Missed epidemics and missing links: international birth cohort trends in multiple sclerosis.

BACKGROUND AND PURPOSE: Many hypotheses on the etiopathogenesis of multiple sclerosis (MS) focus on risk factors occurring early in life. This study examined the variability of birth cohort trends in international MS data by means of age-period-cohort (APC) analysis. METHODS: The data from 25 countries were taken from the WHO mortality database. Data were encoded according to the International Classification of Diseases and covered slightly varying periods between 1951 and 2009. The APC analyses were based on logit models applied to cohort tables with 5-year age- and period intervals. RESULTS: In most countries, the birth cohort estimates peaked in those born in the first half of the 20th century. In countries from Central and Western Europe, the peak concerned those born before and around 1920. A second group of countries (Denmark, Sweden, Italy, Ireland, Scotland) shared a later peak amongst cohorts born in the 1920s and 1930s. Group 3 included Commonwealth countries, the USA and Norway, with a double or extended peak starting in the 1910s or 1920s, and ending by the 1950s. The fourth group, consisting of Mediterranean countries and Finland, was characterized by a steady increase in the birth cohort estimates until the 1950s. The fifth group with countries from Eastern Europe and Japan showed no particular pattern. CONCLUSIONS: Birth cohort trends have influenced the change in MS risk across the 20th century in many Western countries. This silent epidemic points to a most important but unknown latent risk factor in MS.

Firearm suicides and availability of firearms: the Swiss experience.

This study aimed to examine the association between the availability of firearms at home, and the proportion of firearm suicides in Switzerland in an ecological analysis. The data series were analysed by canton and yielded a fairly high correlation (Spearman's rho=0.60). Thus, the association holds also at a sub-national level.

Culture, risk factors and mortality: can Switzerland add missing pieces to the European puzzle?

BACKGROUND: The aim was to compare cause-specific mortality, self-rated health (SRH) and risk factors in the French and German part of Switzerland and to discuss to what extent variations between these regions reflect differences between France and Germany. METHODS: Data were used from the general population of German and French Switzerland with 2.8 million individuals aged 45-74 years, contributing 176 782 deaths between 1990 and 2000. Adjusted mortality risks were calculated from the Swiss National Cohort, a longitudinal census-based record linkage study. Results were contrasted with cross-sectional analyses of SRH and risk factors (Swiss Health Survey 1992/3) and with cross-sectional national and international mortality rates for 1980, 1990 and 2000. RESULTS: Despite similar all-cause mortality, there were substantial differences in cause-specific mortality between Swiss regions. Deaths from circulatory disease were more common in German Switzerland, while causes related to alcohol consumption were more prevalent in French Switzerland. Many but not all of the mortality differences between the two regions could be explained by variations in risk factors. Similar patterns were found between Germany and France. CONCLUSION: Characteristic mortality and behavioural differentials between the German- and the French-speaking parts of Switzerland could also be found between Germany and France. However, some of the international variations in mortality were not in line with the Swiss regional comparison nor with differences in risk factors. These could relate to peculiarities in assignment of cause of death. With its cultural diversity, Switzerland offers the opportunity to examine cultural determinants of mortality without bias due to different statistical systems or national health policies.

[Botulism: prevention, clinical diagnostics, therapy and possible threat]. / Botulismus: Prävention, Diagnostik, Therapie und mögliche Bedrohungslagen.

