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Breast cancer mortality among immigrants in Australia and Canada.

BACKGROUND: By moving between geographic regions with differing levels of breast cancer risk, migrant populations of women provide a unique opportunity to examine the impact of exposure to new environments and lifestyles on breast cancer risk. Breast cancer incidence and mortality rates for the majority of migrant groups originating from countries with low breast cancer risk have been found to increase toward the rates observed in destination countries with populations at higher risk for this disease. Because very little information exists on migrants from high- to low-risk countries, it is not known whether rates for these groups decrease or whether migrant groups generally experience increases in breast cancer rates. PURPOSE: To address these questions, we determined the breast cancer mortality rates for women from both lower and higher risk countries who had immigrated to Australia and Canada and compared these rates with those exhibited by the population in the origin country and by the destination native-born population. METHODS: Individual mortality records covering the years 1984 through 1988 and 1986 census data for Australia and Canada were obtained. Direct age-standardized mortality rates and rate ratios (and their 95% confidence intervals) were calculated for immigrant groups in Australia and Canada. Age-standardized rate ratios by length of residence in Australia were calculated. Weighted regression analyses of observed and expected mortality changes were performed. RESULTS: In Australia, the mortality rates for 12 (75%) of 16 immigrant groups from lower risk countries and 10 (71.4%) of 14 groups from higher risk countries shifted toward the rate of native-born Australians. In Canada, the rates for 12 (60%) of 20 immigrant groups from lower risk countries and four (80%) of five groups from higher risk countries converged to the rate of native-born Canadians. Overall, the extent of convergence (shift of immigrant's mortality rate in origin country toward rate of native-born population) was 50% for immigrants in Australia and 38% for immigrants in Canada. Although there was not a consistent pattern of convergence with length of residence in Australia, after 30 or more years, the mortality rates of 15 (83.3%) of 18 immigrant groups had shifted toward the rate of the native-born Australians. Because of the small number of deaths in many of the immigrant groups studied, the observed differences in the breast cancer mortality age-standardized rates between the origin country and immigrant group, although often substantial, were seldom statistically significant. CONCLUSIONS: Breast cancer mortality rates among women in the majority of immigrant groups shifted from the rate observed in their country of origin toward the rate of the native-born population in the destination country. IMPLICATIONS: These findings indicate that environmental and lifestyle factors associated with the new place of residence influence the breast cancer rates of immigrants and also suggest that, since most migrants migrate as adults, the risk of breast cancer can be altered in later life.

Adult↗

Prognosis in proliferative lupus nephritis: the role of socio-economic status and race/ethnicity.

BACKGROUND: Studies of proliferative lupus nephritis (PLN) suggest that African-Americans have a poorer prognosis than Whites. However, no study has simultaneously examined socio-economic status. We studied rates of progression of PLN among a tri-ethnic population with respect to socio-economic status and race/ethnicity. METHODS: A retrospective cohort study was carried out using individual and census-based neighbourhood data. Consecutive patients in urban tertiary care centres with biopsy-proven PLN were studied. The main outcome was time to doubling of serum creatinine. RESULTS: Among 128 patients with PLN, the percentage of patients who did not double their serum creatinine at 5 years was 67.0% (+/-4.8%) and at 10 years was 58.9% (+/-5.7%). In bivariate analyses, residence in a poor neighbourhood was positively associated with progression (P = 0.03), as was African-American and Hispanic race/ethnicity (P = 0.01). Residence in a poor neighbourhood remained associated with progression of disease after adjustment for age, sex, creatinine, hypertension, cyclophosphamide treatment and race/ethnicity [relative risk (RR) 3.5, 95% confidence interval (CI) 1.2-11, P = 0.03]. After adjustment for poverty and insurance, the RR for African-American race/ethnicity was reduced from 3.5 to 2.7 and was not statistically associated with progression of disease in the full model (P = 0.10). A similar reduction in RR from 5.5 to 3.6 was seen for Hispanic race/ethnicity, but this retained statistical significance (P = 0.03). CONCLUSIONS: Poverty is an important risk factor for progression of PLN, independent of race/ethnicity. Hispanics have an elevated risk similar to or greater than African-Americans. Given these findings, some of the poorer prognosis of African-American patients with PLN may result from socio-economic rather than biological or genetic factors.

