Conference report on stroke mortality in the southeastern United States

A workshop to describe and then seek possible causes for the increased stroke mortality in the southeastern United States briefly considered 30 suspected correlates and discussed in more detail the 10 thought to be most likely. Recent age-adjusted stroke mortality rates in adults from industrialized countries reveal marked geographic differences. Age-adjusted statewide stroke mortality rates also differ, and they are higher in the Southeast than elsewhere in the United States. For five southeastern coastal states in the heart of the "Stroke Belt," excess stroke mortality has been present at least since 1930. In a 20-year follow-up of 10,000 veterans, the Stroke Belt had a 25% increase in all-cause mortality and congestive heart failure. A potential cause of increased fatal stroke included hypertension, which was more frequent in the Stroke Belt. No consistent patterns of lifestyle differences or of differences in potassium or calcium intake seemed to explain the higher rates of fatal strokes in the Stroke Belt; however, detailed investigations of smaller populations in localized areas seem warranted. Some data suggest a relationship between socioeconomic status and the Stroke Belt effect. Other differences in the Southeast that could explain, at least partially, the Stroke Belt effect include presence of soft water throughout most of the area, decreased antioxidant intake, and differences in the use of medical care and in the response to antihypertensive drugs. On the basis of available information, the three most likely explanations or partial explanations for the Stroke Belt are increased levels of blood pressure, localized differences in socioeconomic status, and toxic environmental factor(s). Two major recommendations were made: (1) to encourage both patient and caregiver to use all currently available means of decreasing morbidity and mortality by controlling blood pressures at or below normal levels and by reducing other risk factors and (2) to seek precise information about relationships of identified possible causes of increased morbidity and mortality in the Stroke Belt.     

Declining effect of latitude on melanoma mortality rates in the United States. A preliminary study

This article explores the complex barriers which may have prevented the formal integration of the spiritual dimension within programmes of nurse education in the UK. These barriers have been termed intrinsic (arising from within the educational institutions themselves) and extrinsic (reflecting society's and individuals' values, beliefs and cultural norms). It is argued that these barriers have slowed down curriculum innovation and change, preventing the spiritual dimension from receiving due recognition within programmes of nurse education.     

Excess mortality among blacks and whites in the United States

BACKGROUND: Although the general relations between race, socioeconomic status, and mortality in the United States are well known, specific patterns of excess mortality are not well understood. METHODS: Using standard demographic techniques, we analyzed death certificates and census data and made sex-specific population-level estimates of the 1990 death rates for people 15 to 64 years of age. We studied mortality among blacks in selected areas of New York City, Detroit, Los Angeles, and Alabama (in one area of persistent poverty and one higher-income area each) and among whites in areas of New York City, metropolitan Detroit, Kentucky, and Alabama (one area of poverty and one higher-income area each). Sixteen areas were studied in all. RESULTS: When they were compared with the nationwide age-standardized annual death rate for whites, the death rates for both sexes in each of the poverty areas were excessive, especially among blacks (standardized mortality ratios for men and women in Harlem, 4.11 and 3.38; in Watts, 2.92 and 2.60; in central Detroit, 2.79 and 2.58; and in the Black Belt area of Alabama, 1.81 and 1.89). Boys in Harlem who reached the age of 15 had a 37 percent chance of surviving to the age of 65; for girls, the likelihood was 65 percent. Of the higher-income black areas studied, Queens--Bronx had the income level most similar to that of whites and the lowest standardized mortality ratio (men, 1.18; women, 1.08). Of the areas where poor whites were studied, Detroit had the highest standardized mortality ratios (men, 2.01; women, 1.90). On the Lower East Side of Manhattan, in Appalachia, and in Northeast Alabama, the ratios for whites were below the national average for blacks (men, 1.90; women, 1.95). CONCLUSIONS: Although differences in mortality rates before the age of 65 between advantaged and disadvantaged groups in the United States are sometimes vast, there are important differences among impoverished communities in patterns of excess mortality.     

