-64, in Wisconsin over the last 20 years: is it enough?

INTRODUCTION: Decreasing mortality is an important objective of health improvement. We examined the progress in reducing overall mortality in Wisconsin over the last 2 decades in the age group spanning 45-64 years. Goals for reducing mortality and disparities in mortality by 2010 were addressed. METHODS: We examined trends in all cause mortality for Wisconsin from 1980-1999 for ages 45-64. Mortality data was also examined by subgroups (race and gender) and cause. Mortality data was abstracted from Centers for Disease Control and Prevention's WONDER. RESULTS: From 1980-99, adults aged 45-64 experienced a 22% decline in mortality and, consequently, over 1720 lives were "saved" annually in Wisconsin in this age group between 1995-1999. Mortality in black men and women declined 8% and 10% respectively in this interval as compared to 27% for white males and 19% for white females (P<0.05 for all groups for temporal change in death rates). Significant declines in cardiovascular and cancer mortality were achieved. Deaths from injuries increased slightly. The black to white mortality ratio is projected to increase by 2010. CONCLUSIONS: Wisconsin has done well in reducing overall mortality in persons 45-64 years of age over the last 2 decades. Future challenges include reducing health disparities between blacks and whites.

Black People↗
PubMedDate not supplied

[Time trends in infectious disease mortality in Italy: 1969-1999].

OBJECTIVE: To describe the global impact of infectious diseases on mortality in Italy from 1969 to 1999. DESIGN: Statistical analysis of routinely collected mortality data, using a revised definition of infectious causes of death based on target organs. SETTING: The present paper summarizes time trends of infectious disease mortality widely discussed in the Atlas "30 Anni di Malattie Infettive in Italia: Atlante di Mortalità". MAIN OUTCOME MEASURES: Age standardized mortality rates (/100,000); standardized mortality ratios (SMR); percentage of deaths attributable to infectious diseases. RESULTS: Apart from HIV infection and AIDS, infectious diseases were responsible of 1.7% of the overall mortality that occurred in Italy in the study period: 57.5% of such deaths were not included in the ICD8 and ICD9 codes for infectious diseases. The mortality for all infectious diseases showed a very strong downward trend up to 1994, (with a 6-fold decline). Thereafter, a slight increase in deaths for septicaemias, heart infections and hepatitis was recorded. Over time, an increasing proportions of deaths due to infections occurred in the elderly (i. e., > or = 65 years of age), from 48.1% in 1969-1979 to 77.3% in 1990-1999. Mortality rates were consistently higher in men than in women, and showed a substantial geographic heterogeneity. In newborns, from 1969 thru 1999 mortality rates declined 10-fold all over the country, but an inverse north-south geographic gradient persisted during the whole study period. The spread of HIV infection and AIDS epidemic in the first '80s dramatically interrupted the downward trend in infectious disease mortality outlined above. Between 1993 and 1996, HIV/AIDS was the main cause of death among Italian men aged 30 to 39 years. CONCLUSIONS: This statistical analysis allowed to better quantify the impact of infectious diseases on overall mortality in Italy. Observed time trends were in accordance to the picture recorded in other western Countries, whereas the higher newborn mortality in southern Italy reflects the persistence of geographical inequalities in the health care organization.

Adult↗
PubMed2005

[The impact of high apparent temperature on the increase of Summertime Disease-related mortality in Seoul: 1991-2000].