In times of increased terrorist threat health professionals need to be prepared for bioterrorist events. The goal must be to give doctors an overview over the current state of knowledge and risk assessment of botulinum toxin. This review is based on Information gathered by a systematic analysis of the literature and by contacting experts. The toxicity of botulinum toxin exceeds any other known natural toxin. Clinical features of botulism consist of an acute, afebrile symmetrical and descending paralysis, regardless of the route of exposure, with normal mental status, sensory functions and electrolyte values. The initial diagnosis is often wrong in individual cases of botulism, but clusters with typical symptoms and two or more cases usually provide the diagnosis. Current treatment is primarily supportive care, respiratory support and antitoxin administration. Early application of antitoxin can limit the extent of the paralysis, but will not reverse it. Antitoxin for adult patients is of equine origin, while children in the USA can be treated with a recently developed human antitoxin. A pentavalent toxoid vaccine is available for persons at high risk of exposure. Botulinum toxin is easily extracted and ubiquitously available. These two features, together with the high toxicity, makes misuse easy. Misuse will continue to occur. Although a rare disease in Western Europe, botulism should be included in the differential diagnosis in patients with specific symptoms of paralysis. There is the potential threat of deliberate release of botulinum toxin. For this reason every outbreak of botulism must be assessed for any possible links to terrorism.

Suicide after bereavement: an overlooked problem.

BACKGROUND: To examine the effect of time on suicide after bereavement among widowed persons. METHOD: The data were extracted from Swiss mortality statistics for the period 1987-2005. The time between bereavement and subsequent death, specifically by suicide, was determined by linkage of individual records of married persons. The suicide rates and the standardized mortality ratios in the first week/month/year of widowhood were calculated based on person-year calculations. RESULTS: The annualized suicide rates in widowed persons were highest in the first week after bereavement: 941 males and 207 females per 100,000. The corresponding standardized mortality ratios were approximately 34 and 19 respectively. In the first month(s) after bereavement, the rates and the ratios decreased, first rapidly, then gradually. Except in older widows, they did not reach the baseline levels during the first year after bereavement. CONCLUSIONS: The suicide risk of widowed persons is increased in the days, weeks and months after bereavement. Widowed persons are a clear-cut risk group under the aegis of undertakers, priests and general practitioners.

Causation of injuries in female football players in top-level tournaments.

BACKGROUND: Analyses of tackle parameters in injury situations have provided valuable information regarding men's football. However, there are no similar data for women's football. OBJECTIVE: To categorise the tackle mechanisms leading to injury in elite women's football. STUDY DESIGN: Retrospective video analysis of injury situations. METHODS: Events associated with all reported injuries during six women's top-level tournaments were analysed on video recordings for tackle parameters. RESULTS: More than half of all injuries were due to tackles from the side (52%, 103/200), whereas tackles from behind were much less commonly involved in injury situations (11%, 21/200). One-footed (65%, 130/200) and upper body (21%, 42/200) tackle actions were most common. Sliding-in tackles leading to injury were the least likely to be sanctioned by match referees. Tackling players (45%, 90/200) were almost as likely to be injured as the tackled player (55%). CONCLUSION: The present study found differences between injury mechanisms in women's football and previously published data on men's football. Further research, especially using video analysis, is needed for a better understanding of risk situations in football.

[Forgoing life-sustaining measures in patients at the end of life in the German-speaking part of Switzerland: results of a death certificate study]. / Begrenzung lebenserhaltender Massnahmen bei Patienten am Lebensende in der deutschsprachigen Schweiz -- Resultate einer Todesfallstudie.

BACKGROUND AND OBJECTIVE: There have not been any comprehensive data from German-speaking countries on the medical practice of withholding or withdrawing treatment at the end of life. This study from the German-speaking part of Switzerland provides the first in-depth analysis in this field. This study is based on data from this region and is a contribution to a large empirical research project on medical end-of-life decisions in 6 European countries (EURELD). METHODS: Continuous random samples (n = 4991) were taken from all deaths in the German-speaking part of Switzerland that had been reported to the Swiss Federal Office of Statistics between June and October 2001. Doctors who had been attending the deceased person were asked to complete mailed questionnaires, their replies being kept strictly anonymous. RESULTS: The response rate was 67 %. Medications were withheld or withdrawn in 48 % of all treatments forgone: among these, antibiotics accounted for 17 %. Other potentially life-sustaining medical measures forgone included artificial hydration (12 %), surgery (7 %), artificial feeding (6 %), chemotherapy (6 %), diagnostic tests (4 %), hospital admissions (3 %), renal dialysis (2 %), blood product infusions (2 %), intubation (2 %), ventilation (2 %), resuscitation (2 %), and radiotherapy (1 %). 43 % of all treatments were forgone in patients who died in hospital, 42 % in nursing homes, and 15 % at home. In almost three-quarters (73 %) of the treatments forgone, a primary-care doctor had ordered the treatment to be withheld or withdrawn. On average, forgoing treatment led to a life-shortening effect of more than one month in 8 % of all cases. The proportion was higher for renal dialysis (25 %), blood products infusion (18 %), and diagnostic tests (16 %). CONCLUSIONS: Forgoing life-sustaining medical treatment comprises a wide range of decisions taken in many different clinical settings. In most cases the likely lifespan is only slightly shortened.

