Prevalence, Medicaid use and mortality risk of low FEV1 in adults aged 20-35 years old in the USA: evidence from a population-based retrospective cohort study.

BACKGROUND: The prevalence, Medicaid use and mortality risk associated with low forced expiratory volume in 1 s (FEV1) among young adults aged 20-35 years are not well understood, despite its potential implications for the development of chronic pulmonary disease and overall prognosis. METHODS: A retrospective cohort study was conducted among young adults aged 20-35 years old, using data from the National Health and Nutrition Examination Survey, National Death Index and Centers for Medicare & Medicaid Services. Participants were categorised into a low FEV1 group (pre-bronchodilator FEV1%pred <80%) and a normal FEV1 group (FEV1%pred ≥80%). Weighted logistic regression analysis was employed to identify the risk factors associated with low FEV1, while Cox proportional hazard models were used to calculate the hazard ratio (HR) for Medicaid use and the all-cause mortality between the two groups. RESULTS: A total of 5346 participants aged 20-35 were included in the study, with 329 in the low FEV1 group and 5017 in the normal group. The weighted prevalence of low FEV1 among young adults was 7.1% (95% CI 6.0 to 8.2). Low body mass index (OR=3.06, 95% CI 1.79 to 5.24), doctor-diagnosed asthma (OR=2.25, 1.28 to 3.93), and wheezing or whistling (OR=1.57, 1.06 to 2.33) were identified as independent risk factors for low FEV1. Over a 15-year follow-up, individuals in the low FEV1 group exhibited a higher likelihood of Medicaid use compared with those in the normal group (HR=1.73, 1.07 to 2.79). However, there was no statistically significant increase in the risk of all-cause mortality over a 30-year follow-up period (HR=1.48, 1.00 to 2.19). CONCLUSIONS: A considerable portion of young adults demonstrated low FEV1 levels, a characteristic that was associated with a higher risk of Medicaid use over a long-term follow-up, yet not linked to an augmented risk of all-cause mortality.

Impact of pulmonary complications following esophagectomy on long-term survival: multivariate meta-analysis and restricted mean survival time assessment.

Pulmonary complications (PC) are common after esophagectomy and their impact on long-term survival is not defined yet. The present study aimed to assess the effect of postoperative PCs on long-term survival after esophagectomy for cancer. Systematic review of the literature through February 1, 2023, was performed. The included studies evaluated the effect of PC on long-term survival. Primary outcome was long-term overall survival (OS). Cancer-specific survival (CSS) and disease-free survival (DFS) were secondary outcomes. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. Eleven studies were included (3423 patients). Overall, 674 (19.7%) patients developed PC. The RMSTD analysis shows that at 60-month follow-up, patients not experiencing PC live an average of 8.5 (95% CI 6.2-10.8; p < 0.001) months longer compared with those with PC. Similarly, patients not experiencing postoperative PC seem to have significantly longer CSS (8 months; 95% CI 3.7-12.3; p < 0.001) and DFS (5.4 months; 95% CI 1.6-9.1; p = 0.005). The time-dependent HRs analysis shows a reduced mortality hazard in patients without PC at 12 (HR 0.6, 95% CI 0.51-0.69), 24 (HR 0.64, 95% CI 0.55-0.73), 36 (HR 0.67, 95% CI 0.55-0.79), and 60 months (HR 0.69, 95% CI 0.51-0.89). This study suggests a moderate clinical impact of PC on long-term OS, CSS, and DFS after esophagectomy. Patients not experiencing PC seem to have a significantly reduced mortality hazard up to 5 years of follow-up.

Influence of broader geographic allograft sharing on outcomes and cost in smaller lung transplant centers.