OBJECTIVES: The aim of this paper was to examine the relationship between the summertime (June to August) heat index, which quantifies the bioclimatic apparent temperature in sultry weather, and the daily disease-related mortality in Seoul for the period from 1991 to 2000. METHODS: The daily maximum (or minimum) summertime heat indices, which show synergetic apparent temperatures, were calculated from the six hourly temperatures and real time humidity data for Seoul from 1991 to 2000. The disease-related daily mortality was extracted with respect to types of disease, age and sex, etc. and compared with the time series of the daily heat indices. RESULTS: The summertime mortality in 1994 exceeded the normal by 626 persons. Specifically, blood circulation-related and cancer-related mortalities increased in 1994 by 29.7% (224 persons) and 15.4% (107 persons), respectively, compared with those in 1993. Elderly persons, those above 65 years, were shown to be highly susceptible to strong heat waves, whereas the other age and sex-based groups showed no significant difference in mortality. In particular, a heat wave episode on the 22nd of July 2004 (> 45 degrees C daily heat index) resulted in double the normal number of mortalities after a lag time of 3 days. Specifically, blood circulation-related mortalities, such as cerebral infraction, were predominant causes. Overall, a critical mortality threshold was reached when the heat index exceeded approximately 37 degrees C, which corresponds to human body temperature. A linear regression model based on the heat indices above 37 degrees C, with a 3 day lag time, accounted for 63% of the abnormally increased mortality (> or =+2 standard deviations). CONCLUSIONS: This study revealed that elderly persons, those over 65 years old, are more vulnerable to mortality due to abnormal heat waves in Seoul, Korea. When the daily maximum heat index exceeds approximately 37 degrees C, blood circulation-related mortality significantly increases. A linear regression model, with respect to lag-time, showed that the heat index based on a human model is a more dependable indicator for the prediction of hot weather-related mortality than the ambient air temperature.

Adolescent↗
PubMed1990

[Perinatal mortality in San Luis Postosí, 1988].

Through participation of ten hospital institutions in the city of San Luis Potosí, which systematically take care of newborns, the present collaborative study was performed; this includes all births during the period from january 1st. to december 31st., 1988. The births taken place at home and other sites such as the "Hospital Materno Infantil" during the last six months, were excluded from the study; they accounted approximately 10%. We registered 17,092 births including 204 mortinates. Based on the upper data, the following chart is given, stating weight as well as gestation rates. Precocious fetal mortality (500 to 999 g)--391.30 by thousand; Precocious fetal mortality (20 to 27 weeks)--140.40 by thousand; Late fetal mortality (1,000 g or more)--9.25 by thousand; Late fetal mortality (28 weeks or more)--9.89 by thousand; Hebdomadal mortality (500 to 999 g)--571.40 by thousand; Hebdomadal mortality (20 to 27 weeks)--159.40 by thousand; Hebdomadal mortality (1,000 g or more)--11.96 by thousand; Hebdomadal mortality (28 weeks or more)--12.62 by thousand; Perinatal mortality (1,000 g or more)--21.10 by thousand; Perinatal mortality (28 weeks or more)--22.38 by thousand. The IMSS sent for registration 8,710 births which accounted 51% of the total. Their data revealed the highest values in all rates. In precocious fetal mortality (products between 20 and 27 weeks), the rate value was 543.9 against 140.4 globally counted. Hebdomadal mortality for this 20 to 27 weeks group showed 730.8 against 159.4 globally reported. In 199 out the 204 mortinates, cause of death was registered; 49.7% of these causes was reported as placental circulation insufficiency and 17.1% as major congenital abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Cause of Death↗
PubMed1987

Trends in elderly mortality in the Nordic countries.

This study describes the development of elderly mortality in the Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden) during this century. Long-term trends in total mortality are examined on the basis of life table statistics. More recent trends (from the 1950s onwards) are described by means of annual mortality rates according to a rough classification of causes of death. The series of vital statistics have been utilized as the data source for the long-term trends, and the original data for annual trends have been obtained from the mortality data bank files of the WHO. Marked improvements were observed in survival at advanced ages in the Nordic countries. However, the development has not been stable as in recent decades the elderly mortality rate has fluctuated, roughly comparable to the fluctuations in mortality among the younger age groups. The fact that the rate of recent improvement has been greatest in Finland where there, traditionally, is a high mortality level, and low in Norway and Sweden, where mortality levels are low, is in accordance with the idea of approaching a certain biological lower limit to mortality. However, certain characteristics seem to suggest that further advances are possible. Marked improvements have taken place recently in Iceland even though its mortality level at the end of the 1960s was already low. In addition, a large proportion of the differences in mortality rates between the Nordic countries may be due to external factors related to living conditions or life-style. Recent trends in mortality from several causes of death may also be primarily linked to such factors. Further research focusing particularly on a more detailed classification of causes of death and sociodemographic differentials within the national elderly populations is suggested.

Aged↗
PubMedDate not supplied

[Perinatal mortality in the Hospital Juarez, S.S.A].

