Mortality associated with systemic lupus erythematosus in France assessed by multiple-cause-of-death analysis.

OBJECTIVE: To assess the mortality profile of systemic lupus erythematosus (SLE) patients in France using multiple-cause-of-death analysis. METHODS: Data were collected between 2000 and 2009 in the French Epidemiological Center for the Medical Causes of Death database, and death certificates issued upon the death of an adult for whom SLE was an underlying cause of death (UCD) or a non-underlying cause of death (NUCD) were evaluated using multiple-cause-of-death analysis. Sex, age, sex ratio, standardized mortality rates, as well as frequency of the various causes of death were assessed, at both a national and a regional level. For the main causes of death, the observed number of deaths in relation to the expected number of deaths (O:E ratio) (standardized for age and sex) was calculated. RESULTS: During the study period, 1,593 deaths related to SLE were identified. The mean ± SD age at death was 63.5 ± 18.4 years and the sex ratio (female:male) was 3.5. The mean standardized mortality rate was 3.2 per 1 million people (range 2.7-4.1). When SLE was the UCD (n = 637), the main NUCDs were cardiovascular diseases (49.5%), infectious diseases (24.5%), and renal failure (23.2%). When SLE was an NUCD (n = 956), the most common UCDs were cardiovascular diseases (35.7%), neoplasms (13.9%), and infectious diseases (10.3%). The overall O:E ratio was >1 for infectious and cardiovascular diseases and renal failure (especially among people <40 years of age for the latter 2 causes), but was <1 for neoplasms. CONCLUSION: Cardiovascular disease is the leading cause of death associated with SLE in France.

Automated comparison of last hospital main diagnosis and underlying cause of death ICD10 codes, France, 2008-2009.

BACKGROUND: In the age of big data in healthcare, automated comparison of medical diagnoses in large scale databases is a key issue. Our objectives were: 1) to formally define and identify cases of independence between last hospitalization main diagnosis (MD) and death registry underlying cause of death (UCD) for deceased subjects hospitalized in their last year of life; 2) to study their distribution according to socio-demographic and medico-administrative variables; 3) to discuss the interest of this method in the specific context of hospital quality of care assessment. METHODS: 1) Elaboration of an algorithm comparing MD and UCD, relying on Iris, a coding system based on international standards. 2) Application to 421,460 beneficiaries of the general health insurance regime (which covers 70% of French population) hospitalized and deceased in 2008-2009. RESULTS: 1) Independence, was defined as MD and UCD belonging to different trains of events leading to death 2) Among the deaths analyzed automatically (91.7%), 8.5% of in-hospital deaths and 19.5% of out-of-hospital deaths were classified as independent. Independence was more frequent in elder patients, as well as when the discharge-death time interval grew (14.3% when death occurred within 30 days after discharge and 27.7% within 6 to 12 months) and for UCDs other than neoplasms. CONCLUSION: Our algorithm can identify cases where death can be considered independent from the pathology treated in hospital. Excluding these deaths from the ones allocated to the hospitalization process could contribute to improve post-hospital mortality indicators. More generally, this method has the potential of being developed and used for other diagnoses comparisons across time periods or databases.

Innovations in health care and mortality trends from five cancers in seven European countries between 1970 and 2005.

OBJECTIVES: Although the contribution of health care to survival from cancer has been studied extensively, much less is known about its contribution to population health. We examine how medical innovations have influenced trends in cause-specific mortality at the national level. METHODS: Based on literature reviews, we selected six innovations with proven effectiveness against cervical cancer, Hodgkin's disease, breast cancer, testicular cancer, and leukaemia. With data on the timing of innovations and cause-specific mortality (1970-2005) from seven European countries we identified associations between innovations and favourable changes in mortality. RESULTS: For none of the five specific cancers, sufficient evidence for an association between introduction of innovations and a positive change in mortality could be found. The highest association was found between the introduction of Tamoxifen and breast cancer mortality. CONCLUSIONS: The lack of evidence of health care effectiveness may be due to gradual improvements in treatment, to effects limited to certain age groups or cancer subtypes, and to contemporaneous changes in cancer incidence. Research on the impact of health care innovations on population health is limited by unreliable data on their introduction.