[Nutrition in Switzerland 2002--results of the Swiss Health Survey]. / Ernährung in der Schweiz. Resultate der Schweizerischen Gesundheitsbefragung 2002.

The 2002 Swiss Health Survey is the third survey conducted by the Federal Office of Statistics in intervals of five years. Data are collected of a random sample (n = 19706) of persons aged 15 and over, living in Switzerland: 29% are overweight (BMI 25-29.9 kg/m2), and 8% are obese (BMI 30+ kg/m2). 31% do not care about their nutrition. Less than daily consumption is reported by 34% for fruit, by 18% for vegetable, by 64% for milk, by 39% for milk products. 20% eat every day meat or meat products, 38% do rarely or never consume fish. Inadequate nutritional habits are observed more often in men, young people, and in participants with a low level of education. According to the Swiss Health Surveys of 1992, 1997, and 2002 nutritional habits have hardly improved during the last ten years in Switzerland.

Analysis of the relationship between total cholesterol, age, body mass index among males and females in the WHO MONICA Project.

OBJECTIVE: To explore the relationship between hypercholesterolaemia, age and BMI among females and males. DESIGN: Population-based cross-sectional survey. SUBJECTS: The data came from the initial surveys of the WHO MONICA Project. In all, 27 populations with 48 283 subjects (24 017 males and 24 266 females) aged 25-64 y were used for the analysis. MEASUREMENTS: Total cholesterol, weight, height, BMI, prevalence of hypercholesterolaemia (PHC) defined as cholesterol >/=6.5 mmol/l, and the prevalence of obesity (POB) defined as BMI >/=30 kg/m(2). RESULTS: PHC increased with age, with PHC in males being significantly higher than in females at age range 25-49 y and significantly lower than in females at age range 50-64 y. Age-related increase in hypercholesterolaemia was steeper in females than in males. There was a statistically significant positive association between hypercholesterolaemia and BMI. Multiple logistic regression analysis revealed a negative statistically significant (P<0.001) effect modification involving age and BMI on the risk of having hypercholesterolaemia both in females and males. The relation between PHC and BMI became weaker in higher age groups, with no statistically significant association in females aged 50-64 y. CONCLUSION: Public health measures should be directed at the prevention of obesity in young adults since the strongest effect of obesity on the risk of hypercholesterolaemia has been found in subjects aged 25-39 y.

[Long-term diuretic treatment in heart failure: are there differences between furosemide and torasemide?]. / Diuretika-Langzeitbehandlung bei Herzinsuffizienz: Gibt es Unterschiede zwischen Furosemid und Torasemid?