OBJECTIVE: On November 24, 2017, Organ Procurement and Transplantation Network implemented a change to lung allocation replacing donor service area with a 250 nautical mile radius around donor hospitals. We sought to evaluate the experience of a small to medium size center following implementation. METHODS: Patients (47 pre and 54 post) undergoing lung transplantation were identified from institutional database from January 2016 to October 2019. Detailed chart review and analysis of institutional cost data was performed. Univariate analysis was performed to compare eras. RESULTS: Similar short-term mortality and primary graft dysfunction were observed between groups. Decreased local donation (68% vs 6%; P < .001), increased travel distance (145 vs 235 miles; P = .004), travel cost ($8626 vs $14,482; P < .001), and total procurement cost ($60,852 vs $69,052; P = .001) were observed postimplementation. We also document an increase in waitlist mortality postimplementation (6.9 vs 31.6 per 100 patient-years; P < .001). CONCLUSIONS: Following implementation of the new allocation policy in a small to medium size center, several changes were in accordance with policy intention. However, concerning shifts emerged, including increased waitlist mortality and resource utilization. Continued close monitoring of transplant centers stratified by size and location are paramount to maintaining global availability of lung transplantation to all Americans regardless of geographic residence or socioeconomic status.

Frailty in Lung Transplantation: Candidate Assessment and Optimization.

The concept of frailty has gained considerable interest in clinical solid-organ transplantation over the past decade. Frailty as a phenotypic construct to describe a patient's risk from biologic stresses has an impact on posttransplant survival. There is keen interest in characterizing frailty in lung transplantation, both to determine which patients are suitable candidates for listing and also to prepare for their care in the aftermath of lung transplantation. Here, we review the current status of research on frailty in lung transplant candidates and recipients. This review will highlight areas of uncertainty for frailty in clinical lung transplantation that are likely to impact the state-of-the-art in the field for the next decade.

Causes of death among Federal Black Lung Benefits Program beneficiaries enrolled in Medicare, 1999-2016.

BACKGROUND: Coal miners with totally disabling pneumoconiosis are eligible for benefits through the Federal Black Lung Benefits Program (FBLP). We identify the causes of death among Medicare beneficiaries with a claim for which the FBLP was the primary payer and compare these causes of death to all deceased Medicare beneficiaries to better understand elevated death and disease among miners with occupational respiratory exposures. METHODS: From 1999 to 2016 Medicare data, we extracted beneficiary and National Death Index data for 28,003 beneficiaries with an FBLP primary payer claim. We summarized the International Classification of Diseases, Clinical Modification 10th revision-coded underlying causes of death and entity-axis multiple causes of death for 22,242 deceased Medicare beneficiaries with an FBLP primary payer Medicare claim and compared their causes of death to the deceased Medicare beneficiary population. RESULTS: Among deceased FBLP beneficiaries, the three leading underlying causes of death were chronic obstructive pulmonary disease, unspecified (J44.9, 10.1%), atherosclerotic heart disease (I25.1, 9.3%), and coal workers' pneumoconiosis (CWP) (J60, 9.2%). All diseases of the respiratory system combined (J00-J99) were the underlying cause of death for 29.1% of all beneficiaries, with pneumoconioses (J60-J64) as the underlying cause for 11.0% of all beneficiaries. CONCLUSIONS: Coal miners enrolled in Medicare with an FBLP primary payer claim were more likely to have specific respiratory and cardiovascular diseases listed as a cause of death than deceased Medicare beneficiaries overall, and were also more likely to die from CWP or any pneumoconioses.

Pulmonary Complications After Hip and Knee Arthroplasty in the United States, 2004-2014.