Adolescent↗

Black-white inequalities in mortality and life expectancy, 1933-1999: implications for healthy people 2010.

OBJECTIVES: Optimistic predictions for the Healthy People 2010 goals of eliminating racial/ethnic disparities in health have been made based on absolute improvements in life expectancy and mortality. This study sought to determine whether there is evidence of relative improvement (a more valid measure of inequality) in life expectancy and mortality, and whether such improvement, if demonstrated, predicts future success in eliminating disparities. METHODS: Historical data from the National Center for Health Statistics and the Census Bureau were used to predict future trends in relative mortality and life expectancy, employing an Autoregressive Integrated Moving Average (ARIMA) model. Excess mortality and time lags in mortality and life expectancy for blacks relative to whites were also estimated. RESULTS: Based on data for 1945 to 1999, forecasts for relative black:white age-adjusted, all-cause mortality and white:black life expectancy at birth showed trends toward increasing disparities. From 1979, when the Healthy People initiative began, to 1998, the black:white ratio of age-adjusted, gender-specific mortality increased for all but one of nine causes of death that accounted for 83.4% of all US mortality in 1998. From 1980 to 1998, average numbers of excess deaths per day among American blacks relative to whites increased by 20%. American blacks experienced 4.3 to 4.5 million premature deaths relative to whites in 1940-1999. CONCLUSIONS: The rationale that underlies the optimistic Healthy People 2010 forecasts, that future success can be built on a foundation of past success, is not supported when relative measures of inequality are used. There has been no sustained decrease in black-white inequalities in age-adjusted mortality or life expectancy at birth at the national level since 1945. Without fundamental changes, most probably related to the ways medical and public health practitioners are trained, evaluated, and compensated for prevention-related activities, as well as further research on translating the findings of prevention studies into clinical practice, it is likely that simply reducing disparities in access to care and/or medical treatment will be insufficient. Millions of premature deaths will continue to occur among African Americans.

Adolescent↗

Reversal in mortality trends: evidence from the Agincourt field site, South Africa, 1992-1995.

OBJECTIVE: To examine changes in mortality in rural South Africa over the period 1992-1995 by age, sex and cause of death. DESIGN: As with much of sub-Saharan Africa, South Africa lacks effective vital registration and information on mortality is lacking. The Agincourt demographic and health surveillance system was established to inform health policy and practice with regard to rural subdistrict populations. METHODS: Prospective community-based study involving annual update of a household census with enquiry into all birth, death and migration events. All reported deaths (n = 1001) are the subject of a verbal autopsy. RESULTS: An increasing trend in overall mortality relative to general population growth in the study area is apparent. There is evidence for a reversal in the previously declining trend in mortality among women 20-44 years. A comparison of 1992-1993 with 1994-1995 shows that most of the increase in mortality is concentrated in the younger adult (20-49 year) age group. AIDS and related diseases, particularly tuberculosis, appear primarily responsible. Injuries and violence (especially homicide) and circulatory disease are important, under-recognized causes of death, although their levels have remained constant over the period. CONCLUSIONS: Mortality from AIDS and related diseases appears responsible for the probable reversal in mortality emerging in South Africa's rural northeast. Findings carry implications for the emerging system of decentralized health care.

Acquired Immunodeficiency Syndrome↗

Hospital restructuring and the epidemiology of hospital utilization: recent experience in Ontario.

