Transgenic insertional mutagenesis. Applications to inner-ear genetics

STUDY OBJECTIVE: Despite significant declines since the late 1960s, coronary mortality remains the leading cause of death for African Americans. African Americans in the US South suffer higher rates of cardiovascular disease than African Americans in other regions; yet the mortality experiences of rural-dwelling African Americans, most of whom live in the South, have not been described in detail. This study examined urban-rural differentials in coronary mortality trends among African Americans for the period 1968-86. SETTING: The United States South, comprising 16 states and the District of Columbia. STUDY POPULATION: African American men and women aged 35-74 years. DESIGN: Analysis of urban-rural differentials in temporal trends in coronary mortality for a 19 year study period. All counties in the US South were grouped into five categories: greater metropolitan, lesser metropolitan, adjacent to metropolitan, semirural, and isolated rural. Annual age adjusted mortality rates were calculated for each urban status group. In 1968, observed excesses in coronary mortality were 29% for men and 45% for women, compared with isolated rural areas. Metropolitan areas experienced greater declines in mortality than rural areas, so by 1986 the urban-rural differentials in coronary mortality were 3% for men and 11% for women. CONCLUSIONS: Harsh living conditions in rural areas of the South precluded important coronary risk factors and contributed to lower mortality rates compared with urban areas during the 1960s. The dramatic transformation from an agriculturally based economy to manufacturing and services employment over the course of the study period contributed to improved living conditions which promoted coronary mortality declines in all areas of the South; however, the most favourable economic and mortality trends occurred in metropolitan areas.     

Socioeconomic inequalities in coronary heart disease and stroke mortality among Australian men, 1979-1993

BACKGROUND: During the 1970s in Australia, mortality from coronary heart disease (CHD) and stroke was higher among lower socioeconomic groups and inequalities were widening. This analysis examines subsequent trends in socioeconomic inequalities, with reference to socioeconomic patterns in major cardiovascular risk factors. METHODS: Socioeconomic status was defined by occupation. Age-standardized mortality rates were calculated for men aged 25-64, using death registration data and labour force estimates for 1979-1993. Risk factor data were taken from three cross-sectional population surveys conducted in 1980, 1983 and 1989. RESULTS: Men in manual occupations were at least 35 percent more likely to die from CHD than men in professional occupations and 60 percent more likely to die from stroke. Their 5-year population risk of a coronary event was 30 percent higher. Since 1979, both groups experienced reductions in coronary risk and mortality. CONCLUSIONS: Socioeconomic inequalities in CHD mortality continued to widen during the early 1980s, stabilized thereafter and persisted into the 1990s. Decreases in blood pressure and smoking prevalence contributed most to declines in coronary risk and to socioeconomic differentials.     

Cardiovascular mortality of Turkish nationals residing in West Germany

PURPOSE: To test the hypothesis that cardiovascular mortality of Turkish nationals residing in West Germany (mainly former "guest workers" and their families) has been increasing over the past 15 years. Reasons would be their minority status and migration-related lifestyle changes. METHODS: Using registry data for the period 1981-1994, we calculated mortality rates from cardiovascular disease (CVD) (international classification of diseases (ICD) 390-459), ischemic heart disease (IHD) (ICD 410-414) and cerebrovascular disease (CVA) (ICD 430-438) of Turkish nationals aged 25-64 years and residing in West Germany, numbering 730,000 in 1981 and 941,000 in 1994. RESULTS: Between 1981 and 1994, age-adjusted CVD mortality rates (per 100,000) decline from 103 to 85 (-18%) in Turkish men and from 227 to 149 (-34%) in West German men. IHD mortality declines from 64 to 53 (-16%) in Turkish men and from 138 to 82 (-41%) in German men. CVD mortality of Turkish women remains around 45 while that of West German women declines from 84 to 57 (-33%). CONCLUSIONS: Our hypothesis was not confirmed. Turkish residents experience a stable or decreasing CVD and overall mortality which is lower than that of West Germans. Selective return to Turkey of individuals manifestly ill with CVD is improbable. Neither minority status nor a postulated unfavorable genetic disposition currently have a discernible effect on CVD mortality rates of Turkish residents. Future research should relate individual migration history, socio-economic status, and risk factor levels to mortality experience.     