Diverging trends in educational inequalities in cancer mortality between men and women in the 2000s in France.

BACKGROUND: Socioeconomic inequalities in cancer mortality have been observed in different European countries and the US until the end of the 1990s, with changes over time in the magnitude of these inequalities and contrasted situations between countries. The aim of this study is to estimate relative and absolute educational differences in cancer mortality in France between 1999 and 2007, and to compare these inequalities with those reported during the 1990s. METHODS: Data from a representative sample including 1% of the French population were analysed. Educational differences among people aged 30-74 were quantified with hazard ratios and relative indices of inequality (RII) computed using Cox regression models as well as mortality rate difference and population attributable fraction. RESULTS: In the period 1999-2007, large relative inequalities were found among men for total cancer and smoking and/or alcohol related cancers mortality (lung, head and neck, oesophagus). Among women, educational differences were reported for total cancer, head and neck and uterus cancer mortality. No association was found between education and breast cancer mortality. Slight educational differences in colorectal cancer mortality were observed in men and women. For most frequent cancers, no change was observed in the magnitude of relative inequalities in mortality between the 1990s and the 2000s, although the RII for lung cancer increased both in men and women. Among women, a large increase in absolute inequalities in mortality was observed for all cancers combined, lung, head and neck and colorectal cancer. In contrast, among men, absolute inequalities in mortality decreased for all smoking and/or alcohol related cancers. CONCLUSION: Although social inequalities in cancer mortality are still high among men, an encouraging trend is observed. Among women though, the situation regarding social inequalities is less favourable, mainly due to a health improvement limited to higher educated women. These inequalities may be expected to further increase in future years.

Mortality differences between the foreign-born and locally-born population in France (2004-2007).

In contrast to the situation in many European countries, the mortality of immigrants in France has been little studied. The main reasons for the lack of studies are based on ethical and ideological considerations. The objective of this study is to explore mortality by country of birth in Metropolitan (i.e. 'mainland') France. Complete mortality data were used to study the relative risks of mortality of the foreign- and locally-born populations by gender, age and cause of death for the period 2004-2007 in Metropolitan France. Analyses were conducted by countries of birth grouped into geographic areas and by the Human Development Index (HDI). The differentials in mortality between foreign-born and locally-born populations were not homogeneous. The figures varied by age (higher foreign-born mortality for the young; lower mortality for migrants aged 15-64 years), gender (female migrants more frequently had higher relative mortality than men migrants), country of birth (Eastern European-born migrants had higher mortality, while those born in Morocco, Central Asia, 'other Asian countries' and America had lower mortality) and cause of death (migrant mortality was higher overall for deaths caused by infectious diseases and diabetes, and lower for violent death and neoplasm). Moreover, mortality relative risks for male, violent deaths and cancer were positively associated with country-of-birth HDI, while female mortality and infectious disease mortality were negatively associated with country-of-birth HDI. Some important caveats have to be considered because the study did not control for individuals socioeconomic position in France, or length of residence in the host country. A strong healthy migrant effect was suggested and its intensity varies with age and gender (which may reflect different reasons for migration). For some specific causes of death, a lifestyle effect seems to explain mortality differentials. The associations between HDI and mortality show that mortality trends are partly related to the educational, sanitary and economic conditions of the country of birth. Further studies would enrich the differential analysis of mortality by country of birth by contributing additional detailed data on socioeconomic and living conditions in the host country as well as in the country of origin.

Long-term cardiovascular mortality after radiotherapy for breast cancer.

