Two decades of increasing mortality from Parkinson's disease among the US elderly.

To examine the possible role of environmental factors in the cause of Parkinson's disease (PD), we reviewed mortality trends for PD in the United States from 1962 through 1984. We found that age-specific mortality for PD in all demographic groups had changed notably during this 23-year interval. Among whites of both sexes, substantial declines were observed among the middle-aged, while notable increases were seen in the geriatric age groups. Similar changes were found in nonwhites; among nonwhites in the geriatric age range, increases of 22% to 553% were observed among women. Men generally had a 100% higher risk of death due to PD than did women. Whites were at three times the risk of nonwhites. The observed temporal changes appear to reflect improved treatment, better case ascertainment, and a true rise in the incidence of PD, particularly among the elderly. This rise may be due to preventable environmental causes and will require further investigation.

Mortality from primary pulmonary hypertension in the United States, 1979-1996.

STUDY OBJECTIVES: To determine whether primary pulmonary hypertension mortality in the United States increased since 1979 coincident with the introduction of anorexigens. DESIGN: Examination of annual age-adjusted and age-specific primary pulmonary hypertension mortality in the United States from 1979 through 1996 and in five selected states from 1992 through 1996. SETTING: The United States, from 1979 through 1996. PATIENTS OR PARTICIPANTS: Residents of the United States, from 1979 through 1996. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Annual age-adjusted mortality increased at different rates among white men and women and black men and women. The greatest increase was among black women (who also had the highest rates). Age-specific mortality showed a high rate among infants < 1 year old, a low rate in childhood, and an ascending rate throughout the remainder of life. Similar patterns were identified at the state level. CONCLUSIONS: Primary pulmonary hypertension mortality in the United States has increased notably since 1979. Some portion of this increase may be related to the introduction of anorexigens. Improvements in diagnostic recognition may also explain part of the increase in mortality. These results need to be confirmed in a diagnosis validation study, particularly because the same mortality data suggest that the disease may be more common in the elderly than has been previously reported.

Mortality from pulmonary embolism in the United States: 1962 to 1984.

To examine the effect of advances in the prevention of and therapy for PE, we reviewed mortality for PE in the United States from 1962 to 1984. Age-adjusted PE mortality increased by 67 to 100 percent between 1962 and 1974 for white and non-white men and women. From 1975 to 1984, these rates declined by 20 to 28 percent. Non-white PE mortality was greater than white PE mortality; men had a greater risk of PE death than women. Age-specific patterns (more than 40 years of age) of PE mortality followed those of the age-adjusted death rates, with increases noted in all groups between 1962 and 1974 and declines during the 1975-1984 period. These patterns might reflect improved ascertainment of cases and better prevention of disease. The magnitude of the rates suggests that the list of indications for prophylactic anticoagulation should be re-examined for possible expansion.

Decreasing mortality from pulmonary embolism in the United States, 1979-1996.

BACKGROUND: Mortality trends and patterns for pulmonary embolism may yield clues to its aetiology. Previous investigations had identified several mortality contrasts in pulmonary embolism mortality among US residents. These findings had been made in the context of a trend of increasing rates during 1962-1984. METHODS: Annual age-specific and age-adjusted pulmonary embolism mortality rates for US residents during 1979-1996 were compiled from the US National Center for Health Statistics web site. These data were analysed for mortality contrasts and trends. RESULTS: For all racial-gender groups, age-adjusted mortality declined throughout the period. The greatest rate of decline was found among black men, followed by (in decreasing order) black women, white men, other men, white women, and other women. In 1996, the previously observed demographic contrasts of blacks experiencing the highest pulmonary embolism mortality, followed by whites and then others, and the male rate being higher than the female one were still present despite this decline. Age-specific mortality from pulmonary embolism in the US during 1996 also mirrored that reported for the 1970s, with mortality increasing during the life span (the risk of death doubling with each decade of life). Specifically, the annual age-adjusted pulmonary embolism mortality rate in 1996 for white men was 2.4 per 100 000 persons; white women, 2.3 per 100 000 persons; black men, 6.0 per 100 000 persons; black women, 4.8 per 100 000 persons; non-black non-white men, 1.0 per 100 000 persons; and non-black non-white women, 0.7 per 100 000 persons. CONCLUSIONS: Mortality from pulmonary embolism in the US declined significantly during 1979-1996. Several demographic contrasts, particularly an excess among men, continue to exist.

Epidemiology 101: the new frontier.

An introductory course in epidemiology for pre-baccalaureate junior and senior undergraduate students is described as part of a Public Health Option programme. The course was similar to that given in schools of public health with additional material on vital statistics. It was well received by the students and stimulated several students to enter graduate programmes in epidemiology in schools of public health. Epidemiology has now matured as an independent scientific discipline so that consideration should be given to establishing University Departments of Epidemiology similar to those in such fields as statistics and biology.

Disposal-related sharps injuries at a New York City Teaching Hospital.