BACKGROUND: Pulmonary complications after total joint arthroplasty (TJA) are uncommon but have significant cost impact. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are 2 of the 5 top procedures requiring inpatient stay within the United States. Subsequent pulmonary complications therefore may impose substantial cost burden for US health care. The purpose of this study was to describe the incidence, risk factors, and clinical implications of pulmonary complications (ie, pneumonia, respiratory failure, pulmonary embolism [PE], and aspiration) after TJA in the United States. METHODS: The National Inpatient Sample (NIS) was queried for all patients undergoing primary, elective THA and TKA between years 2004 and 2014. Pulmonary complications were defined as the occurrence of pneumonia, respiratory failure, PE, or aspiration after TJA. Demographic and clinical characteristics, inpatient cost, length of stay (LOS), and mortality were compared between patients with and without documented perioperative pulmonary complications. Given the stratified nature of the NIS database, estimates of incidence throughout the United States were made with application of trend weights to observed database frequencies. Analyses of estimated annual complication rates were made using χ tests. RESULTS: Between 2004 and 2014, an estimated 2,679,351 patients underwent elective primary THA. A total of 5,527,205 patients were estimated to have undergone elective primary TKA. THA 1.42% (95% CI, 1.37%-1.47%) and 1.71% (95% CI, 1.66%-1.76%) of TKA procedures were complicated by pneumonia, respiratory failure, PE, or aspiration. During this time, the incidence of perioperative pulmonary complications decreased from 1.57% (95% CI, 1.41%-1.73%) to 1.01% (95% CI, 0.92%-1.10%) after THA (P < .0001) and from 2.03% (95% CI, 1.88%-2.18%) to 1.33% (95% CI, 1.25%-1.42%) after TKA (P < .0001). The adjusted odds ratio (aOR) of experiencing a pulmonary complication was highest among patients with history of significant weight loss (aOR = 4.77; 99.9% CI, 3.97-5.73), fluid/electrolyte disorders (aOR = 3.33; 99.9% CI, 3.11-3.56), congestive heart failure (CHF; aOR = 3.32; 99.9% CI, 3.07-3.58), preexisting paralytic condition (aOR = 2.03; 99.9% CI, 1.57-2.61), and human immunodeficiency virus infection (aOR = 2.00; 99.9% CI, 1.06-3.78). Perioperative pulmonary complications were associated with increased LOS (THA = 3.03 days; 99.9% CI, 2.76-3.31; TKA = +2.72 days; 99.9% CI, 2.58-2.86), increased hospital costs (THA = +9163 US dollars; 99.9% CI, 8054-10,272; TKA = +7257 US dollars; 99.9% CI, 6650-7865), and increased mortality (THA: aOR = 121; 99.9% CI, 78-187; TKA: aOR = 150; 95% CI, 97-233). CONCLUSIONS: Despite a decline in overall incidence, perioperative pulmonary complications represent a significant potential source of perioperative morbidity and mortality. The current study highlights potential risk factors for pulmonary complications. Recognition of these factors may help to better stratify patients and mitigate risk of potential complications. This is particularly true of respiratory failure as it is associated with the high increases in resource utilization and mortality in this group.

Lung Transplantation.

Lung transplantation is an appropriate therapeutic option for select patients with end-stage lung diseases and offers the possibility of improved quality of life and longer survival. Unfortunately, the transplant recipient is at risk for numerous immunologic, infectious, and medical complications that threaten both of these goals. Median survival after lung transplantation is approximately 6 years. Optimizing outcomes requires close partnership between the patient, transplant center, and primary medical team. Early referral to a transplant center should be considered for patients with idiopathic pulmonary fibrosis and related interstitial lung diseases due to risk of acute exacerbation and accelerated development of respiratory failure.

Utilization and Cost Analysis of Lung Transplantation and Survival After 10 Years of Adapting the Lung Allocation Score.

BACKGROUND: Lungs are allocated in the United States using the lung allocation score (LAS). We investigated the effect of LAS trends on lung transplant-related costs, healthcare utilization, and mortality. METHODS: Utilization data from Mayo Clinic (Florida and Minnesota) from 2005 to 2015 were obtained from the electronic health records (N = 465). Costs were categorized as 1-year posttransplant or transplant episode and standardized using 2015 Medicare reimbursement and cost-to-charge ratios. Regression analysis was used to assess the relationship of LAS to length of stay (LOS), mortality, and cost of transplant. RESULTS: The mean LAS at transplant increased from 45.7 to 58.3 during the study period, whereas the 1-year survival improved from 88.1% to 92.5% (P < 0.0001). The proportion of patients transplanted with LAS of 60 or greater increased from 16.9% to 33.3%. Posttransplant, overall, and intensive care unit LOS increased with increasing LAS. Patients with higher LAS had substantially higher transplant episode costs. An increase of LAS at transplant by 10 points increased inflation-adjusted costs by 12.0% (95% confidence interval, 9.3%-14.5%). CONCLUSIONS: The mean LAS at transplant has significantly increased over time associated with increases in LOS, resource utilization and cost. Lung allocation score has not jeopardized overall survival, but a high LAS (>60) at transplant is associated with increased mortality.