OBJECTIVES: This study sought to investigate long-term cardiovascular mortality and its relationship to the use of radiotherapy for breast cancer. BACKGROUND: Cardiovascular diseases are among the main long-term complications of radiotherapy, but knowledge is limited regarding long-term risks because published studies have, on average, <20 years of follow-up. METHODS: A total of 4,456 women who survived at least 5 years after treatment of a breast cancer at the Institut Gustave Roussy between 1954 and 1984 were followed up for mortality until the end of 2003, for over 28 years on average. RESULTS: A total of 421 deaths due to cardiovascular diseases were observed, of which 236 were due to cardiac disease. Women who had received radiotherapy had a 1.76-fold (95% confidence interval [CI]: 1.34 to 2.31) higher risk of dying of cardiac disease and a 1.33-fold (95% CI: 0.99 to 1.80) higher risk of dying of vascular disease than those who had not received radiotherapy. Among women who had received radiotherapy, those who had been treated for a left-sided breast cancer had a 1.56-fold (95% CI: 1.27 to 1.90) higher risk of dying of cardiac disease than those treated for a right-sided breast cancer. This relative risk increased with time since the breast cancer diagnosis (p = 0.05). CONCLUSIONS: This study confirmed that radiotherapy, as delivered until the mid-1980s, increased the long-term risk of dying of cardiovascular diseases. The long-term risk of dying of cardiac disease is a particular concern for women treated for a left-sided breast cancer with contemporary tangential breast or chest wall radiotherapy. This risk may increase with a longer follow-up, even after 20 years following radiotherapy.

Reliability of recording uterine cancer in death certification in France and age-specific proportions of deaths from cervix and corpus uteri.

French uterine cancer recordings in death certificates include 60% of "uterine cancer, Not Otherwise Specified (NOS)"; this hampers the estimation of mortalities from cervix and corpus uteri cancers. The aims of this work were to study the reliability of uterine cancer recordings in death certificates using a case matching with cancer registries and estimate age-specific proportions of deaths from cervix and corpus uteri cancers among all uterine cancer deaths by a statistical approach that uses incidence and survival data. Deaths from uterine cancer between 1989 and 2001 were extracted from the French National database of causes of death and case-to-case matched to women diagnosed with uterine cancer between 1989 and 1997 in 8 cancer registries. Registry data were considered as "gold-standard". Among the 1825 matched deaths, cancer registries recorded 830 cervix and 995 corpus uteri cancers. In death certificates, 5% and 40% of "true" cervix cancers were respectively coded "corpus" and "uterus, NOS" and 5% and 59% of "true" corpus cancers respectively coded "cervix" and "uterus, NOS". Miscoding cervix cancers was more frequent at advanced ages at death and in deaths at home or in small urban areas. Miscoding corpus cancers was more frequent in deaths at home or in small urban areas. From the statistical method, the estimated proportion of deaths from cervix cancer among all uterine cancer deaths was higher than 95% in women aged 30-40 years old but declined to 35% in women older than 70 years. The study clarifies the reason for poor encoding of uterus cancer mortality and refines the estimation of mortalities from cervix and corpus uteri cancers allowing future studies on the efficacy of cervical cancer screening.

Estimating the number of alcohol-attributable deaths: methodological issues and illustration with French data for 2006.

AIMS: Computing the number of alcohol-attributable deaths requires a series of hypotheses. Using French data for 2006, the potential biases are reviewed and the sensitivity of estimates to various hypotheses evaluated. METHODS: Self-reported alcohol consumption data were derived from large population-based surveys. The risks of occurrence of diseases associated with alcohol consumption and relative risks for all-cause mortality were obtained through literature searches. All-cause and cause-specific population alcohol-attributable fractions (PAAFs) were calculated. In order to account for potential under-reporting, the impact of adjustment on sales data was tested. The 2006 mortality data were restricted to people aged between 15 and 75 years. RESULTS: When alcohol consumption distribution was adjusted for sales data, the estimated number of alcohol-attributable deaths, the sum of the cause-specific estimates, was 20 255. Without adjustment, the estimate fell to 7158. Using an all-cause mortality approach, the adjusted number of alcohol-attributable deaths was 15 950, while the non-adjusted estimate was a negative number. Other methodological issues, such as computation based on risk estimates for all causes for 'all countries' or only 'European countries', also influenced the results, but to a lesser extent. DISCUSSION: The estimates of the number of alcohol-attributable deaths varied greatly, depending upon the hypothesis used. The most realistic and evidence-based estimate seems to be obtained by adjusting the consumption data for national alcohol sales, and by summing the cause-specific estimates. However, interpretation of the estimates must be cautious in view of their potentially large imprecision.

Changes in cancer mortality among HIV-infected patients: the Mortalité 2005 Survey.