Geographic variation in the decline of stroke mortality in the United States

BACKGROUND AND PURPOSE: This study examines the geographic variation in the decline of stroke mortality rates in the United States. METHODS: National Center for Health Statistics and Bureau of the Census data were used to assess regional and state level temporal trends of stroke mortality in the United States for 1970 to 1989. RESULTS: Underlying- and multiple-cause stroke mortality rates have declined fairly steadily in all regions of the United States and for all race/sex groups, although the rates of decline were greater during 1970 to 1978 than during 1979 to 1989. The declines in underlying-cause rates could not be attributed to a shift toward reporting stroke as a contributing rather than underlying cause of death, since both underlying- and multiple-cause rates declined similarly. There was significant regional variation in the rate of decline, particularly during 1979 to 1989. The South initially had the highest rates, but it experienced the most rapid decline, so that by 1989 the South no longer had the highest rates. States with the most rapid rates of decline were significantly clustered in the South and particularly the Southeast. Most of the decline in overall stroke mortality was due to declines in ischemic stroke mortality. CONCLUSIONS: During 1970 to 1989 there was significant geographic variation in the rate of decline of stroke mortality rates, with the most rapid rates of decline concentrated in the high-rate areas of the South and particularly the Southeast. As a result, there has been a decrease in interregional and interstate variation in stroke mortality rates, which is apparently not due to an artifact of changing reporting patterns.     

The effect of modern intensive monitoring in obstetrics on infant mortality and the incidence of hypoxia and acidosis

We consider intensive monitoring to be fetal monitoring during labor and in the newborn period of all births using the most efficient methods. During the last ten years we have sequentially used the following techniques: Amnioscopy, blood analysis, estrogen determinations in urine, external and internal cardiotokography and internal pressure determinations, gas analyses of umbilical blood. amniotic fluid analyses (phospholipids), ultrasound (B-apparatus) and HCS determinations. All clinics dealing with risk pregnancies should have these techniques available. Total perinatal mortality decreased to below 2% after introduction of cardiotokography. During the last year it decreased to 0.89%. Premature mortality shows the same decrease and is 50% of total mortality. The frequency of premature deliveries remained unchanged at 6.2%. Both improved intensive monitoring and neonatal reanimation and intensive care contributed to the reduction of perinatal mortality. Continuous heart rate recordings make it possible to uncover hypoxic and acidotic states in time and this is of particular value for the premature infant. The incidence of acidosis (pH less than 7.10) was 2.03% before monitoring was introduced and fell to 0.45% this year when intensive monitoring became the rule. No pH lower than 7.0 was found this year. It is thus not sufficient to monitor only cases at risk, since in about 50% of infants born with acidosis no alarming symptoms were found that would have indicated the need for intensive monitoring. Conclusion: Infant mortality should be reduced to less than 1% if the diagnostic tools available are applied. Below this nonviable infants limit further improvement. Perinatal hypoxia and acidosis (below pH 7.10) should also be lower than 0.5% but at least lower than 1%.     

Income dynamics and adult mortality in the United States, 1972 through 1989

OBJECTIVES: The aim of this study was to examine relationships between income and mortality, focusing on the predictive utility of single-year and multiyear measures of income, the shape of the income gradient in mortality, trends in this gradient over time, the impact of income change on mortality, and the joint effects of income and age, race, and sex on mortality risk. METHODS: Data were taken from the Panel Study of Income Dynamics for the years 1968 through 1989. Fourteen 10-year panels were constructed in which predictors were measured over the first 5 years and vital status over the subsequent 5 years. The panels were pooled and logistic regression was used in the analysis. RESULTS: Income level was a strong predictor of mortality, especially for persons under the age of 65 years. Persistent low income was particularly consequential for mortality. Income instability was also important among middle-income individuals. Single-year and multiyear income measures had comparable predictive power. All effects persisted after adjustment for education and initial health status. CONCLUSIONS: The issues of low income and income instability should be addressed in population health policy.     

Maternal and infant care: comparisons between Western Europe and the United States

A series of studies between 1986 and 1990 gathered data on maternal and infant care in ten Western European countries with lower infant mortality rates than the United States and compared the findings both within the European countries and in aggregate with the United States. Results from these studies reveal great variation among the study countries in how perinatal care is financed, staffed by professional and nonprofessional health workers, and provided by public clinics or private offices, and in the number of and locale of the recommended number of prenatal visits. Invariably consistent among the study countries is the nearly complete enrollment of childbearing women in early and continuous prenatal care, and the strong linkage of that care to a generous spectrum of social supports and financial benefits. None of the benefits generally pertains in the United States. The relevance of these observations for the United States suggests that current policies intended to lower economic barriers to a highly medicalized version of maternity care may yield disappointing results unless the perinatal sequence is linked to a more generous set of maternity-related social supports and financial benefits than is now contemplated.     

Trends in United States ovarian cancer mortality, 1979-1995

The authors have compared the results of scalp reductions with extenders with their earlier results of scalp reductions without extenders. The extenders seem to prevent "stretch-back" and provide 30 to 86% more effectiveness when a second reduction is performed 4 weeks later.     