Relative risk of all-cause mortality in patients with nontuberculous mycobacterial lung disease in a US managed care population.

RATIONALE: The risk of all-cause mortality of nontuberculous mycobacterial lung disease (NTMLD) in the United States (US) population is not well established. OBJECTIVES: This study aims to assess the public health burden of NTMLD in the US by comparing the relative risk of all-cause mortality in the NTMLD population with an age- and sex-matched cohort from the general population. METHODS: Patients with physician claims for NTMLD (ICD-9 0.031; ICD-10 A31.0) were identified between 2007 and 2016 from a large US national managed care insurance plan covering approximately 15-18 million members annually. A control group with no NTMLD ICD-9 or 10 codes was randomly selected from the general population and matched 3:1 to the NTMLD sample according to birth year, gender, and insurance benefit coverage. The date of first NTMLD diagnosis of each patient was assigned to the matched controls as the index date. The Cox proportional hazard method compared survival between cohorts, adjusting for demographic factors and baseline comorbidities. RESULTS: A total of 2005 patients with NTMLD and 6014 controls were identified, with a mean follow-up duration of 3.4 years and 3.7 years, respectively. The NTMLD group had substantially higher proportions of patients with asthma (23.3% versus 3.5%), bronchiectasis (36.5% versus 0.1%), COPD (52.0% versus 5.9%), arrhythmia (22.6% versus 6.5%), coronary artery disease (18.5% versus 6.6%), heart failure (11.9% versus 4.1%), and cancer (18.5% versus 5.0%). The unadjusted rate of all-cause mortality from the index date was 20.7 per 1000 person-years in the NTMLD group vs 5.6 per 1000 person-years in the control group (rate ratio = 3.73; 95% CI: 2.93-4.75). Multivariable Cox regression, adjusted for the above variables as well as all other important baseline covariates, showed a doubling risk of all-cause mortality (hazard ratio [HR] = 2.06; CI: 1.52-2.79; P < 0.001) in the NTMLD vs control group. CONCLUSIONS: All-cause mortality, adjusted for other factors, more than doubled with NTMLD compared with an age-sex-matched control group in a large US national managed care insurance plan.

Improved survival in simultaneous lung-liver recipients and candidates in the modern era of lung allocation.

BACKGROUND: Liver-lung transplantation (LLT) is a rare procedure performed for patients with end-stage liver and lung disease. The lung allocation score (LAS), introduced in 2005, guides lung allocation including those receiving LLT. However, the impact of the LAS on outcomes in LLT is currently unknown. MATERIALS AND METHODS: The OPTN/United Network for Organ Sharing STAR file was queried for LLT candidates and recipients from 1988 to 2016. Demographic characteristics before (historic) and after (modern) the LAS were compared. Survival was analyzed with the Kaplan-Meier method and log-rank test. RESULTS: In total, 167 candidates were listed for LLT, and 62 underwent LLT. The historic cohort had a higher FEV1% (48.22% versus 29.82%, P = 0.014), higher creatinine (1.22 versus 0.72, P < 0.001), and a higher percentage with pulmonary hypertension as the indication for transplantation (40% versus 0%, P = 0.003) compared with the modern cohort. LLT candidates in the historic cohort had a lower rate of transplant per 100 candidates (10.87 versus 33.33, P < 0.0001) and worse waitlist survival (1 y: 69.6% versus 80.9%, 3 y: 39.1% versus 66.8%, P = 0.004). Post-transplant survival was significantly lower in the historic cohort (1 y: 50.0% versus 82.7%, 5 y: 40.0% versus 69.0%, 10 y: 20.0% versus 55.5%, P = 0.0099). CONCLUSIONS: Most analyses of LLT have included patients before and after the introduction of the LAS. Our study shows that LLT candidates and recipients before the modern allocation system had distinct baseline characteristics and worse overall survival. Although many factors contributed to recent improved outcomes, these cohorts are significantly different and should be treated as such in future studies.