BACKGROUND: The goal of the current study was to describe the distribution and characteristics of malignancy related deaths among human immunodeficiency virus (HIV)-infected patients with use of data obtained from a national survey conducted in France in 2005 and to compare with results obtained from a similar survey conducted in 2000. METHOD: The underlying cause of death was documented using a standardized questionnaire fulfilled in French hospital wards and networks that were involved in the treatment of HIV-infected patients. RESULTS: Among the 1042 deaths reported in 2005 (964 were reported in 2000), 344 were cancer related (34%), which represented a significant increase from 2000 (29% of deaths were cancer related) (P=.02); 134 of the cancer-related deaths were AIDS related and 210 were not AIDS related. Among the cancer-related causes of death, the proportion of hepatitis-related cancers (6% in 2000 vs. 11% in 2005) and non-AIDS/hepatitis-related cancers (38% in 2000 vs 50% in 2005) significantly increased from 2000 to 2005 (P=.03 and P=.01, respectively), compared with the proportion of cancer that was AIDS related and adjusting for age and sex. Among cases involving AIDS, the proportion of non-Hodgkin lymphoma-associated deaths did not change statistically significantly between 2000 and 2005 (11% and 10% of deaths, respectively). CONCLUSIONS: In this study, an increasing proportion of lethal non-AIDS-related cancers was demonstrated from 2000 to 2005; meanwhile, the proportion of lethal AIDS-related cancers remained stable among HIV-infected patients. Thus, cancer prophylaxis, early diagnosis, and improved management should be included in the routine long-term follow-up of HIV-infected patients.

Emerging role of hepatocellular carcinoma among liver-related causes of deaths in HIV-infected patients: The French national Mortalité 2005 study.

BACKGROUND/AIMS: Longer exposure to hepatitis C (HCV) or B virus (HBV) and the increased use of hepatitis treatment might have an impact on liver-related deaths in patients co-infected with the Human Immunodeficiency Virus (HIV). We describe the proportion of liver-related deaths among HIV-infected patients in 2005 compared with 2000. METHODS: In a nationwide survey (341 hospital departments involved in HIV management), all deaths of HIV-infected patients were prospectively reported. Deaths from either cirrhosis, hepatocellular carcinoma or fulminant hepatitis were defined as liver-related deaths. RESULTS: Of the 898 deaths reported in 2005, liver-related causes accounted for 15.4%; this is compared to 13.4% in 2000. Among liver-related deaths, hepatocellular carcinoma increased from 15% to 25% (p=0.04). Among hepatocellular carcinoma-related deaths: in 2000, 10% were HCV-infected; in 2005, 25% were HCV-infected (p=0.03). Half of the HCV-related deaths had been treated for HCV but 98% remained HCV-RNA positive at time of death. The proportion of HBV-related deaths remained stable between 2000 and 2005. CONCLUSIONS: Liver-related deaths, mainly liver cancers, have increased in HIV-infected patients in France despite wide access to HCV treatment. The stability of HBV-related deaths might be explained by the use of dually active antiretroviral drugs in co-infected patients.

Ecological association between a deprivation index and mortality in France over the period 1997 - 2001: variations with spatial scale, degree of urbanicity, age, gender and cause of death.

BACKGROUND: Spatial health inequalities have often been analysed in terms of deprivation. The aim of this study was to create an ecological deprivation index and evaluate its association with mortality over the entire mainland France territory. More specifically, the variations with the degree of urbanicity, spatial scale, age, gender and cause of death, which influence the association between mortality and deprivation, have been described. METHODS: The deprivation index, 'FDep99', was developed at the 'commune'(smallest administrative unit in France) level as the first component of a principal component analysis of four socioeconomic variables. Proxies of the Carstairs and Townsend indices were calculated for comparison. The spatial association between FDep99 and mortality was studied using five different spatial scales, and by degree of urbanicity (five urban unit categories), age, gender and cause of death, over the period 1997-2001. 'Avoidable' causes of death were also considered for subjects aged less than 65 years. They were defined as causes related to risk behaviour and primary prevention (alcohol, smoking, accidents). RESULTS: The association between the FDep99 index and mortality was positive and quasi-log-linear, for all geographic scales. The standardized mortality ratio (SMR) was 24% higher for the communes of the most deprived quintile than for those of the least deprived quintile. The between-urban unit category and between-région heterogeneities of the log-linear associations were not statistically significant. The association was positive for all the categories studied and was significantly greater for subjects aged less than 65 years, for men, and for 'avoidable' mortality. The amplitude and regularity of the associations between mortality and the Townsend and Carstairs indices were lower. CONCLUSION: The deprivation index proposed reflects a major part of spatial socioeconomic heterogeneity, in a homogeneous manner over the whole country. The index may be routinely used by healthcare authorities to observe, analyse, and manage spatial health inequalities.