OBJECTIVES: The author highlights changes in hospital utilization that have occurred in association with restructuring of Ontario hospitals. The basic features of the epidemiology of hospital utilization described link the analysis of the organizational and structural components of hospitals with a more comprehensive evaluation of the impacts of their restructuring and have implications for international comparative studies. METHODS: Data from the Canadian Institute for Health Information and the Canadian census were analyzed to provide a population-based description of hospital utilization and care. These hospital data provided information on changes in the patterns of care that occurred during restructuring, based on hospital separations for the fiscal years 1991-1992 through 1995-1996. RESULTS: Analysis of hospital utilization patterns revealed a 30% decrease in the days of care provided per 1,000 population during the period, the result of declines in both the age-adjusted inpatient separation rates and average length of hospital stay. The shift of surgical treatment to outpatient settings contributed to the reduction in inpatient days of care. The decline in utilization was experienced unevenly across age groups, with the elderly experiencing less of the decline than did younger age groups. Individuals living in the poorest areas used more inpatient care than did those living in the richest areas, although the gap in utilization narrowed over the period. CONCLUSIONS: International comparisons of the epidemiology of hospital utilization and the impact of hospital restructuring will require the use of multiple data sources and the development of shared evaluative frameworks. Health data systems in Canada support the assessment of the broader impacts of hospital restructuring and offer a framework for developing research projects that can provide useful information on these important changes in health-care policy.

Adolescent↗

Projections of demand and capacity for colonoscopy related to increasing rates of colorectal cancer screening in the United States.

BACKGROUND: There is debate about the optimal colorectal cancer screening test, partly because of concerns about colonoscopy demand. AIM: To quantify the demand for colonoscopy with different screening tests, and to estimate the ability of the United States health care system to meet demand. METHODS: We used a previously published Markov model and the United States census data to estimate colonoscopy demand. We then used an endoscopic database to compare current rates of screening-related colonoscopy with those projected by the model, and to estimate the number of endoscopists needed to meet colonoscopy demand. RESULTS: Annual demand for colonoscopy ranges from 2.21 to 7.96 million. Based on current practice patterns, demand exceeds current supply regardless of screening strategy. We estimate that an increase of at least 1360 gastroenterologists would be necessary to meet demand for colonoscopic screening undergone once at age 65, while colonoscopy every 10 years could require 32 700 more gastroenterologists. A system using dedicated endoscopists could meet demand with fewer endoscopists. CONCLUSIONS: Colorectal cancer screening leads to demand for colonoscopy that outstrips supply. Systems to train dedicated screening endoscopists may be necessary in order to provide population-wide screening. The costs and feasibility of establishing this infrastructure should be studied further.

Aged↗

Differential fertility of adopted schizophrenics and their half-siblings.

The paper presents data on the differential fertility of schizophrenics and controls, and the fertility of their siblings. This study used several methodological procedures in the study of schizophrenia reproduction, which strengthens the validity of the findings. Firstly, both male and female rates were examined. Secondly, the method of selection of a control avoided the biases introduced by using census data or other non-matched controls. Third, a diagnostic criterion was used which minimizes the possibility of the inclusion of other psychiatric illnesses. The results obtained support prior reports of the lowered reproductive rates of schizophrenics. Further, the siblings of schizophrenics were found not to have a reproductive advantage when contrasted to control siblings. The failure to find a reproductive advantage conflicts with a hypothesis of a balanced polymorphism as the mechanism maintaining an apparent constant rate of schizophrenia.

Adult↗

Trends in BB/pellet gun injuries in children and teenagers in the United States, 1985-99.