A retrospective analysis on perinatal mortality was carried out at "Hospital Juárez" in México City, between June 1975 and May 1976. The collected data shows a gross perinatal mortality rate of 89.7 per one thousand live borns with a late fetal mortality rate of 33.1 and early mortality rate of 56.6. A prospective study was planned in order to record the perinatal mortality rate between June the first 1976, to May 31, 1977 showing a perinatal mortality rate of 60.8, with a late fetal mortality rate of 25.4 and early neonatal mortality rate of 35.4. The significant decrease in the rate of perinatal mortality could be the result of an accurate perinatal clinical history, specifically designed for such purpose, allowing a better supervision of the pregnant mother, the fetus and the newborn, which permitted to disclose many diagnoses that otherwise would not be obtained and this also contributted to the establishment of better opportunities for treatment. Besides the establishment of routine practices in the handling of newborns, the better relationships between pediatrician and obstetrician and the redistribution of medical and nursing personnel in critical areas, allowed a better perinatal attention. The relationships between perinatal mortality with maternal age and number of pregnancies and the relationships between neonatal mortality with birth weight and gestational age are presented. The factors that have favored the high rates of perinatal mortality in this hospital are also reviewed and corrective measures are proposed.

Female↗
PubMed1994

[Cancer mortality analysis among aborigines in Taiwan].

Mortality among Aborigines tribes in Taiwan from malignant neoplasms in the 1971-80 and 1981-90 decades were analyzed. Sex and tribe specific standardized mortality ratios were calculated from death certificate data and compared with the number of expected deaths derived from the cancer mortality of the entire population of Taiwan. Mortality due to oral cancer was statistically significantly higher than expected among Paiwan men in the 1971-80 decade and among Paiwan women from 1971-80 and 1981-90; as was mortality from nasopharyngeal cancer among Bunun, Paiwan and Rukai men from 1981-90 and among Bunun and Paiwan women from 1971-80 and 1981-90; mortality due to stomach cancer among the Atayal, Bunun and Paiwan people from 1971-80 and 1981-90, among Rukai men from 1971-80 and among the Tsou and mixed group women from 1981-90; mortality from liver cancer among Atayal and Bunun men in 1971-80, among Bunun women from 1971-80 and 1981-90 and among Paiwan women in 1981-90; mortality due to nasal cavity, middle ear and paranasal sinuses cancer among Rukai men from 1981-90; and mortality due to bone cancer among Tsou men and Atayal women from 1981-90. Mortality due to colorectal cancer was statistically significantly lower than expected among mixed group men from 1971-80 and in Atayal women from 1981-90; as was mortality from lung cancer among Atayal men and Paiwan women from 1971-80 and among Paiwan and mixed group men in the 1981-90 decade. Overall, the standardized mortality ratio of all cancers in aborigines was a little higher than in the general population of Taiwan. However, differences for ratio or site existed in different tribes.

Female↗
PubMed1993

The changing in-hospital mortality of women undergoing percutaneous transluminal coronary angioplasty.

OBJECTIVE: To compare in-hospital mortality among women and men undergoing percutaneous transluminal coronary angioplasty (PTCA) and determine whether mortality differences have changed recently. DESIGN: A retrospective cohort study. SETTING: Tertiary referral institution. PATIENTS: Consecutive series of 3557 patients (27% women) who underwent 4071 PTCA procedures. Two cohorts were analyzed: patients treated between 1979 and 1987 (n = 1970) and those treated between 1988 and 1990 (n = 2101). MAIN OUTCOME MEASURES: In-hospital and periprocedural mortality. RESULTS: Women were older than men (P < .001) and more had class III or IV angina (P < .001), unstable angina (P < .001), angina at rest (P < .001), cardiac failure (P < .001), and diabetes mellitus, hypertension, and hypercholesterolemia (P < .001). The PTCA was successful in 85% of women and 86% of men with an in-hospital mortality rate of 4.2% and 2.7%, respectively (P = .005). No significant change in mortality occurred in men between the early (2.2%) and late (3.1%) eras in contrast to a significant increase among women, 2.9% to 5.4% (P = .04). Periprocedural mortalities for women and men between 1979 and 1987 were 1.0% and 1.2% (P = not significant) and between 1988 and 1990 were 2.9% and 1.4% (P = .02), respectively. The multivariate odds ratio of in-hospital mortality for women vs men was 1.51 (95% confidence interval, 1.00 to 2.29; P = .05), although six other baseline variables were more powerful predictors of in-hospital mortality. Accounting for body surface area resulted in no significant association between gender and in-hospital mortality. Periprocedural mortality was not independently associated with gender. CONCLUSIONS: In-hospital mortality among women has increased in recent years, but their higher mortality compared with men is related more to the severity of their underlying disease rather than gender alone.