Changes in causes of death among adults infected by HIV between 2000 and 2005: The "Mortalité 2000 and 2005" surveys (ANRS EN19 and Mortavic).

BACKGROUND: The multicenter national Mortalité 2005 survey aimed at describing the distribution of causes of death among HIV-infected adults in France in 2005 and its changes as compared with 2000. METHODS: Physicians involved in the management of HIV infection notified deaths and documented the causes using a standardized questionnaire similar to the previous survey performed in 2000. RESULTS: Overall, 1042 deaths were notified in 2005 (vs 964 in 2000): with median age, 46 years (vs 41 years); men, 76%; and median last CD4 cell count, 161/mm (vs 94). The proportion of underlying causes of death due to AIDS decreased (36% in 2005 vs 47% in 2000), and the proportion of cancer not related to AIDS or hepatitis (17% vs 11%), liver related disease (15% vs 13%: hepatitis C, 11%, and hepatitis B, 2%), cardiovascular disease (8% vs 7%), or suicide (5% vs 4%) increased. Among the 375 AIDS-related deaths, the most frequent event was non-Hodgkin lymphoma (28%). Among cancers not related to AIDS or hepatitis, the most frequent localizations were lung (31%) and digestive tract (14%). Among the 154 liver-related deaths, 24% were due to hepatocarcinoma. CONCLUSIONS: The heterogeneity of causes of death among HIV-infected adults was confirmed and intensified in 2005, with 3 causes following AIDS: cancers and liver-related and cardiovascular diseases.

Mortality related to chronic hepatitis B and chronic hepatitis C in France: evidence for the role of HIV coinfection and alcohol consumption.

BACKGROUND/AIMS: Mortality related to HCV and HBV infections was estimated in France. METHODS: A random sample (n=999) of death certificates was obtained from all death certificates listing HBV, HCV, hepatitis, liver disease, possible complication of cirrhosis, bacterial infection, HIV, or transplantation (n=65,000) in France in 2001. Physicians who reported the deaths were sent a questionnaire to identify how many deaths were related to HBV/HCV infection. Completed forms were independently analyzed by a panel of hepatologists. Death rates were estimated according to national population census data. RESULTS: Estimated annual number of deaths associated with HCV and HBV infection was 3618 and 1507, respectively (6.1 and 2.5 deaths per 100,000 inhabitants, respectively). Estimated number of deaths attributable to HCV or HBV infection was 2646 and 1327, respectively (4.5 and 2.2 deaths per 100,000 inhabitants, respectively). In the HCV infection group, 95 percent had cirrhosis; 33 percent had hepatocellular carcinoma (HCC). In the HBV infection group, 93 percent had cirrhosis; 35 percent had HCC. Eleven percent of deaths occurred in patients with HIV coinfection. Deaths related to HBV or HCV infection occurred at an earlier age in patients with a history of excessive alcohol consumption. CONCLUSIONS: In France, 4000-5000 deaths related to HCV and HBV infection occurred in 2001. Alcohol consumption and HIV infection were important co-factors. These data emphasize the need for ongoing, efficient public health programs that include screening, management, and counseling for HCV- and HBV-infected individuals.

The impact of major heat waves on all-cause and cause-specific mortality in France from 1971 to 2003.

