Death on the waiting list for cardiac surgery in The Netherlands in 1994 and 1995.
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OBJECTIVE: To describe the causes and circumstances of death regarding patients who died in 1994 and 1995 while on a waiting list for cardiac surgery in the Netherlands. DESIGN: Retrospective multicentre case study. SETTING: 11 Dutch cardiac surgery centres. PATIENTS: All patients reported as dying while on the waiting list for cardiac surgery in 1994 and 1995. MAIN OUTCOME MEASURES: Classification of death by an independent adjudication committee into "erroneously reported", "waiting list related" or "not waiting list related". Death was judged as "waiting list related" if the clinical course would have been substantially different if there had been unrestricted surgical capacity. RESULTS: 138 and 129 deaths were reported in 1994 and 1995, respectively. 43 deaths (16%) were considered as erroneously reported. 181 of the remaining 224 cases were adjudicated as waiting list related. Median time from acceptance for surgery to death was 35 days (interquartile range 14-75 days). 97 of 181 deaths occurred within six weeks following addition to the waiting list. The estimated incidence of death ranged from 1.33 per 1000 patient-weeks during weeks 2-4 to 0.68 per 1000 patient-weeks after 12 weeks. CONCLUSIONS: The causes and circumstances of death are waiting list related for approximately 100 patients per year in the Netherlands. At least half of the deaths may occur within the first six weeks. Waiting lists for cardiac surgery engender high risks for the patients involved. (+info)
Mortality in a cohort of licensed pesticide applicators in Florida.
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OBJECTIVES: Although the primary hazard to humans associated with pesticide exposure is acute poisoning, there has been considerable concern surrounding the possibility of cancer and other chronic health effects in humans. Given the huge volume of pesticides now used throughout the world, as well as environmental and food residue contamination leading to chronic low level exposure, the study of possible chronic human health effects is important. METHODS: This was a retrospective cohort study, analysed by general standardised mortality ratio (SMR) of licensed pesticide applicators in Florida compared with the general population of Florida. A cohort of 33,658 (10% female) licensed pesticide applicators assembled through extensive data linkages yielded 1874 deaths with 320,250 person-years from 1 January 1975 to 31 December 1993. RESULTS: The pesticide applicators were consistently and significantly healthier than the general population of Florida. As with many occupational cohorts, the risks of cardiovascular disease and of diseases associated with alcohol and tobacco use were significantly lower, even in the subpopulations--for example, men, women, and licence subcategories. Among male applicators, prostate cancer mortality (SMR 2.38 (95% confidence interval (95% CI) 1.83 to 3.04) was significantly increased. No cases of soft tissue sarcoma were confirmed in this cohort, and non-Hodgkin's lymphoma was not increased. The number of female applicators was small, as were the numbers of deaths. Mortality from cervical cancer and breast cancer was not increased. Additional subcohort and exposure analyses were performed. CONCLUSIONS: Consistent with previous publications on farmers but at odds with current theories about the protective effects of vitamin D, prostate cancer was increased in these pesticide applicators. Female breast cancer was not increased despite theories linking risk of breast cancer with exposure to oestrogen disruptors--such as the organochlorines. The lack of cases of soft tissue sarcoma is at odds with previous publications associating the use of the phenoxy herbicides with an increased risk of these cancers. (+info)
Mortality among residents near cokeworks in Great Britain.
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OBJECTIVES: To investigate whether residents near cokeworks have a higher standardised mortality than those further away, particularly from cardiovascular and respiratory causes, which may be associated with pollution from cokeworks. METHOD: Cross sectional small area study with routinely collected postcoded mortality data and small area census statistics. Populations within 7.5 km of 22 cokeworks in Great Britain, 1981-92. Expected numbers of deaths within 2 and 7.5 km of cokeworks, and in eight distance bands up to 7.5 km of cokeworks, were calculated by indirect standardisation from national rates stratified for age and sex and a small area deprivation index, and adjusted for region. Age groups examined were all ages, 1-14, 15-64, 65-74, > or = 75. Only the 1-14 and 15-44 age groups were examined for asthma mortality. RESULTS: There was a 3% (95% confidence interval (95% CI) 1% to 4%) excess of all deaths within 2 km of cokeworks, and a significant decline in mortality with distance from cokeworks. The excess of deaths within 2 km was slightly higher for females and elderly people, but excesses within 2 km and declines in risk with distance were significant for all adult age groups and both sexes. The size of the excess within 2 km was 5% (95% CI 3% to 7%) for cardiovascular causes, 6% (95% CI 3% to 9%) for ischaemic heart disease, and 2% (95% CI -2% to 6%) for respiratory deaths, with significant declines in risk with distance for all these causes. There was a non-significant 15% (95% CI -1% to 101%) excess in asthma mortality in the 15-44 age group. There were no significant excesses in mortality among children but 95% CIs were wide. Within 2 km of cokeworks, the estimated additional excess all cause mortality for all ages combined related to region and mainly to the greater deprivation of the population over national levels was 12%. CONCLUSIONS: A small excess mortality near cokeworks as found in this study is plausible in the light of current evidence about the health impact of air pollution. However, in this study the effects of pollution from cokeworks, if any, are outweighed by the effects of deprivation on weighed by the effects of deprivation on mortality near cokeworks. It is not possible to confidently exclude socioeconomic confounding or biases resulting from inexact population estimation as explanations for the excess found. (+info)
Variations in 'avoidable' mortality: a reflection of variations in incidence?