Aged↗
PubMed1996

[Socioeconomic differences in mortality in 8 Spanish provinces].

BACKGROUND: The scarce fulfillment of the job in the Bulletin on Death (BD) has limited the study of the socioeconomic differences in mortality in Spain. Nonetheless, the authors have studied the socioeconomic differences in mortality by different causes of death, using the Spanish geographical areas in which the information regarding the occupation of the deceased persons in the BD is of good quality. METHODS: Males between 30-64 years of age who died in eight Spanish provinces from 1988-1990 were included in the study. Overall mortality was compared by the relative risk of mortality adjusted for age and by the main causes of death among the professionals and managers, manual workers and farmers. The relative risk was calculated with the use of log-lineal models (Poisson regression) taking the group of professionals and managers as the reference group. RESULTS: The global relative risk of mortality in the group of manual workers was 1.72 and was 1.56 in the farmers. The highest mortality by different causes of death was observed in the manual workers while intermediate mortality was found in the farmers. The exceptions to this general pattern were colon and rectum cancer and leukemias with a higher mortality being found in the group of professionals and managers, although the differences were not statistically significant. Cerebrovascular diseases, suicide and cancer of the nervous system showed the highest relative risk of mortality in the farmers. Both the manual workers and the farmers demonstrated the highest relative risks of mortality in the youngest age groups although this difference attenuated with age. CONCLUSIONS: Except for colon and rectal cancer and leukemias, manual workers and farmers present higher mortality than professionals and managers. Furthermore, these differences may be underestimated since only the active economic population was studied, thereby excluding the individuals pertaining to the population groups with higher mortality rates.

Adult↗
PubMed1996

Ozone exposure and daily mortality in Mexico City: a time-series analysis.

Daily death counts in Mexico City were examined in relation to ambient ozone levels during 1990-1992 for the purpose of investigating the acute, irreversible effects of air pollution, with emphasis on ozone exposure. Air pollution data were obtained from nine monitoring stations operated by the Departamento del Distrito Federal. Mortality data were provided by the Instituto Nacional de Estadística, Geografía, e Informática. Increases in numbers of deaths were positively associated with elevated air pollution levels on the same day and on the previous day. The magnitude of the increases was small but statistically significant, after Poisson regression models were used to adjust for temperature and long-term trends. In models using data for a single pollutant, the "crude" ratio for total mortality associated with an increase of 100 parts per billion (ppb)* in one-hour maximum ozone concentration was 1.029 (95% CI 1.015, 1.044). A moving average of ozone showed a stronger association (rate ratio [RR] = 1.048, 95% CI 1.025, 1.070), and excess mortality (an increase in the number of deaths, relative to the average on days with low pollution levels) was more evident for persons over 65 years of age. Separate analyses of the effect of elevated ozone for different areas of the city showed similar results, but they were not statistically significant. Other pollutants also were related to mortality. The RR was 1.075 (95% CI 0.984, 1.062) per 100-ppb increase for sulfur dioxide and 1.049 (95% CI 1.030, 1.067) per 100 micrograms/m3 increase in total suspended particulates (TSP) when these pollutants were considered in separate models. However, when all three pollutants were considered simultaneously, only TSP remained associated with mortality, indicating excess mortality of 5% per 100 micrograms/m3 increase [RR = 1.052, 95% CI 1.034, 1.072]. The excess mortality associated with TSP is consistent with that observed in other cities in America and Europe. This study provides some evidence that ozone is associated with all-cause mortality and with mortality among the elderly after controlling for long-term cycles. However, ozone levels exhibited little or no effect on mortality rates when other air pollutants were considered simultaneously. Particulate matter appeared to be an important pollutant; it independently predicted changes in mortality. Nevertheless, because of the complexity and variability of the mixtures to which people are exposed, it is difficult to attribute the observed effects to a single pollutant. The technical feasibility and scientific validity of isolating the effect of single pollutants in such complex mixtures requires further research and careful consideration. Given the large population living in and exposed to ambient air pollution in Mexico City and other metropolises throughout the world, these small but significant associations of mortality with air pollution indices are of public health concern.