Lung transplantation in the Lung Allocation Score era: Medium-term analysis from a single center.

In 2005, the Lung Allocation Score (LAS) was implemented as the allocation system for lungs in the US. We sought to compare 5-year lung transplant outcomes before and after the institution of the LAS. Between 2000 and 2011, 501 adult patients were identified, with 132 from January 2000 to April 2005 (Pre-LAS era) and 369 from May 2005 to December 2011 (Post-LAS era). Kruskal-Wallis or chi-squared test was used to determine significance between groups. Survival was censored at 5 years. Overall, the post-LAS era was associated with more restrictive lung disease, higher LAS scores, shorter wait-list times, more preoperative immunosuppression, and more single lung transplantation. In addition, post-LAS patients had higher O2 requirements with greater preoperative pulmonary impairment. Postoperatively, 30-day mortality improved in post-LAS era (1.6% vs 5.3%, P = .048). During the pre- and post-LAS eras, 5-year survival was 52.3% and 55.3%, respectively (P = .414). The adjusted risk of mortality was not different in the post-LAS era (P = .139). Freedom from chronic lung allograft dysfunction was significantly higher in the post-LAS era (P = .002). In this single-center report, implementation of the LAS score has led to allocation to sicker patients without decrement in short- or medium-term outcomes. Freedom from CLAD at 5 years is improving after LAS implementation.

State of the Art in Pediatric Lung Transplantation.

Pediatric lung transplantation is a highly specialized therapy for end-stage pulmonary disease in children, and is performed in only a handful of transplant centers around the world. Advancement in the field has been made on many fronts in recent years, including in public policy and organ allocation strategies, donor selection and management, emerging technologies for donor lung rehabilitation and bridge-to-transplant support of listed candidates, and ongoing refinement of surgical techniques. Despite this progress, children continue to suffer discrepant waitlist mortality and longer waiting times than their adult counterparts, and face special challenges of donor availability and size matching. Here, we assess the current state of the art in pediatric lung transplantation, reviewing progress made to date and further opportunities to improve care for this unique group of patients.

Quantitative assessment of human health risks induced by vehicle exhaust polycyclic aromatic hydrocarbons at Zhengzhou via multimedia fugacity models with cancer risk assessment.

Traffic-related pollution released a large amount of atmospheric polycyclic aromatic hydrocarbons (PAHs) which have severely influenced environmental safety and human health until now. However, the important issue of polycyclic aromatic hydrocarbon (PAH) emission from vehicle exhaust in urban populated areas has not been sufficiently investigated yet. This study focused on environmental behavior of vehicle exhaust PAHs (VEPAHs) and resultant health risk on local residents in urban populated areas. This study combined the multimedia fugacity models (Level III and Level IV) and the incremental lifetime cancer risk (ILCR) model, for analyzing the VEPAHs' environmental fate and related health risk on local residents in Zhengzhou of the central China. Regression models were applied to explore correlation between atmospheric concentration of VEPAHs and local pulmonary disease mortality rate. Our results demonstrate that the majority of VEPAH was sunk into the soil compartment in 2013, but the calculated BaP-equivalent concentrations of total VEPAHs in the air compartment exceeded the annual average standard limit of China (1ng/m3) yet. The human exposure routes of VEPAHs caused cancer risk in the following order: inhalation>dermal contact>ingestion.