OBJECTIVES: The aim of the study was to identify the major heat waves (HW) that occurred in France from 1971 to 2003 and describe their impact on all-cause and cause-specific mortality. METHODS: Heat waves were defined as periods of at least three consecutive days when the maximum and the minimum temperature, averaged over the whole France, were simultaneously greater than their respective 95th percentile. The underlying causes of death were regrouped into 18 categories. Heatstroke, hyperthermia and dehydration were assigned to the "heat-related causes" (HRC) category. The numbers of deaths observed (O) during the identified HW were compared to those expected (E) on the basis of the mortality rates reported for the three preceding years. RESULTS: Six HW were identified from the period 1971 to 2003. They were associated with great excess mortality (from 1,300 to 13,700 deaths). The observations are compatible with a moderate harvesting effect for four of the six HW. The mortality ratios increased with age for subjects aged over 55 years and were higher for women than for men over 75 years. For the six HW, the excess mortality was significant for almost all the causes of death: (1) the greatest excess mortality (O-E) were observed for cardiovascular diseases, neoplasms, respiratory system diseases, HRC, ill-defined conditions and injury and poisoning, and (2) the mortality ratios (O/E) were highest for HRC, respiratory diseases, nervous system diseases, mental disorders, infectious diseases, and endocrine and nutritional diseases. CONCLUSIONS: Heat waves associated with excess mortality are not rare events in this temperate-climate country. The excess mortality is much greater than HRC mortality. Some populations are particularly vulnerable to HW: the elderly, women and people with some specific diseases. However, no segment of the population may be considered protected from the risks associated with HW.

Childhood leukemia incidence and exposure to indoor radon, terrestrial and cosmic gamma radiation.

This study was undertaken to evaluate the ecological association between terrestrial and cosmic gamma radiation, indoor radon, and acute leukemia incidence among children under 15 y of age. From 1990 to 2001, 5,330 cases of acute leukemia were registered by the French National Registry of Childhood Leukemia and Lymphoma. Exposure to terrestrial gamma radiation was based on measurements, using thermoluminescent dosimeters, at about 1,000 sites covering all the "Départements." In addition, 8,737 indoor terrestrial gamma dose rate measurements covering 62% of the "Départements" and 13,240 indoor radon concentration measurements covering all the "Départements" were made during a national campaign. Cosmic ray doses were estimated in each of the 36,363 "Communes" of France. There was no evidence of an ecological association between terrestrial gamma dose (range: 0.22-0.90 mSv y) or total gamma dose (range: 0.49-1.28 mSv y) and childhood acute leukemia incidence, for acute myeloid leukemia (AML) or for acute lymphoblastic leukemia (ALL), in univariate or multivariate regression analyses including indoor radon. A significant positive association between indoor radon (range: 22-262 Bq m) and AML incidence among children was observed and remained significant in multivariate regression analyses including either terrestrial gamma dose [SIR per 100 Bq m = 1.29 (1.09-1.53)] or total gamma dose [SIR per 100 Bq m = 1.29 (1.09-1.53)]. The study showed no ecological association between terrestrial gamma radiation and childhood leukemia for the range of variation in gamma dose rates observed in France. The moderate ecological association between childhood AML incidence and indoor radon does not appear to be confounded by terrestrial gamma dose.

Opportunistic infections as causes of death in HIV-infected patients in the HAART era in France.

The objective of the study was to describe the underlying causes of death of HIV-infected patients in the HAART era and to focus on those related to opportunistic infection (OI), in a national multicentre study ('Mortalité 2000'). A total of 964 deaths were recorded and 924 cases were available for analysis. Underlying cause of death were AIDS-related (47%), viral hepatitis (11%), non-AIDS cancers (11%), cardiovascular diseases (7%) and others (11%). Among patients who died of AIDS events, 262 (27%) died of at least one OI. OIs reported at the time of death were Cytomegalovirus infection 67 times, Pneumocystis jiroveci pneumonia 56, disseminated Mycobacterium avium intracellulare infection 53 and cerebral toxoplasmosis 48. Compared to patients who died of other causes, patients who died of OIs were younger and more likely to be infected through heterosexual contact, in poor socioeconomic conditions, migrants, more recently diagnosed for HIV infection, and naive of antiretroviral therapy and OI prophylaxis. OIs are still a major cause of death in HIV-infected patient in the HAART era, especially among patients recently diagnosed for HIV infection and who do not have access to care, as well as in long term infected patients where prophylaxis should be revisited.

Liver disease as a major cause of death among HIV infected patients: role of hepatitis C and B viruses and alcohol.