Adolescent↗
PubMed1997

Human development index as a predictor of infant and maternal mortality rates.

OBJECTIVE: The United Nations Human Development Index (HDI) is a composite index of life expectancy, literacy, and per capita gross domestic product that measures the socioeconomic development of a country. We estimated infant and maternal mortality rates in the world and assessed how well the HDI and its individual components predicted infant and maternal mortality rates for individual countries. MATERIALS: Data on mortality rates and values for HDI components were obtained from the United Nations and the World Bank. RESULTS: For the 1987 to 1990 period, approximately 9 million infant deaths and 349,000 maternal deaths occurred in the world annually, yielding global infant and maternal mortality rates of 67 per 1000 and 250 per 100,000 live births, respectively. HDI is a powerful predictor of both infant and maternal mortality rates. It accounts for 85% to 92% of the variation in infant mortality rates, and 82% to 85% of the variation in maternal mortality rates among countries. Each component of HDI is also strongly correlated with both infant and maternal mortality rates (significance of all values for r, p < 0.001), and eliminating life expectancy from HDI does not decrease significantly the predictive power of HDI for infant or maternal mortality rates. CONCLUSION: HDI is not only a useful measure for socioeconomic development, but also a powerful predictor of infant and maternal mortality rates for individual countries.

Adolescent↗
PubMed1994

Sex differences of infant and child mortality in China.

The purpose of this paper was to study the sex differences in infant mortality and mortality before the age of 5 in China, and the differences between urban and rural areas on the one hand and urban areas of mainland China and Hong Kong on the other. Published data from the 1982 and 1990 national censuses, the mortality survey of 1976, and UN's publications were used to calculate sex differences and sex ratios of mortality. Infant mortality of both sexes decreased notably from the 1970's onwards, the sex ratios of mortality being 1.15 in 1973-75, 1.06 in 1981 and 0.86 in 1990. A remarkable decline of mortality before the age of 5 was also seen in both sexes, but the sex ratios of mortality were not greatly altered, remaining less than 1 from the 1970's on. In rural areas female infants and young children had a higher mortality compared with males than in urban areas. In Hong Kong, the sex differences of infant and early child mortality were much smaller than in urban areas of mainland China.

Child, Preschool↗
PubMed1998

Effective lipid modification by partial ileal bypass reduced long-term coronary heart disease mortality and morbidity: five-year posttrial follow-up report from the POSCH. Program on the Surgical Control of the Hyperlipidemias.

BACKGROUND: In 1990, when the Program on the Surgical Control of the Hyperlipidemias (POSCH) reported its in-trial results strongly supporting the conclusion that effective lipid modification reduces progression of atherosclerosis, the differences for the end points of overall mortality and mortality from atherosclerotic coronary heart disease (ACHD) did not reach statistical significance. METHODS: The Program on the Surgical Control of the Hyperlipidemias recruited men and women with a single documented myocardial infarction between the ages of 30 and 64 years who had a plasma cholesterol level higher than 5.69 mmol/L (220 mg/dL) or higher than 5.17 mmol/L (200 mg/dL) if the low-density lipoprotein cholesterol level was in excess of 3.62 mmol/L (140 mg/dL). Between 1975 and 1983, 838 patients were randomized: 417 to the diet control group and 421 to the diet plus partial ileal bypass intervention group. Mean patient follow-up for this 5-year posttrial report was 14.7 years (range, 12.2-20 years). RESULTS: At 5 years after the trial, statistical significance was obtained for differences in overall mortality (P = .049) and mortality from ACHD (P = .03). Other POSCH end points included overall mortality (left ventricular ejection fraction > or =50%) (P = .01), mortality from ACHD (left ventricular ejection fraction > or =50%) (P = .05), mortality from ACHD and confirmed nonfatal myocardial infarction (P<.001), confirmed nonfatal myocardial infarction (P<.001), mortality from ACHD, confirmed and suspected myocardial infarction and unstable angina (P<.001), incidence of coronary artery bypass grafting or percutaneous transluminal coronary angioplasty (P<.001), and onset of clinical peripheral vascular disease (P = .02). There were no statistically significant differences between groups for cerebrovascular events, mortality from non-ACHD, and cancer. All POSCH patients have been available for follow-up. CONCLUSION: At 5 years after the trial, all POSCH mortality and atherosclerosis end points, including overall mortality and mortality from ACHD, demonstrated statistically significant differences between the study groups.