OBJECTIVE: To characterize disposal-related sharps injuries. DESIGN: A three-part study including (a) descriptive analysis of disposal-related injuries in a 1-year period, (b) 4:1 matched case-control study of nurses injured while using sharps disposal containers, and (c) survey to solicit opinions of users of containers. SETTING: An 1,181-bed teaching hospital in New York City. PARTICIPANTS: For epidemiologic analyses, persons with self-reported injuries identified via New York State and Occupational Safety and Health Administration forms and control nurses without self-reported injuries. For survey, convenience sample of hospital nurses, laboratory workers, and maintenance workers. MAIN OUTCOME MEASURES: Circumstances of injuries determined by study questionnaires. Employee opinions obtained by questionnaires and discussions during small group sessions. RESULTS: Three hundred sixty-one persons reported sharps injuries, of whom 72 (20%) had disposal-related injuries. Persons with disposal-related injuries included four hospital visitors and one patient. Of 67 disposal-related injuries among employees, 25 (37%) directly involved use of a sharps disposal container. Significant risk factors for injury included container height greater than 4 ft above the floor, distance less than 5 ft from site of sharp object use to nearest container, and lack of attendance at universal precautions inservice classes. Survey groups involved 69 employees who identified a variety of preferred features for sharps disposal containers. CONCLUSIONS: Disposal of sharp objects is an important cause of sharps injuries. Ergonomic factors, worker education, and appropriate container design should be considered in injury prevention strategies. Relevant guidelines and regulations are lacking and are needed.

Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery.

During a 30-month period, 20 median sternotomy wound infections or endocarditis occurred after 20 of 1204 (1.7%) cardiac surgery procedures in adults at the University of Maryland Hospital. We examined four risk factors related to the individual undergoing surgery: age, sex, and index of obesity (weight/height), and presence of diabetes mellitus. The odds ratio estimates of the relative risk of infection observed with use of a population control group were as follows: sex (female) 3.5 (p less than 0.05), obesity 2.0, and presence of diabetes mellitus 3.8. For a second control group matched for age, type of operative procedure, and date of operation, the estimated relative risks of infection were sex (female) 2.1, obesity 6.2 (p less than 0.05), and diabetes mellitus 2.0. More precise definition of the relative risk of sternotomy infection associated with obesity and diabetes is required to aid surgeons and patients in making judgments about the relative benefits of surgery and to alert nursing personnel to be particularly aware of early signs of infection in patients at high risk.

Asbestos-associated pleural mesothelioma in school teachers: a discussion of four cases.

The causal relationship between malignant mesothelioma and exposure to asbestos is well established. In part as a result of that association, much public attention has focused on asbestos abatement in buildings, such as public schools, in which that asbestos was used as a construction material. The present communication is a report of four cases of malignant mesothelioma in school teachers whose only apparent exposure to asbestos was in the schools in which they taught. The concerns raised by this report are also discussed.

On antibiotic prophylaxis in cardiac surgery: a risk factor for wound infection.

During a 30-month period, median sternotomy wound infections or endocarditis developed during the first 60 days postoperatively following 20 of 1,204 (1.7%) adult cardiac procedures at the University of Maryland Hospital. Fifty percent of the infected patients received perioperative clindamycin prophylaxis. A retrospective study was conducted in which the odds ratio estimate of the relative risk of sternotomy infection or endocarditis for patients receiving clindamycin prophylaxis compared with patients receiving cefamandole was found to be 17.0 (p less than .001) using population controls and 8.25 (p less than .001) using matched controls. Seventy-five percent of the organisms causing infections, principally Staphylococcus epidermidis, were resistant in vitro to clindamycin. Perioperative clindamycin administration was not fully effective in preventing wound infection following cardiac surgery at our hospital, thus providing indirect evidence for the efficacy of prophylaxis with cephalosporin-containing regimens. Trials of alternative antibiotics to clindamycin for prophylaxis in penicillin-allergic patients undergoing cardiac surgery are indicated.

No association between serum cholesterol and growth in preadolescent American children.

To determine the relation between serum cholesterol level (SCL) and growth in preadolescent children (2-12 years of age) in the United States, we examined the association of SCL and three measures of growth in a national sample of American children from 1971 to 1974. We investigated three parameters: sitting height, standing height, and weight and undertook separate analyses for sex and race. We found no consistent statistically significant associations with any of these three measures of growth. This result did not change when we adjusted the data for age alone or for age, poverty index, serum protein level, and hematocrit. We conclude that growth in this population group is not dependent on SCL.

The "missing cases" of pleural malignant mesothelioma in Minnesota, 1979-81: preliminary report.

Malignant mesothelioma is a sentinel neoplasm for population exposure to asbestiform fibers. Public health officials may be alerted to temporal or spatial clustering of malignant mesothelioma through analyses of vital records, such as death certificates. Hence, the maintenance of the integrity of the vital statistics system, particularly the cause of death statement on the death certificate, is very important. The report by a northeastern Minnesota radiologist in January 1985 of an elevated prevalence of pleural plaques (related to asbestiform fiber exposure) to the Minnesota Department of Health resulted in an investigation of pleural malignant mesothelioma mortality trends in that area and in three other similar areas in the State. In that study, we noted that in several instances malignant mesothelioma (either intrathoracic or unspecified site) was listed on the death certificate in such a manner as to imply that the neoplasm was either a lung cancer or a malignancy of an unspecified site. The effect of this misclassification is to underestimate the mortality from malignant mesothelioma by fourfold to eightfold. Given the importance of malignant mesothelioma as a proxy for past asbestos exposure, it is necessary to determine the extent of such misclassification for all deaths in the United States.