Dementia mortality in the United States. Results of the 1986 National Mortality Followback Survey

It has been proposed that hematopoietic and endothelial cells are derived from a common cell, the hemangioblast. In this study, we demonstrate that a subset of CD34(+) cells have the capacity to differentiate into endothelial cells in vitro in the presence of basic fibroblast growth factor, insulin-like growth factor-1, and vascular endothelial growth factor. These differentiated endothelial cells are CD34(+), stain for von Willebrand factor (vWF), and incorporate acetylated low-density lipoprotein (LDL). This suggests the possible existence of a bone marrow-derived precursor endothelial cell. To demonstrate this phenomenon in vivo, we used a canine bone marrow transplantation model, in which the marrow cells from the donor and recipient are genetically distinct. Between 6 to 8 months after transplantation, a Dacron graft, made impervious to prevent capillary ingrowth from the surrounding perigraft tissue, was implanted in the descending thoracic aorta. After 12 weeks, the graft was retrieved, and cells with endothelial morphology were identified by silver nitrate staining. Using the di(CA)n and tetranucleotide (GAAA)n repeat polymorphisms to distinguish between the donor and recipient DNA, we observed that only donor alleles were detected in DNA from positively stained cells on the impervious Dacron graft. These results strongly suggest that a subset of CD34+ cells localized in the bone marrow can be mobilized to the peripheral circulation and can colonize endothelial flow surfaces of vascular prostheses.     

Epidemiology of hyaline membrane disease in the United States: analysis of national mortality statistics

National mortality statistics for hyaline membrane disease (HMD) and respiratory distress syndrome (RDS) were examined in this study for the years 1968 to 1973. Detailed data were obtained by computer analysis of magnetic tapes from the National Center for Health Statistics. During the six-year interval, HMD/RDS was determined to be the underlying cause of death in 54,064 infants or 9,010 +/- 560 (mean +/- SD) infants per year. Analysis of individual death certificates for 1968 revealed the disease to a major contributing factor in another 24%. Thus, it may be estimated that HMD was involved in the demise of nearly 12,000 neonates per year over this period. This amounts to approximately 20% of all neonatal deaths. On the basis of mortality rates, a trend toward an increased incidence of fatal HMD/RDS was established from 1968 to 1973. Deaths tend to cluster in the summer months and January-February represent the lowest months of recorded fatalities. Analysis of the age at death, reflecting time course of the disease, revealed idential patterns for 1968 to 1970. The number of deaths was found to decline exponentially between the first and fourth 24-hour periods so that 92% of all deaths occurred by 4 days of age. Boys contributed more prominently to the death totals than girls with ratios from 1.62 to 1.76. Examination of mortality rates by race suggested that black permatures have a lower incidence of fatal HMD/RDS. In addition to nationwide figures, those of individual states were compared for three years. Generally, HMD/RDS mortality rates correlated with overall neonatal mortality statistics. Exceptions were observed, however, such as Illinois where low rates for the former coexist with relatively high neonatal death rates. These data respresent the first national mortality statistics for HMD and may prove useful in planning and providing intensive neonatal care.     

Occupational injury and illness in the United States. Estimates of costs, morbidity, and mortality

OBJECTIVE: To estimate the annual incidence, the mortality and the direct and indirect costs associated with occupational injuries and illnesses in the United States in 1992. DESIGN: Aggregation and analysis of national and large regional data sets collected by the Bureau of Labor Statistics, the National Council on Compensation Insurance, the National Center for Health Statistics, the Health Care Financing Administration, and other governmental bureaus and private firms. METHODS: To assess incidence of and mortality from occupational injuries and illnesses, we reviewed data from national surveys and applied an attributable risk proportion method. To assess costs, we used the human capital method that decomposes costs into direct categories such as medical and insurance administration expenses as well as indirect categories such as lost earnings, lost home production, and lost fringe benefits. Some cost estimates were drawn from the literature while others were generated within this study. Total costs were calculated by multiplying average costs by the number of injuries and illnesses in each diagnostic category. RESULTS: Approximately 6500 job-related deaths from injury, 13.2 million nonfatal injuries, 60,300 deaths from disease, and 862,200 illnesses are estimated to occur annually in the civilian American workforce. The total direct ($65 billion) plus indirect ($106 billion) costs were estimated to be $171 billion. Injuries cost $145 billion and illnesses $26 billion. These estimates are likely to be low, because they ignore costs associated with pain and suffering as well as those of within-home care provided by family members, and because the numbers of occupational injuries and illnesses are likely to be undercounted. CONCLUSIONS: The costs of occupational injuries and illnesses are high, in sharp contrast to the limited public attention and societal resources devoted to their prevention and amelioration. Occupational injuries and illnesses are an insufficiently appreciated contributor to the total burden of health care costs in the United States.     