Cholesterol, LDL↗
PubMed2002

Rates and predictors of mortality in an aging, rural, community-based cohort: the role of depression.

CONTEXT: Depression, functional disability, cognitive impairment, and self-rated health all predict mortality in the elderly population. There is no consensus on their relative contributions when examined together. OBJECTIVES: To measure rates and identify predictors of mortality in an aging community-based cohort. DESIGN: Ten-year prospective epidemiological study. Predictor variables examined in Cox proportional hazards models were self-rated health, ability to perform instrumental activities of daily living (IADLs), depressive symptoms, and cognitive functioning, controlling for age, sex, education, and number of prescription drugs. SETTING: A largely blue-collar rural community in southwestern Pennsylvania. PARTICIPANTS: A population-based cohort of 1064 adults, 67 years or older at the beginning of follow-up. MAIN OUTCOME MEASURES: Mortality at 3, 5, and 10 years (133, 218, and 482 deaths, respectively). RESULTS: Mortality rates were similar to those of the 1990 US population. Older age, male sex, IADL disability, and number of prescription drugs measured at baseline were significant predictors of mortality at all 3 follow-up end points. Depression at baseline predicted earlier (3- and 5-year) mortality but not later (10-year) mortality. The interaction between self-rated health and depression independently and strongly predicted mortality at all end points. Cognitive functioning predicted mortality only when IADL disability was excluded from the model. CONCLUSIONS: Age, sex, depression, and functional disability are strong and consistent independent predictors of mortality in older adults in the community, in addition to objective medical burden (prescription drugs). Depression alone predicts mortality in the shorter rather than longer term, but in combination with poor self-rating of health, it strongly predicts mortality at all end points.

Activities of Daily Living↗
PubMed2003

Impact of valve surgery on 6-month mortality in adults with complicated, left-sided native valve endocarditis: a propensity analysis.

CONTEXT: Complicated, left-sided native valve endocarditis causes significant morbidity and mortality in adults. The presumed benefits of valve surgery remain unproven due to lack of randomized controlled trials. OBJECTIVE: To determine whether valve surgery is associated with reduced mortality in adults with complicated, left-sided native valve endocarditis. DESIGN AND SETTING: Retrospective, observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances. PATIENTS: Of the 513 adults with complicated, left-sided native valve endocarditis, 230 (45%) underwent valve surgery and 283 (55%) received medical therapy alone. MAIN OUTCOME MEASURE: All-cause mortality at 6 months after baseline. RESULTS: In the 6-month period after baseline, 131 patients (26%) died. In unadjusted analyses, valve surgery was associated with reduced mortality (16% vs 33%; hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.29-0.63; P<.001). After adjustment for baseline variables associated with mortality (including hospital site, comorbidity, congestive heart failure, microbial etiology, immunocompromised state, abnormal mental status, and refractory infection), valve surgery remained associated with reduced mortality (adjusted HR, 0.35; 95% CI, 0.23-0.54; P<.02). In further analyses of 218 patients matched by propensity scores, valve surgery remained associated with reduced mortality (15% vs 28%; HR, 0.45; 95% CI, 0.23-0.86; P =.01). After additional adjustment for variables that contribute to heterogeneity and confounding within the propensity-matched group, surgical therapy remained significantly associated with a lower mortality (HR, 0.40; 95% CI, 0.18-0.91; P =.03). In this propensity-matched group, patients with moderate to severe congestive heart failure showed the greatest reduction in mortality with valve surgery (14% vs 51%; HR, 0.22; 95% CI, 0.09-0.53; P =.001). CONCLUSIONS: Valve surgery for patients with complicated, left-sided native valve endocarditis was independently associated with reduced 6-month mortality after adjustment for both baseline variables associated with the propensity to undergo valve surgery and baseline variables associated with mortality. The reduced mortality was particularly evident among patients with moderate to severe congestive heart failure.