Utilization of non-invasive imaging tools for assessment of peripheral skeletal muscle size and composition in chronic lung disease: A systematic review.

OBJECTIVES: Non-invasive imaging modalities allow for detailed assessment of peripheral skeletal muscle wasting, which is associated with increased morbidity and mortality in chronic lung disease. Given the increased utilization of imaging tools, a systematic review was conducted using PRISMA guidelines to describe the modalities and acquisition techniques used to evaluate skeletal muscle in chronic lung disease and assess the relationships of muscle size and composition with strength, physical performance, structural alterations and clinical outcomes. METHODS: Six electronic databases were searched (inception-May 2017) to identify prospective studies measuring peripheral skeletal muscle size or composition using computed tomography (CT), magnetic resonance imaging/spectroscopy (MRI/MRS), or ultrasound (US) in adult chronic lung disease patients. RESULTS: Fifty-eight articles were included, which utilized: CT (n = 26), MRI/MRS (n = 16) and US (n = 16) in 2254 participants. All studies measured muscle size, predominantly of the lower extremity (n = 53), and only nine assessed muscle composition (i.e. fat infiltration) mainly with CT or MRI/MRS (n = 7). Thigh muscle size had a significant association with strength (r = 0.43-0.83, n = 13/14 studies), 6-min walk distance (r = 0.60-0.62, n = 3/6) and physical activity (r = 0.30-0.82, n = 3). Thigh muscle atrophy was independently associated with increased re-hospitalization (n = 1) and mortality (n = 3). Increased muscle fat infiltration had a moderate association with reduced physical performance partly related to increased anaerobic metabolism, but its prognostic utility was not assessed. CONCLUSION: Imaging modalities are valuable tools for the characterization of skeletal muscle dysfunction in chronic lung disease in clinical and research settings. The use of muscle imaging as a prognostic marker is promising and requires further study.

Refining Low Physical Activity Measurement Improves Frailty Assessment in Advanced Lung Disease and Survivors of Critical Illness.

RATIONALE: The frail phenotype has gained popularity as a clinically relevant measure in adults with advanced lung disease and in critical illness survivors. Because respiratory disease and chronic illness can greatly limit physical activity, the measurement of participation in traditional leisure time activities as a frailty component may lead to substantial misclassification of frailty in pulmonary and critical care patients. OBJECTIVES: To test and validate substituting the Duke Activity Status Index (DASI), a simple 12-item questionnaire, for the Minnesota Leisure Time Physical Activity (MLTA) questionnaire, a detailed questionnaire covering 18 leisure time activities, as the measure of low activity in the Fried frailty phenotype (FFP) instrument. METHODS: In separate multicenter prospective cohort studies of adults with advanced lung disease who were candidates for lung transplant and older survivors of acute respiratory failure, we assessed the FFP using either the MLTA or the DASI. For both the DASI and MLTA, we evaluated content validity by testing floor effects and construct validity through comparisons with conceptually related factors. We tested the predictive validity of substituting the DASI for the MLTA in the FFP assessment using Cox models to estimate associations between the FFP and delisting/death before transplant in those with advanced lung disease and 6-month mortality in older intensive care unit (ICU) survivors. RESULTS: Among 618 adults with advanced lung disease and 130 older ICU survivors, the MLTA had a substantially greater floor effect than the DASI (42% vs. 1%, and 49% vs. 12%, respectively). The DASI correlated more strongly with strength and function measures than did the MLTA in both cohorts. In models adjusting for age, sex, comorbidities, and illness severity, substitution of the DASI for the MLTA led to stronger associations of the FFP with delisting/death in lung transplant candidates (FFP-MLTA hazard ratio [HR], 1.42; 95% confidence interval [CI], 0.55-3.65; FFP-DASI HR, 2.99; 95% CI, 1.03-8.65) and with mortality in older ICU survivors (FFP-MLTA HR, 2.68; 95% CI, 0.62-11.6; FFP-DASI HR, 5.71; 95% CI, 1.34-24.3). CONCLUSIONS: The DASI improves the construct and predictive validity of frailty assessment in adults with advanced lung disease or recent critical illness. This simple questionnaire should replace the more complex MLTA in assessing the frailty phenotype in these populations.