The effect of WIC participation on small-for-gestational-age births: Michigan, 1992

Portal thrombectomy with extended hepatectomy for extensively progressive primary liver cancer (Vp 3), in which the tumor thrombus has spread beyond the first portal branches, will make other non-surgical treatments possible and improve patients quality of life. We have performed extensive resections in 15 cases of such Vp 3 liver cancer. One patient with huge HCC involving retrohepatic IVC underwent in situ extended left hepatectomy without reconstruction of IVC, resulting in postoperative renal failure because of thrombosis in the bilateral renal veins, but 14 other patients' postoperative courses were uneventful. Ten of 14 patients relapsed within one year, but these patients underwent non-surgical treatments, resulting in improvement in the quality of life. The 1-, and 3-year survival rates were 55.6% and 32.5%, respectively.     

The state of psychotherapy in the United States.

This article stems from the 2003 Society for the Exploration of Psychotherapy Integration (SEPI) international panel on the state of psychotherapy. I am pleased to be included in the printed version of this discussion. The state of psychotherapy in the United States is a huge topic. Does psychotherapy reach enough people and meet enough needs? What changes have occurred in response to political, financial, or cultural influences? Many of the subheadings deserve entire conference meetings to thoroughly consider the issues. However, in a time of significant transition for psychotherapy, a broad look at trends and influences may help keep the field of psychotherapy on a desired course. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The history of euthanasia debates in the United States and Britain

Debates about the ethics of euthanasia and physician-assisted suicide date from ancient Greece and Rome. After the development of ether, physicians began advocating the use of anesthetics to relieve the pains of death. In 1870, Samuel Williams first proposed using anesthetics and morphine to intentionally end a patient's life. Over the next 35 years, debates about the ethics of euthanasia raged in the United States and Britain, culminating in 1906 in an Ohio bill to legalize euthanasia, a bill that was ultimately defeated. The arguments propounded for and against euthanasia in the 19th century are identical to contemporary arguments. Such similarities suggest four conclusions: Public interest in euthanasia 1) is not linked with advances in biomedical technology; 2) it flourishes in times of economic recession, in which individualism and social Darwinism are invoked to justify public policy; 3) it arises when physician authority over medical decision making is challenged; and 4) it occurs when terminating life-sustaining medical interventions become standard medical practice and interest develops in extending such practices to include euthanasia.     

Healthy behaviors among women in the United States and Ontario: the effect on use of preventive care

OBJECTIVES: This study examined how several healthy behaviors among women in Ontario and the United States explained (1) the use of preventive health services, (2) differences in use between socioeconomic groups, and (3) differences in use between the two health systems. METHODS: 1990 data on women from the Ontario Health Survey (n = 22,985) and the US National Health Interview Survey (n = 19,092) were analyzed. A woman who avoided smoking and obesity, used seatbelts, and regularly engaged in aerobic exercise was defined as having a healthy lifestyle. Women were considered screened if they reported a mammogram or a breast exam within the previous year or a Pap smear within 2 years. RESULTS: A healthy lifestyle was more common in the United States than Canada among more highly educated groups (odds ratio [OR] = 1.40; 95% confidence interval [CI] = 1.22, 1.60 for college educated) but less common in the United States for those with less than a high school education (OR = 0.52; 95% CI = 0.40, 0.67). Each additional unhealthy behavior decreased the odds of having undergone a mammogram in the previous year by 20%. However, adjusting for the number of unhealthy behaviors did not substantially change the relationship between socioeconomic status and use of preventive services. CONCLUSIONS: The number of healthy behaviors is an important measure of demand for preventive health services. This measure varies across country and socioeconomic group.     

The diffusion of new hospital technologies in the United States

Increases in the real resources used in hospital care have been an important cause behind rising hospital costs in the United States. Many of these resources have taken the form of new hospital technologies, and this paper begins by reviewing the trends in adoption of new hospital technologies over the years 1950-1974. The resource requirements, costs , and to the extent possible the patient benefits, of two of these technologies are then discussed in more detail: intensive care, a widespread facility with many variations, has been a major contributor to hospital costs; radiotherapy has been characterized by a succession of competing technologies. Regulatory efforts such as certificiate-of-need reviews would be more effective if they viewed hospitals as flexible collections of such technologies-with the costs and patient benefits of each to be weighed separately-rather than primarily in terms of numbers of beds. A national center to collect information on the separate technological functions of hospitals and make it available to interested groups would make a useful contribution to hospital regulation.