OBJECTIVE: To characterize national trends in non-fatal BB/pellet gun related injury rates for persons aged 19 years or younger in relation to trends in non-fatal and fatal firearm related injury rates and discuss these trends in light of injury prevention and violence prevention efforts. SETTING: The National Electronic Injury Surveillance System (NEISS) includes approximately 100 hospitals with at least six beds that provide emergency services. These hospitals comprise a stratified probability sample of all US hospitals with emergency departments. The National Vital Statistics System (NVSS) is a complete census of all death certificates filed by states and is compiled annually. METHODS: National data on BB/pellet gun related injuries and injury rates were examined along with fatal and non-fatal firearm related injuries and injury rates. Non-fatal injury data for all BB/pellet gun related injury cases from 1985 through 1999, and firearm related injury cases from 1993 through 1999 were obtained from hospital emergency department records using the NEISS. Firearm related deaths from 1985 through 1999 were obtained from the NVSS. RESULTS: BB/pellet gun related injury rates increased from age 3 years to a peak at age 13 years and declined thereafter. In contrast, firearm related injury and death rates increased gradually until age 13 and then increased sharply until age 18 years. For persons aged 19 years and younger, BB/pellet gun related injury rates increased from the late 1980s until the early 1990s and then declined until 1999; these injury rates per 100 000 population were 24.0 in 1988, 32.8 in 1992, and 18.3 in 1999. This trend was similar to those for fatal and non-fatal firearm related injury rates per 100 000 which were 4.5 in 1985, 7.8 in 1993, and 4.3 in 1999 (fatal) and 38.6 in 1993 and 16.3 in 1999 (non-fatal). In 1999, an estimated 14 313 (95% confidence interval (CI) 12 025 to 16 601) cases with non-fatal BB/pellet gun injuries and an estimated 12 748 (95% CI 7881-17 615) cases with non-fatal firearm related injuries among persons aged 19 years and younger were treated in US hospital emergency departments. CONCLUSIONS: BB/pellet gun related and firearm related injury rates show similar declines since the early 1990s. These declines coincide with a growing number of prevention efforts aimed at reducing injuries to children from unsupervised access to guns and from youth violence. Evaluations at the state and local level are needed to determine true associations.

Accident Prevention↗

Increased risk of lung cancer among male professional drivers in urban but not rural areas of Sweden.

OBJECTIVES: To study the risk of lung cancer in different subgroups of professional drivers in urban and rural areas of Sweden. METHODS: Information on occupation and geographical region was obtained from the Swedish census of 1970 and data on the incidence of lung cancer between 1971 and 1984 from the National Swedish Cancer Registry. Professional drivers were separated into bus, taxi, and long and short distance lorry drivers. Comparisons of cumulative incidence of lung cancer were made between each particular group of drivers and gainfully employed men in the same region. RESULTS: Taxi drivers, and long and short distance lorry drivers in Stockholm County showed increased relative risks (RRs) of lung cancer with the highest risk among the short distance lorry drivers (RR 2.0, 95% confidence interval (95% CI) 1.5 to 2.6). These categories of drivers also showed increased risks in the other two large conurbations in Sweden. In the rest of the country (mainly rural areas) there were no increased RRs for any category of driver. The RR for bus drivers was not increased in any region. After adjustment for assumed differences in smoking habits the RRs remained significantly increased for lorry drivers in Stockholm but not for other groups of drivers in other areas. However, the RRs remained numerically higher in large conurbations than in rural regions for all groups of drivers. CONCLUSIONS: These findings suggest that some factors present in the urban environment play a substantial part in the excess of lung cancer among short distance lorry drivers in urban areas of Sweden. Exposure to motor exhaust fumes may have contributed to this excess.

Adult↗

Initial emergency department blood pressure as predictor of survival after acute ischemic stroke.

OBJECTIVE: To evaluate the association of diastolic blood pressure (dBP), systolic blood pressure (sBP), and mean arterial pressure (MAP) in the emergency department (ED) with mortality within 90 days in patients with acute ischemic stroke (AIS). METHODS: This observational study was conducted at an ED with an annual census of 70,000 visits, with approximately 500 for AIS. The cohort consisted of 357 patients who presented to the ED within 24 hours of stroke symptom onset. sBP and dBP were measured at triage by a nurse blinded to the study. The duration of follow-up was limited to the first 90 days following ED presentation. BP levels were categorized as low, normotensive, and high after examining scatter plots of a patient's risk of death adjusted for duration of follow-up vs dBP, sBP, and MAP. These BP categories were evaluated using indicator variables in Cox proportional hazards models, after adjusting for age, sex, and the National Institute of Health Stroke Scale (NIHSS) score. RESULTS: Patients with low BP (dBP <70, sBP <155, or MAP <100 mm Hg) were significantly more likely to die within 90 days than those with BP in the normotensive range (dBP 70 to 105, sBP 155 to 220, MAP 100 to 140 mm Hg). These associations were significant even after adjusting for age, gender, and NIHSS score. CONCLUSIONS: There appears to be an optimal acute BP range below which early mortality is greater following AIS, suggesting avoidance of hypotension in the first 24 hours.