BACKGROUND/AIMS: We analyzed the characteristics of HIV infected patients who died from liver disease, focusing on hepatitis virus co-infection. METHODS: One-hundred and eighty-five French hospital departments involved in HIV/AIDS management prospectively notified all deaths occurring in 2000. Patients whose hepatitis C (HCV) and hepatitis B (HBV) serostatus was known were classified as being infected by HCV alone, HBV alone (HBsAg positive), both HCV and HBV, or neither HCB nor HBV. RESULTS: Among 822 HIV infected patients, 29% were infected by HCV alone, 8% by HBV alone, and 4% by both HCV and HBV. The most frequent causes of death were liver disease (31% of cases) and AIDS (29%) among HIV-HCV co-infected patients, and AIDS (38%) and liver disease (22%) among HIV-HBV co-infected patients. Liver disease was a more frequent cause of death among patients co-infected by both HCV and HBV (44% of cases). Hepatocellular carcinoma was present in 15% of patients who died from liver disease, and was associated with HBV co-infection. Nearly half the patients who died from liver disease had more than 200 CD4/mm3. CONCLUSIONS: Liver disease is now a leading cause of death among HIV-HCV co-infected patients and is becoming an important cause of death among HIV-HBV co-infected patients. The risk of death from liver disease is highest in patients co-infected by both HCV and HBV.

Causes of death among human immunodeficiency virus (HIV)-infected adults in the era of potent antiretroviral therapy: emerging role of hepatitis and cancers, persistent role of AIDS.

BACKGROUND: In the era of highly active antiretroviral therapy (HAART) mortality has decreased substantially among human immunodeficiency virus (HIV)-infected people with access to HAART, but there are concerns regarding co-morbidities and adverse effects of HAART, which may impair vital prognosis. The Mortality 2000 study examined the causes of death in HIV-infected adults at a national level in France in the year 2000. METHODS: All French hospital wards known to be involved in the management of HIV infection were asked to notify prospectively the deaths that occurred in 2000 among HIV-infected adults. The causes of death were documented using a standardized questionnaire. RESULTS: The 185 participating wards notified 964 deaths. The main underlying causes of death were AIDS-related (47%, non-Hodgkin's lymphoma: 23%), viral hepatitis (11%, hepatitis C: 9%, hepatitis B: 2%), cancer not related to AIDS or hepatitis (11%), cardiovascular disease (7%), bacterial infections (6%), suicide (4%), and adverse effect of antiretroviral treatments (1%). Among AIDS-related deaths, HIV infection had been diagnosed recently in 20%. Smoking was recorded in 72% of cancer-related deaths and alcohol consumption in 54% of hepatitis-related deaths. Among non-HIV related deaths between 25 and 64 years, the proportion of infectious diseases (including HCV and HBV-related deaths) was higher in HIV-infected adults than in the general population. CONCLUSIONS: Improved strategies for detecting HIV infection before AIDS-defining complications occur are needed in the era of HAART. The prevention of non-AIDS related cancers, especially lung cancer, the management of non-Hodgkin's lymphoma, and of viral hepatitis are also important priorities.

Incidence of gastrointestinal cancers in France.

AIM: Monitoring cancer incidence and time trends is essential for cancer research and health care planning. The aim of the study was to compare the incidence of gastrointestinal cancers in twelve administrative area in France to estimate the national cancer incidence during 2000 compared with the preceding 20 years. METHODS: Incidence data was provided by cancer registries and mortality data by the French national medical research institute (INSERM). The two data sets were modeled separately over the period 1988-1997 using age-cohort models. The incidence/mortality ratio obtained from these models was applied to the mortality rates of an age-cohort model of the entire population. RESULTS: The estimated number of new cases of gastrointestinal cancer was 61,465 in 2000. Colorectal cancer was the leading localization with 36,257 cases. The incidence of gastrointestinal cancers was slightly higher in northern than in southern area. Incidence of esophageal cancer was three times that of liver cancer. Variations in incidence were less marked for other localizations. The incidence of gastric and esophageal cancer in the male population decreased between 1980 and 2000, on average by slightly more than 2% per year. Incidence of other cancers increased. The number of new cases of colorectal cancer increased by 50%. The rise in the incidence of liver cancer was particularly striking, with an increase from 2000 incident cases in 1980 to nearly 6000 in 2000. CONCLUSION: For most localizations, incidence of gastrointestinal cancers displays few geographical differences in France, but there has been a striking change in incidence trends over the past 20 years.