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BACKGROUND: Variations in 'avoidable' mortality may reflect variations in the quality of care, but they may also be due to variations in incidence or severity of diseases. We studied the association between regional variations in 'avoidable' mortality and variations in disease incidence. For a selection of conditions we also analysed whether the proportion of in-hospital deaths can explain the regional variations in incidence-adjusted mortality. METHODS: Relative risks for mortality, incidence, incidence-adjusted mortality and in-hospital mortality (1984-1994) were calculated by log-linear regression. Linear regression was used to examine the relationship between mortality and incidence on the one hand, and between incidence-adjusted mortality and in-hospital mortality on the other. RESULTS: Significant regional mortality variations were found for cervical cancer, cancer of the testis, hypertensive and cerebrovascular disease, influenza/pneumonia, cholecystitis/lithiasis, perinatal causes and congenital cardiovascular anomalies. Regional mortality differences in general were only partly accounted for by incidence variations. The only exception was cervical cancer, which no longer showed significant variations after adjustment for incidence. The contribution of inhospital mortality variations to total cause-specific mortality variations varied between conditions: the highest percentage of explained variance was found for mortality from CVA (60.1%) and appendicitis (29.2%). CONCLUSIONS: Incidence data are a worthy addition to studies on 'avoidable' mortality. It is to be expected that the incidence-adjusted mortality rates are more sensitive for quality-of-care variations than the 'crude' mortality variations. Nevertheless, further research at the individual level is needed to identify possible deficiencies in health care delivery. (+info)
A Markov chain model to assess the efficacy of screening for non-insulin dependent diabetes mellitus (NIDDM).
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BACKGROUND: The high prevalence and severe consequences of non-insulin dependent diabetes mellitus (NIDDM) in Taiwan calls for urgent measures to detect this disease in the asymptomatic phase. However, the efficacy of early detection of NIDDM is highly dependent on its natural history from the disease-free state, through the asymptomatic to the symptomatic phase and death from NIDDM or other causes. METHODS: In order to project the above progression, a five-state illness-and-death Markov chain model was proposed to estimate these transition parameters using data from two rounds of a blood sugar screening programme for NIDDM in Puli, in central Taiwan. RESULTS: Results showed that the annual incidence for asymptomatic NIDDM was 10.67 per 1000 (95% CI: 8.26-13.79) and the average duration between the asymptomatic and symptomatic phases (the sojourn time) was 8 years (95%CI: 5.74-11.29). The 10-year survival rate for asymptomatic NIDDM (79.35%) was better than that for symptomatic NIDDM (69.45%). Prediction of deaths from NIDDM was performed to assess how the efficacy of screening for NIDDM varied by different screening frequencies (annual, biennial, 4-yearly and the control group). Results indicated there is no substantial difference in mortality reduction from NIDDM among the annual, biennial and 4-yearly screening regimens. However, a 4-yearly screening regimen significantly reduced deaths from NIDDM by 40% (95% CI: 26-51%). CONCLUSIONS: A long sojourn time and the substantial reduction in mortality suggest that a 4-yearly screening regime for NIDDM would be most effective and feasible in Taiwan. The proposed five-state Markov chain model can be applied to other similar NIDDM screening projects. (+info)
Variations in infant mortality rates among municipalities in the state of Ceara, Northeast Brazil: an ecological analysis.