Prevalence of aortic aneurysms in the Twin Cities metropolitan area, 1979-84.

The discharge summaries for Minneapolis-St. Paul metropolitan area residents hospitalized during 1979-84 were reviewed for diagnoses of aortic aneurysms. Annual age-specific and age-adjusted sex-specific hospital discharge diagnosis rates were calculated for all aortic aneurysms, dissecting aortic aneurysms, thoracic aortic aneurysms (nondissecting), and abdominal aortic aneurysms (nondissecting). For each aortic aneurysm type, hospital discharge diagnosis rates were found to increase with age for both men and women. Abdominal aortic aneurysms were the most common type reported (age-adjusted annual rates for men varied between 40.6 and 49.3 per 100,000 population; for women, between 6.8 and 12.0 per 100,000 population). Men were noted to have higher rates for each aneurysm type. An increasing temporal trend was observed for all aortic aneurysms and abdominal aortic aneurysms among men. These findings are reviewed in light of recent data on mortality from aortic aneurysms in the United States.

Gastric cancer etiology: a biochemical hypothesis.

We have proposed a two-stage biochemical model for the etiology of "intestinal" gastric cancer. The model postulates that the gastric mucosal barrier is biochemically pierced as a result of chemical interactions between the mucoproteins and mucopolysaccharides of the barrier and ingested polysaccharrides (starches). This would allow the growth of gastric flora which could produce carcinogenic nitrosamines and/or nitrosamides. Observational and experimental evidence in favor of the model is provided. The model suggests various research initiatives, the results of which might provide the basis for biochemical and physiological methods for the prevention and/or treatment of gastric cancer. Various ways in which the model may be tested are also noted.

Sensitivity and specificity of a screening questionnaire for dry eye.

We developed a Dry Eye Screening Questionnaire for the Dry Eye Epidemiology Projects (DEEP), a proposed large epidemiologic study. All persons who screen positive and a small sample of those who screen negative are to be invited for a diagnostic examination. Containing 19 questions, of which only 14 were used in the analysis, the questionnaire takes only a few minutes to administer on the telephone. To construct a discriminator function and thus a ROC curve, we used stepwise multiple regression on screening responses from a clinic series of 77 cases and 79 controls. Stepwise regression may incorporate into the predictor equation variables whose relation to the predicted is only accidental. Further, misclassification rates are underestimated by the resubstitution method, in which the proportion misclassified is obtained from the same dataset in which the discriminator function was fitted. To counter these problems, we randomly divided the data in half. We chose as predictors only those variables (Dry and Irritated) selected by stepwise regression in both data halves. We estimated unbiased misclassification rates using the unbiased test set method, in which the discriminator is fitted in one data half, and misclassification rates are calculated in the other half. Comparison of ROC curves arising from resubstitution and test set estimates indicates that resubstitution bias in misclassification rate estimation is negligible in our data. A resubstitution estimate made on the entire data is thus preferred. The resulting sensitivity/specificity values are reasonably high (e.g., 60%/94%), suggesting that the questionnaire will be a useful screening tool in the DEEP study. A second discriminator using the sum of all 14 responses is similar in its misclassification characteristics to the first discriminator. A second potentially significant error, arising from applying results from a clinical series to a general population, will be investigated as survey results in DEEP become available.

'Best clinical practice': assessment of processes of care and of outcomes in the US Military Health Services System.

The National Quality Management Program of the Military Health Services System of the United States has undertaken a series of projects whose objective is the active, on-going monitoring and improvement of the effectiveness and efficiency of the care provided to a broad population that encompasses troops on active duty, retirees and dependents. The analytic activities consist of (1) identification by clinical panels of conditions and procedures of interest; (2) collection of data from electronic repositories and from charts to characterize the patients, how they are managed, the clinical outcomes they experience, the resource costs their care entails, and, from questionnaires, their functional status and level of satisfaction, and (3) generation of 'report cards' that inform organizational units down to the level of the hospital of the characteristics of their patients, their practices, and the risk-adjusted outcomes they achieve. The patterns of care employed by the hospitals that obtain the best risk-adjusted outcomes and resource utilization ('best clinical practice') are identified and made known. In addition, (4) a systematic process of developing outcomes-based practice guidelines has been devised. It intent is to serve as a decision-support tool for clinicians. Initial estimates have been obtained of the probable consequences of the application of this tool to operative interventions in childbirth. Use of the tool would result in a higher occurrence of elective Caesarean sections, a reduced rate of emergency Caesarean sections and much lower use of forceps, with an overall improvement in outcomes and lower resource costs. This program is currently in the early phases of implementation. The two principal requirements for the immediate future are (1) education of the clinical and administrative communities in the use of the data and the decision-support tools and (2) evaluation of the consequences of the use of the data by the clinical and administrative communities.