BACKGROUND: Treatment for congestive heart failure (CHF) is an important factor in rising health care costs especially in patients requiring repeated hospitalisations. Diuretics remain the most frequently utilized drugs in symptomatic patients. In this study the long-term outcome under furosemide and torasemide, two loop diuretics with different pharmacokinetic properties, were evaluated during one year in an ambulatory care setting. AIMS: Comparison of hospitalization rates and estimated costs under long-term treatment with furosemide and torasemide in patients with CHF. METHODS: Retrospective analysis of disease course and resource utilization in 222 ambulatory patients receiving long-term treatment with furosemide (n = 111) or torasemide (n = 111). Data were also compared to those of a similar study including 1000 patients in Germany. RESULTS: Patients receiving long-term treatment with torasemide had a lower hospitalisation rate (3.6%) compared to patients on furosemide (5.4%). Corresponding hospitalization rates in the German study were 1.4% under torasemide and 2% under furosemide. The higher hospitalisation rates in Swiss patients could be explained by a higher average age (75 years vs. 69 years) and a longer duration of symptomatic heart failure (4.1 yrs vs. 0.7 yrs). Cost estimates based on the average number of hospital days (0.54 under torasemide compared to 1.05 under furosemide) indicated that the financial burden could be halved by a long-term torasemide treatment. CONCLUSION: Torasemide with its more complete and less variable bioavailability offers potential clinical and economic advantages over furosemide in the long-term treatment in patients with CHF.

[Depression among the elderly in Switzerland]. / Depression bei Betagten in der Schweiz.

Data for this analysis came from a cross-sectional study on dementia, depression, and disability conducted in Zurich and Geneva in 1995/96. The random sample stratified by age and gender consisted of 921 subjects aged 65 and more. Based on the Canberra Interview for the Elderly, depression was assessed by means of psychogeriatric assessment scales (PAS) according to DSM-III-R criteria. The number of depressive symptoms (NDS) and the prevalence rate of depression (PRD) were computed for the whole sample as well as according to age and gender. To evaluate the independent effects of age as well as gender with regard to the risk of being depressed, multivariate analyses were conducted. On average, 13% of females vs 8% of males reported having at least one depressive symptom. The PAS yielded 298 (41.8%) subjects without depressive symptoms, 341 (50.2%) with 1-3 symptoms, and 60 (8.0%) with four or more. The average NDS was 1.27 (95% CI 1.16-1.39). For females, NDS values statistically significantly higher than those for males were calculated (1.53, 95% CI 1.35-1.70 vs 1.05, 95% CI 0.90-1.20). The NDS increased significantly with age. Subjects with low education levels and being divorced or widowed had statistically significantly higher NDS values than highly educated, married, or single persons. There were strong positive associations between NDS, dementia, and activities of daily living. Multivariate regression analysis revealed gender - however, not age - as a strong risk factor for NDS. Overall PRD amounted to 8.0% (95% CI 5.7-10.2%). Females had statistically significantly higher PRD values than males (10.4%, 95% CI 7.0-13.9% vs 3.9, 95% CI 2.0-5.9%). The PRD increased substantially with age. After adjustment for other risk factors, multivariate logistic regression analysis confirmed the positive statistically significant association between age, gender, and depression.

[Safety aspects of folic acid for the general population]. / Sicherheitsaspekte der Folsäure für die Gesamtbevölkerung.

Periconceptional use of folic acid reduces the risk of neural tube defects considerably. In Switzerland, implementation of these findings could be improved through fortification of a staple food with folic acid. The present paper reviews possible hazards associated with high intake of folic acid in the general population. Among the potential safety issues are interaction between folic acid and zinc, interaction between folic acid and drugs (phenytoin, methotrexate etc.) and hypersensitivity to folic acid. Of main concern are adverse effects of folic acid in cobalamin deficiency. Solutions are discussed.

Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study.

BACKGROUND: Heroin-assisted substitution treatment for severely opioid-dependent drug users has been available in Switzerland since 1994. Our aim was to ascertain the feasibility, safety, and efficacy of this treatment. METHODS: We did a cohort study in 21 community outpatient treatment centres. We assessed 1969 opioid-dependent drug users, who began heroin-assisted substitution treatment between January, 1994, and December, 2000, to ascertain admission and discharge patterns, and patient characteristics. We also followed up a subset of 237 patients who began treatment between Jan 1, 1994, and March 31, 1995, and who stayed with the programme for at least 18 months. We used questionnaires, interviews, and medical examinations done at entry and after 6, 12, and 18 months to assess somatic and mental health, social integration, and treatment outcomes. FINDINGS: More than 70% (1378) of patients remained in treatment for more than a year. Treatment showed positive effects with respect to health and social outcomes. A long stay in treatment was related to a higher chance of starting abstinence-oriented therapy than a short stay. INTERPRETATION: Heroin-assisted substitution treatment might be an effective option for chronically addicted patients for whom other treatments have failed.