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BACKGROUND: Infant mortality rates vary substantially among municipalities in the State of Ceara, from 14 to 193 per 1000 live births. Identification of the determinants of these differences can be of particular importance to infant health policy and programmes in Brazil where local governments play a pivotal role in providing primary health care. METHODS: Ecological study across 140 municipalities in the State of Ceara, Brazil. RESULTS: To determine the interrelationships between potential predictors of infant mortality, we classified 11 variables into proximate determinants (adequate weight gain and exclusively breastfeeding), health services variables (prenatal care up-to-date, participation in growth monitoring, immunization up-to-date, and decentralization of health services), and socioeconomic factors (female literacy rate, household income, adequate water supply, adequate sanitation, and per capita gross municipality product), and included the variables in each group simultaneously in linear regression models. In these analyses, only one of the proximate determinants (exclusively breastfeeding (inversely), R2 = 9.3) and one of the health services variables (prenatal care up-to-date (inversely), R2 = 22.8) remained significantly associated with infant mortality. In contrast, female literacy rate (inversely), household income (directly) and per capita GMP (inversely) were independently associated with the infant mortality rate (for the model including the three variables R2 = 25.2). Finally, we considered simultaneously the variables from each group, and selected a model that explained 41% of the variation in infant mortality rates between municipalities. The paradoxical direct association between household income and infant mortality was present only in models including female illiteracy rate, and suggests that among these municipalities, increases in income unaccompanied by improvements in female education may not substantially reduce infant mortality. The lack of independent associations between inadequate sanitation and infant mortality rates may be due to the uniformly poor level of this indicator across municipalities and provides no evidence against its critical role in child survival. CONCLUSIONS: These results suggest that promotion of exclusive breastfeeding and increased prenatal care utilization, as well as investments in female education would have substantial positive effects in further reducing infant mortality rates in the State of Ceara. (+info)
Epidemiology of child deaths due to drowning in Matlab, Bangladesh.
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BACKGROUND: Although the recent decline in child mortality in Bangladesh is remarkable, death from causes other than infectious diseases and malnutrition remains an important component of child mortality. Death from drowning of children can be expected to be a problem in Bangladesh given the geographical features of the country. OBJECTIVE: The objectives of this study are to determine the trend, pattern, and correlates of drowning deaths. METHODS: Data are presented on deaths of children (1-4 years) due to drowning derived from a longitudinal, population-based surveillance system in operation in a rural area of Bangladesh in 1983-1995. Moreover, a case-control study was carried out to identify the risk factors associated with drowning. RESULTS: Deaths due to drowning ranged from about 10% to 25% of child deaths during 1983-1995. The absolute risk of dying from drowning remained almost the same over the study period but the proportion of drownings to all causes of death has increased. Drowning is especially prevalent in the second year of life. Age of the mother and parity have a significant impact on drowning. The risk of dying from drowning increases with the age of mother and much more sharply with the number of living children in the family. Two socioeconomic variables did not have an influence on the risk of drowning. CONCLUSIONS: A substantial proportion of child deaths could be averted if parents and other close relatives paid more attention to the safety of children. The Child Health Programme of the Ministry of Health and Family Welfare of Bangladesh should develop health education programmes for villagers alerting them to the dangers of drowning and measures to prevent it. (+info)
Mortality in rheumatoid arthritis patients with disease onset in the 1980s.
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OBJECTIVE: Several previous studies have shown increased mortality in rheumatoid arthritis (RA) patients. This study investigated if this was true also for patients with disease onset in the 1980s. PATIENTS AND METHODS: The study group comprised 183 patients (67 men and 116 women) with definite RA participating in an ongoing prospective study. Mean age at onset of disease was 51 years, and mean duration of joint symptoms at inclusion was 11 months. The patients were included between 1985-89. Seventy five per cent of the patients were rheumatoid factor (RF) positive, 85% carried the shared epitope, and 90% became erosive. By 1 September 1997 the number and causes of death, obtained from the death certificates, were recorded. Standardised mortality ratio (SMR) was calculated, comparing the observed number of deaths in the cohort with the expected number of deaths in the general population in the same area, age and sex matched. The predictive values of demographics, genotype, RF status, and clinical data at baseline were estimated using the Cox proportional hazards regression model. RESULTS: Eighteen patients (11 men and 7 women) had died compared with 20 expected deaths. SMR with 95% confidence intervals was 87 (53, 136). There was no significant increase in the number of deaths at any time during follow up for either sex. RA was not the main cause of death in any of the cases. By reading the patient charts two cases were found where RA or its treatment could have contributed to death. No RA related variable contributed significantly to an increased risk of death. CONCLUSION: There was no increased mortality during the first 8-13 years of disease in this group of patients who developed RA in the 1980s. (+info)