Acute Disease↗

Increasing longevity and Medicare expenditures.

Official Medicare projections forecast that the elderly population will be less healthy and more costly over the next century. This prediction stems from the use of age as an indicator of health status: increases in longevity are assumed to increase demand for health care as individuals survive to older and higher-use ages. In this paper I suggest an alternative approach, in which time until death replaces age as the demographic indicator of health status. Increases in longevity are assumed to postpone the higher Medicare use and costs associated with the final decade of life. I contrast the two approaches, using mortality forecasts consistent with recent projections from the U.S. Census Bureau and the Social Security Administration. The time-until-death method yields significantly lower-cost forecasts. The hypothetical cost savings from improved health care small, however, relative to the size of the Medicare solvency problem caused by population aging.

Accounting↗

A regression approach to estimating the average number of persons per household.

In the housing unit method, population is calculated as the number of households times the average number of persons per household (PPH), plus the population residing in group quarters facilities. Estimates of households and the group quarters population can be derived directly from concurrent data series, but estimates of PPH have traditionally been based on previous values or estimates for larger areas. In our study, we developed several regression models in which PPH estimates were based on symptomatic indicators of PPH change. We tested these estimates using county-level data in four states and found them to be more precise and less biased than estimates based on more commonly used methods.

Censuses↗

[Mortality among Japanese migrants residing in the municipality of São Paulo, Brazil, 1990].

The mortality patterns of Japanese migrants (issei) and their descendants (nissei/sansei) resident in the City of S. Paulo, Brazil, are compared with those of their native country (Japan) and their place of adoption (S. Paulo), in 1980. The mortality data were obtained from death certificates for the issei and nissei/sansei populations and from official tabulations for deaths in Japan and S. Paulo. The population estimates were based upon the S. Paulo and Japanese censuses. The age-standardized populations were calculated according to the Jowett method. The five leading causes of death were basically the same for these populations under study. S. Paulo residents had the highest age-standardized mortality rates, except as regards deaths due to neoplasms, higher in Japan. The issei population (both sexes) presented intermediate values for deaths due to endocrine, nutritional, and metabolic diseases and diseases of the respiratory system; the female migrants also showed an intermediate rate for deaths due to diseases of the circulatory system. For the other causes, the lowest risk of dying was that registered for the issei population. The comparisons of the rates for cancers of stomach, breast, prostate, diabetes mellitus, ischaemic heart diseases, cerebrovascular diseases, homicide and suicide resulted in the detection of a possible transition experienced by the issei population, leading to the belief that the issei pattern of mortality is showing a deviation from the Japanese pattern and resembles that of S. Paulo. Since social and cultural changes are thought to be occurring among the migrants, one might argue that the role of environmental factors (including diet) is more important than the role of genetic factors in the incidence of and mortality due to these diseases.

Adolescent↗

State smoking prevalence estimates: a comparison of the Behavioral Risk Factor Surveillance System and current population surveys.

OBJECTIVES: This study examined whether there are systematic differences between the Behavioral Risk Factor Surveillance System (BRFSS) and the Current Population Survey (CPS) for state cigarette smoking prevalence estimates. METHODS: BRFSS telephone survey estimates were compared with estimates from the US Census CPS tobacco-use supplements (the CPS sample frame includes persons in households without telephones). Weighted overall and sex- and race-specific BRFSS and CPS state estimates of adults smoking were analyzed for 1985, 1989, and 1992/1993. RESULTS: Overall estimates of smoking prevalence from the BRFSS were slightly lower than estimates from CPS (median difference: -2.0 percentage points in 1985, -0.7 in 1989, and -1.9 in 1992/1993; P < .05 for all comparisons), but there was variation among states. Differences between BRFSS and CPS estimates were larger among men than among women and larger among Blacks than among Hispanics or Whites; for most states, these differences were not significant. CONCLUSIONS: The BRFSS generally provides state estimates of smoking prevalence similar to those obtained from CPS, and these are appropriate for ongoing state surveillance of smoking prevalence.

Adult↗

Geographic analysis of pertussis infection in an urban area: a tool for health services planning.