Methods of the National Check Bus Project.

OBJECTIVES: Prevention at the worksite is considered increasingly important. This paper describes the methods used in a nationwide prevention campaign performed at a large Swiss bank and a Swiss industrial company. The aim of this project was to encourage general health awareness among company employees. We also aimed to provide the companies with general health analyses of their staff as a basis for future health promotion. Furthermore, new screening methods were evaluated in the field of research. METHODS: Participation in the programme was voluntary and free of charge. The programme targeted all 25,243 employees of the two companies in all regions of Switzerland. A mobile unit was available on site. The programme included a written health questionnaire and medical examinations (e.g., blood pressure, blood tests, ultrasound of the common carotid artery, osteodensitometry, examinations of the eye, etc). Analysis of individual test results, information brochures, and a telephone information service were also provided. Based on the data of the individuals, the "health status" of the employees of the two companies was analysed. The companies did not have access to the data of the individuals. The programme ran from August 1996 to August 1998. RESULTS: With a total of 10,321 persons taking part in the project, the participation rate was 41%. For the different examinations offered, patterns of participation were identifiable that varied with age, hierarchical status within the concern, body mass index, and number of physical complaints of the employee. Some of the variables showed the same trend for different tests, while others showed opposite trends. CONCLUSIONS: Participation in worksite health promotion programmes is dependent on a complex system of individual and structural variables that need to be considered when planning worksite health promotion programmes. Consideration of specific target population characteristics, including motivations and incentives as well as structural constraints is likely to improve participation rates in worksite health promotion programmes among employees.

[Dementia, depression and activity of daily living as risk factors for falls in elderly patients]. / Demenz, Depressionen und Aktivitäten des täglichen Lebens als Risikofaktoren von Stürzen bei Betagten.

OBJECTIVES: Falls among elderly are a well-recognised public health problem. The purpose of the present study was to explore the relation between dementia, number of depressive symptoms, activities of daily living, setting, and risk of falling. METHODS: Data for the analysis came from a cross-sectional study about dementia, depression, and disabilities, carried out 1995/96 in Zurich and Geneva. The random sample stratified, by age and gender consisted of 921 subjects aged 65 and more. The interview was conducted by means of the Canberra interview for the Elderly, extended by short questionnaire. The subject was classified as a faller if the subject and/or the informant had reported a fall within the last 12 months prior to the interview. Logistic-regression analysis was used to determine the independent impact of dementia, depressive symptoms, and ADL-score on risk of falling. RESULTS: The stepwise logistic regression analysis has revealed a statistically significant association between dementia (OR 2.14, 95% CI 1.15-3.96), two resp. three depressive symptoms (OR 1.64, 95% CI 1.04-2.60) as well as four or more depressive symptoms (OR 2.64, 95% CI 1.39-5.02) and the risk of falling. There was no statistically significant relationship between studied risk factors and the risk of being one-time faller. However, we found a strong positive association between dementia (OR 3.92, 95% CI 1.75-8.79), four or more depressive symptoms (OR 3.90, 95% CI 1.55-9.83) and the risk of being recurrent faller. Moreover, residents of nursing homes (OR 8.50, 95% CI 2.18-33.22) and elderly aged 85 or more (OR 2.29, 95% CI 1.08-4.87) were under statistically significant higher risk of sustaining recurrent falls. CONCLUSIONS: The results of the present study confirm that dementia and depression substantially increase the risk of falling.

[Is the general practice laboratory medically and economically valuable?]. / Ist das Praxislabor medizinisch und wirtschaftlich sinnvoll?