Fukushima after the Great East Japan Earthquake: lessons for developing responsive and resilient health systems.

BACKGROUND: On 11 March 2011, the Great East Japan Earthquake, followed by a tsunami and nuclear-reactor meltdowns, produced one of the most severe disasters in the history of Japan. The adverse impact of this 'triple disaster' on the health of local populations and the health system was substantial. In this study we examine population-level health indicator changes that accompanied the disaster, and discuss options for re-designing Fukushima's health system, and by extension that of Japan, to enhance its responsiveness and resilience to current and future shocks. METHODS: We used country-level (Japan-average) or prefecture-level data (2005-2014) available from the portal site of Official Statistics of Japan for Fukushima, Miyagi, and Iwate, the prefectures that were most affected by the disaster, to compare trends before (2005-2010) and after (2011-2014) the 'disaster'. We made time-trend line plots to describe changes over time in age-adjusted cause-specific mortality rates in each prefecture. FINDINGS: All three prefectures, and in particular Fukushima, had lower socio-economic indicators, an older population, lower productivity and gross domestic product per capita, and less higher-level industry than the Japan average. All three prefectures were 'medically underserved', with fewer physicians, nurses, ambulance calls and clinics per 100 000 residents than the Japan average. Even before the disaster, age-adjusted all-cause mortality in Fukushima was in general higher than the national rates. After the triple disaster we found that the mortality rate due to myocardial infarction increased substantially in Fukushima while it decreased nationwide. Compared to Japan average, spikes in mortality due to lung disease (all three prefectures), stroke (Iwate and Miyagi), and all-cause mortality (Miyagi and Fukushima) were also observed post-disaster. The cause-specific mortality rate from cancer followed similar trends in all three prefectures to those in Japan as a whole. Although we found a sharp rise in ambulance calls in Iwate and Miyagi, we did not see such a rise in Fukushima: a finding which may indicate limited responsiveness to acute demand because of pre-existing restricted capacity in emergency ambulance services. CONCLUSIONS: We analyze changes in indicators of health and health systems infrastructure in Fukushima before and five years following the disaster, and explored health systems' strengths and vulnerabilities. Spikes in mortality rates for selected non-infectious conditions common among older individuals were observed compared to the national trends. The results suggest that poorer reserves in the health care delivery system in Fukushima limited its capacity to effectively meet sudden unexpected increases in demand generated by the disaster.

Burden of non-tuberculous mycobacterial pulmonary disease in Germany.

The objective of this study was to estimate the burden of disease in incident patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD).A sample of 7 073 357 anonymised persons covered by German public statutory health insurances was used to identify patients with NTM-PD. In total, 125 patients with newly diagnosed NTM-PD in 2010 and 2011 were matched with 1250 control patients by age, sex and Charlson Comorbidity Index, and followed for 39 months.The incidence rate for NTM-PD was 2.6 per 100 000 insured persons (95% CI 2.2-3.1). The mortality rate for patients with NTM-PD and the control group in the observational period was 22.4% and 6%, respectively (p<0.001). Mean direct expenditure per NTM-PD patient was €39 559.60 (95% CI 26 916.49-52 202.71), nearly 4-fold (3.95, 95% CI 3.73-4.19) that for a matched control (€10 006.71, 95% CI 8907.24-11 106.17). Hospitalisations were three times higher in the NTM-PD group and accounted for 63% of the total costs. Attributable annual direct costs and indirect work-loss costs in NTM-PD patients were €9093.20 and €1221.05 per control patient, respectively. Only 74% of NTM-PD patients received antibiotics and nearly 12% were prescribed macrolide monotherapy.Although NTM-PD is considered rare, the attributable mortality and financial burden in Germany are high. Efforts to heighten awareness of appropriate therapy are urgently needed.