Adult↗
PubMed2005

Primary care, social inequalities and all-cause, heart disease and cancer mortality in US counties: a comparison between urban and non-urban areas.

OBJECTIVE: The objective of this study was to test whether the association between primary care and income inequality on all-cause, heart disease and cancer mortality at county level differs in urban (Metropolitan Statistical Area-MSA) compared with non-urban (non-MSA) areas. STUDY DESIGN: The study consisted of a cross-sectional analysis of county-level data stratified by MSA and non-MSA areas in 1990. Dependent variables included age and sex-standardized (per 100,000) all-cause, heart disease and cancer mortality. Independent variables included primary care resources, income inequality, education levels, unemployment, racial/ethnic composition and income levels. METHODS: One-way analysis of variance and multivariate ordinary least squares regression were employed for each health outcome. RESULTS: Among non-MSA counties, those in the highest income inequality category experienced 11% higher all-cause mortality, 9% higher heart disease mortality, and 9% higher cancer mortality than counties in the lowest income inequality quartile, while controlling for other health determinants. Non-MSA counties with higher primary care experienced 2% lower all-cause mortality, 4% lower heart disease mortality, and 3% lower cancer mortality than non-MSA counties with lower primary care. MSA counties with median levels of income inequality experienced approximately 6% higher all-cause mortality, 7% higher heart disease mortality, and 7% higher cancer mortality than counties in the lowest income inequality quartile. MSA counties with low primary care (less than 75th percentile) had significantly lower levels of all-cause, heart disease and cancer mortality than those counties with high primary care. CONCLUSIONS: In non-MSA counties, increasing primary physician supply could be one way to address the health needs of rural populations. In MSA counties, the association between primary care and health outcomes appears to be more complex and is likely to require intervention that focuses on multiple fronts.

Analysis of Variance↗
PubMed2006

The sequence of vaccinations and increased female mortality after high-titre measles vaccine: trials from rural Sudan and Kinshasa.

OBJECTIVE: West African studies have hypothesized that increased female mortality after high-titre measles vaccine (HTMV) was due to subsequent diphtheria-tetanus-pertussis (DTP) and inactivated polio vaccine (IPV) vaccinations. We tested two deductions from this hypothesis in HTMV studies from rural Sudan and Kinshasa; first, there should be no excess female mortality for HTMV recipients when DTP was not given after HTMV and second, excess female mortality should only be found among those children who received DTP after HTMV. STUDIES: The Sudanese trial randomised 510 children to Edmonston-Zagreb (EZ) HTMV, Connaught HTMV or a control vaccine (meningococcal). Both the Connaught HTMV and the control group received standard measles vaccine at 9 months. In the Kinshasa study 1023 children received one dose of HTMV at 6 months or two doses at 312 and 912 months of age. FINDINGS: First, the Sudan trial is one of the few randomised studies of measles vaccine; the EZ HTMV group had lower mortality between 5 and 9 months of age than controls, the mortality ratio (MR) being 0.00 (p = 0.030). This effect was not due to prevention of measles infection. Second, both studies provided evidence that HTMV per se was associated with low mortality. In a combined analysis comparing both HTMV groups with controls, the HTMV groups had a MR of 0.09 (0.01-0.71) between 5 and 9 months of age. In Kinshasa, the HTMV recipients who did not receive simultaneous DTP had an annual mortality rate of only 1.0% between 6 months and 3 years of age. Third, the female-male MR was related to subsequent DTP vaccinations. In Kinshasa, the female-male MR was only 0.40 (0.13-1.27) among the HTMV recipients who did not receive further doses of DTP. In Sudan, the female-male mortality ratio in the EZ group was 3.89 (95% CI 1.02-14.83) and the female-male MR increased with number of doses of DTP likely to have been given during follow-up (trend, p = 0.043). Fourth, in Kinshasa, mortality was higher among children who had received HTMV and DTP simultaneously than among children who had received HTMV alone (MR = 5.38 (1.37-21.2)). CONCLUSIONS: Measles vaccine is associated with non-specific beneficial effects. When not given with DTP, HTMV per se was associated with low mortality. Increased female mortality was not found among children who did not receive DTP after HTMV. Hence, our deductions were supported and the sequence or combination of vaccinations may have an effect on sex-specific mortality patterns in low-income countries.

Age Factors↗