UNLABELLED: Between 1998 and 2000 we evaluated the office-based laboratory activities of general practitioners. The aim was to clarify whether there is a medical and economic benefit of these activities. METHODS: The study was performed in four parts: I. A cross-sectional study with a random sample of general practitioners of the German and French speaking part of Switzerland. II. A prospective evaluation of the office-based laboratory activities of 56 GP's. III. A cross-sectional study of the preference of 837 patients in 52 of GP's offices. IV. A consensus panel with nine experts using the RAND method. RESULTS: 1999 there were 55.4 Million laboratory tests ordered by GP's (excl. pediaters) of which 78.9% were analysed in the office-based laboratory. The probability of a second visit is reduced by 60%, if all of the tests could be performed in the office-based laboratory. 85% of the patients appreciate the possibility to discuss the test results within the same consulation. In the consensus panel, 43 tests were proposed of which only bicarbonate, chloride and urea were assessed as not useful for the office based laboratory. CONCLUSION: The office-based laboratory is a well embodied institution in Switzerland. It's predominant advantage is the possibility of point of care testing. It allows a quick management of the patient and avoids unnecessary second consultations.

Infectious diseases and public health: risk-taking behavior during participation in the Swiss program for a medical prescription of narcotics (PROVE).

The medically controlled prescription of narcotics program (PROVE) followed a uniform protocol from January 1, 1994 until December 31, 1996. The program included 800 slots for heroin prescription, 200 slots for intravenous methadone prescription, and 200 slots for intraveneous morphine. Admission criteria were age 20 and above, minimum 2-year duration of daily heroin consumption, failure in at least two previous treatments, and documented social and/or health deficits. There was a very high seroprevalence of hepatitis B (73%) and hepatitis C (82%) among the 1035 entrants. The rate of HIV (15%) was also high compared with prevalence of infection in other therapy programs (methadone program, inpatient therapy). The prevalence of HIV and hepatitis B/C increased with the duration of drug dependence and cocaine use. During treatment, use of street heroin and cocaine could be reduced substantially. After 18 months of continued participation in the program, 74% of patients reported no illegal heroin consumption, and the rate of cocaine abstinence increased from 15% at entry to 41%. Significant declines in visits to the drug scene, illegal income, and needle sharing were also observed. The high prevalence of HIV and hepatitis B and C confirm that a group of drug dependence with severe medical problems was reached in accordance with the admission criteria for the studies. During treatment, a significant reduction in risk-taking behavior was observed in a target population of heroin-dependent persons who failed in previous treatments.

The role of folate, antioxidant vitamins and other constituents in fruit and vegetables in the prevention of cardiovascular disease: the epidemiological evidence.

Evidence that fruit and vegetables may protect against coronary heart disease is accumulating. It is unclear which constituents of fruit and vegetables are responsible for this protective effect. Folate as a co-substrate in homocysteine metabolism may be important. An intake of about 400 micrograms folate equivalents/day seems to be required to achieve stable low homocysteine blood levels. Five of eight epidemiologic studies show significant inverse associations between folate and cardiovascular disease. These associations could be confounded by antioxidant vitamins and/or other substances. In trials examining an association between folate and cardiovascular disease such confounding must be excluded, before specific recommendations can be given. Observational studies suggest that vitamin C plays a role in the aetiology of cardiovascular disease, but there are no completed intervention trials of this vitamin alone. With regard to vitamin E two cohort studies point to cardiovascular benefits with the long-term use of supplements of at least 100 IU/day, but the results of controlled trials are inconclusive. There is some evidence from observational studies of an inverse association between beta-carotene and cardiovascular disease, particularly in smokers. Intervention trials do not support this hypothesis, rather, they suggest a possible harmful effect of beta-carotene supplements in smokers. Nevertheless, protective effects of beta-carotene and vitamin E in different dosages, durations of administration, or different combinations are still possible. The last paragraph of this review discusses limitations of the present and priorities of future research.