OBJECTIVE: This study examined whether incident cases of pertussis cluster in urban census tracts and identified community characteristics that predict high-incidence areas. METHODS: An ecological study design was used. The study population included all persons diagnosed with pertussis from January 1, 1986, through December 31, 1994. Maps of rates were constructed via a geographic information system and clustering was statistically confirmed. Associations between pertussis rates and community characteristics were tested. RESULTS: Mapping and statistical analysis revealed spatial clustering of pertussis. Higher age-adjusted rates of pertussis infection were associated with higher proportions of residents below poverty level. CONCLUSIONS: In urban areas pertussis infection clusters in areas of poverty.

Age Distribution↗

Fertility estimates of Bangladesh using 1974 and 1981 census data.

"This paper provides some estimates of fertility level for different periods from 1974 and 1981 census data [for Bangladesh]. The fertility levels were estimated using some indirect methods of estimation. The birth rate during the 70's decade was observed to fall in the range of 45-48 per thousand.... During the last intercensal period no significant change was observed between the measures of fertility."

Asia↗

The demographic characteristics of New Zealand medical students: the New Zealand Wellbeing, Intentions, Debt and Experiences (WIDE) Survey of Medical Students 2001 study.

AIMS: To develop and administer the first nationwide survey of all medical students in New Zealand. This paper reports the demographic characteristics of medical students and compares them with the general population. METHODS: A questionnaire was developed, with questions modelled on the New Zealand Census, and administered to all New Zealand medical students. Data were then compared with the New Zealand Census. RESULTS: The response rate was 83%. Female students made up 55.9% of the class. The ethnic composition of the class, Maori (6.8%), Pacific Islander (4.3%), NZ European (50.9%), Asian (31.4%), differed significantly from the general New Zealand population. Maori and Pacific Island students, and students from a rural background were significantly under-represented. Permanent residents represented 11.1% of the student population. Three quarters of medical students reported that at least one of their parents had a tertiary qualification. CONCLUSIONS: Medical students are more likely to be socioeconomically advantaged and from an urban community, and less likely to be of Maori or Pacific Island descent, than the general population. In the context of a shortage of practitioners in rural, lower socioeconomic and Maori or Pacific Island areas, these differences are worrying. The number of permanent residents and female students may have implications for the New Zealand medical workforce.

Asian People↗

[Education level and origin as predictors of hospitalization among Jewish adults in Israel: a population-based study].

BACKGROUND: Age, sex, origin and level of education are recognized as predictors of healthcare utilization. However, the joint effects of these variables on the risk of hospitalization have yet to be described for specific diagnostic categories, such as diseases of the circulatory, respiratory, genitourinary, digestive and nervous systems, infectious and parasitic diseases, malignant neoplasms, injury and poisoning. OBJECTIVES: To evaluate the association between origin, education, sex, age and the risk of hospitalization due to major diagnostic categories. METHODS: Cross-sectional study linking population-based databases, including Israeli census and hospitalization records. RESULTS: The study encompassed 35,413 hospitalized subjects and 386,317 non-hospitalized subjects. Origin other than Israel was a risk factor for hospitalization, with an odds ratio of 1.31 (95% CI 1.25-1.36) for Asia, 1.43 (1.37-1.50) for Africa, and 1.24 (1.20-1.29) for Europe-America (P for all origins <0.0001). Compared to subjects with post-high school educations, those with high school educations were 1.18 times more likely to be hospitalized (1.14-1.21), while those with elementary school educations experienced a risk of 1.32 (1.28-1.37) (P < 0.0001). Origin was a marked risk factor for hospitalization due to malignancy, with an odds ratio of 2.19 (1.71-2.79) for European-American origin relative to Israeli origin (P < 0.0001). The inverse association between education level and risk of hospitalization was constant across all diagnostic categories other than malignancy. CONCLUSIONS: Lower education was found to be a significant risk factor for hospitalization in most diagnostic categories. Origin was associated with increased risk for hospitalization due to malignant neoplasms and diseases of the respiratory, nervous, genitourinary and circulatory systems.

Americas↗