Poland and United States Collaborative Study on Cardiovascular Epidemiology. A comparison of HDL cholesterol and its subfractions in populations covered by the United States Atherosclerosis Risk in Communities Study and the Pol-MONICA Project

HDL cholesterol (HDL-C) levels are inversely related to coronary heart disease (CHD) risk, and HDL-C distributions vary among countries. Poland is one of the few developed countries in which CHD rates are increasing at the same time that US rates have been falling, but whether these differences are explained by differences in risk factors such as HDL-C has not been determined. To examine this possibility, levels of HDL-C and its subfractions were compared in US and Polish urban and rural men and women aged 45 to 64 years. Age-adjusted HDL-C means were 0.20 mmol/L higher in urban Polish men and 0.37 mmol/L higher in rural Polish men than in their US counterparts (P < .0001); means in urban Polish women were 0.06 mmol/L higher (P < .05) and in rural Polish women 0.09 mmol/L higher (P < .001) than in their US counterparts. Adjustment for age, education, alcohol intake, smoking, BMI, heart rate, and menopause status (in women) had little effect on differences. Means of HDL2 and HDL3 levels showed similar between-country differences, although differences were minimal for HDL2 in urban men and women, and HDL3 means did not differ between rural women. BMI was inversely related to HDL-C and both subfractions in all gender-country-site strata (P < .001), and alcohol was directly related to HDL-C (P < .001) in all strata except Polish women. Cigarette smoking was negatively related to HDL-C and both subfractions in all US samples except HDL2 in urban men, whereas in Polish samples, significant associations were found only in urban women for HDL-C and in rural and urban women for HDL3. Age, heart rate, and education showed inconsistent or no association with HDL-C and its subfractions in either country. This profile of HDL-C and its subfractions in Polish samples contrasts sharply with the opposite trend in CHD mortality rates, which suggests either that other risk factors may account for the trends or that the relationship between HDL-C and CHD may differ between the two countries.     

Diversity in the renal hemodynamic effects of dihydropyridine calcium blockers in spontaneously hypertensive rats

BACKGROUND: Death rates from coronary hearts disease have exhibited remarkable declines in most industrialised countries. Cardiovascular mortality has been the subject of extensive research and we considered it important to analyse recent local population based data on hospital outcomes of acute myocardial infarction (AMI). AIM: To document the trends in in-hospital mortality from AMI in Victoria from 1987-1994. METHODS: This was a retrospective analysis of data from the Victorian Inpatient Minimum Database relating to all public acute care hospitals. All separations recording a principal diagnosis 410 (AMI) were selected. Changes in distribution of AMI separations, in-hospital mortality, and changes in length of stay were examined. RESULTS: The mean age of women admitted was 72 years compared with 64 years for men. Women comprised around a third of the overall sample but the proportion varied from 13% in those under 50 years to 57% among those aged 80 years and over. A striking decline in mortality was observed throughout the eight year period. The relative age adjusted decline was 33.5% (40% in males and 26% in females) with rates remaining higher in women. This decline occurred despite the increasing representation of those aged over 80 years. There was a significant decline in the mean length of stay (1.8 days) over the eight year period but this is likely to have had only minimal impact on mortality rates. CONCLUSION: We have documented welcome declines in in-hospital mortality from AMI that are not an artefact of declining lengths of stay. Our observations parallel those in similar overseas studies. Large changes in medical management have taken place from the mid 1980s and may be partly responsible, but a change in disease process cannot be ruled out.     

Risk factors for cardiorespiratory and all cause mortality in men and women in urban Scotland: 15 year follow up

STUDY OBJECTIVE: To describe the relationship between risk factors, risk behaviours, symptoms and mortality from cardiorespiratory diseases in an urban area with high levels of socioeconomic deprivation. A cohort study of 15,411 men and women aged 45-64, comprising 80% of the general population of Paisley and Renfrew, Scotland. OUTCOMES: Mortality after 15 years from coronary heart disease(ICD 410-4), stroke(ICD 430-8), respiratory disease(ICD 460-519) and all causes. MAIN RESULTS: Mortality rates from all causes were 19% in men aged 45-49, 31% in men aged 50-54, 42% in men aged 55-59 and 57% in men aged 60-64. The rates are considerably higher than those reported in previous UK prospective studies. For women the rates were 12%, 18%, 25% and 38% respectively. In general men and women showed similar relationships between risk factor levels and mortality rates. People in manual occupations had higher mortality rates. Raised levels of systolic and diastolic blood pressure were associated with increased coronary, stroke and all cause mortality rates. Plasma cholesterol had no such association with all cause mortality rates. High and low levels of body mass index were associated with higher mortality rates than intermediate levels. A relationship between short stature and increased mortality rates was observed in men and women. FEV1 expressed as a percentage of the expected value showed the strongest relationship with mortality rates, particularly for respiratory disease, but also for deaths from coronary heart disease, stroke and all causes. CONCLUSIONS: A similar pattern of relationship between risk factor levels and mortality rates exists in men and women in Renfrew and Paisley. Respiratory impairment as measured by FEV1% predicted appears to be the most likely explanation of the observed high all cause mortality rates in this population.     

Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991

OBJECTIVE: To investigate the reasons for the decline in deaths attributed to ischaemic heart disease in Poland since 1991 after two decades of rising rates. DESIGN: Recent changes in mortality were measured as percentage deviations in 1994 from rates predicted by extrapolation of sex and age specific death rates for 1980-91 for diseases of the circulatory system and selected other categories. Available data on national and household food availability, alcohol consumption, cigarette smoking, socioeconomic indices, and medical services over time were reviewed. MAIN OUTCOME MEASURES: Age specific and age standardised rates of death attributed to ischaemic heart disease and related causes. RESULTS: The change in trend in mortality attributed to diseases of the circulatory system was similar in men and women and most marked (> 20%) in early middle age. For ages 45 to 64 the decrease was greatest for deaths attributed to ischaemic heart disease and atherosclerosis (around 25%) and less for stroke (< 10%). For most of the potentially explanatory variables considered, there were no corresponding changes in trend. However, between 1986-90 and 1994 there was a marked switch from animal fats (estimated availability down 23%) to vegetable fats (up 48%) and increased imports of fruit. CONCLUSION: Reporting biases are unlikely to have exaggerated the true fall in ischaemic heart disease; neither is it likely to be mainly due to changes in smoking, drinking, stress, or medical care. Changes in type of dietary fat and increased supplies of fresh fruit and vegetables seem to be the best candidates.     

National trends in the use of antibiotics by primary care physicians for adult patients with cough

BACKGROUND: Increased antibiotic use for outpatient illnesses has been identified as an important determinant of the recent rise in antibiotic resistance among common respiratory pathogens. Efforts to reduce the inappropriate use will need to be evaluated against current trends in the outpatient use of antibiotics. OBJECTIVES: To examine national trends in the use of antibiotics by primary care physicians in the care of adult patients with cough and identify patient factors that may influence antibiotic use for these patients. METHODS: This study was based on a serial analysis of results from all National Ambulatory Medical Care Surveys beginning in 1980 (when therapeutic drug use was first recorded) to 1994 (the most recent survey year available). These surveys are a random sampling of visits to US office-based physicians in 1980, 1981, 1985, and annually from 1989-1994. Eligible visits included those by adults presenting to general internists, family practitioners, or general practitioners with a chief complaint of cough. A total of 3416 visits for cough were identified over the survey years. Survey results were extrapolated, based on sampling weights in each year, to project national rates of antibiotic use for patients with cough. Additional analyses examined the rates of antibiotic use stratified by patient age, race, and clinical diagnosis. RESULTS: Overall, an antibiotic was prescribed 66% of the time during office visits for patients with cough: 59% of patient visits in 1980 rising to 70% of visits in 1994 (P = .002 for trend). In every study year, white, non-Hispanic patients and patients younger than 65 years were more likely to receive antibiotics compared with nonwhite patients and patients 65 years or older, respectively. CONCLUSIONS: The rate of antibiotic use by primary care physicians for patients with cough remained high from 1980 to 1994, and was influenced by nonclinical characteristics of patients.     

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.     

Stroke incidence, case fatality, and mortality in the WHO MONICA project. World Health Organization Monitoring Trends and Determinants in Cardiovascular Disease

BACKGROUND AND PURPOSE: This report compares stroke incidence, case fatality, and mortality rates during the first years of the WHO MONICA Project in 16 European and 2 Asian populations. METHODS: In the stroke component of the WHO MONICA Project, stroke registers were established with uniform and standardized rules for case ascertainment and validation of events. RESULTS: A total of 13,597 stroke events were registered from 1985 through 1987 in a total background population of 2.9 million people aged 35 to 64 years. Age-standardized stroke incidence rates per 100,000 varied from 101 to 285 in men and from 47 to 198 in women. The combined stroke attack rates for first and recurrent events were approximately 20% higher than incidence rates in most populations and varied to the same extent. Stroke incidence rates were very high among the population of Finnish men tested. The incidence of stroke was, in general, higher among populations in eastern than in western Europe. It was also relatively high in the Chinese population studied, particularly among women. The case-fatality rates at 28 days varied from 15% to 49% among men and from 18% to 57% among women. In half of the populations studied, there were only minor differences between official stroke mortality rates and rates measured on the basis of fatal events registered and validated for the WHO MONICA stroke study. CONCLUSIONS: The WHO MONICA Project provides a unique opportunity to perform cross-sectional and longitudinal comparisons of stroke epidemiology in many populations. The present data show how large differences in stroke incidence and case-fatality rates contribute to the more than threefold differences in stroke mortality rates among populations.     

Random coil conformation of a Gly/Ala-rich insert in IkappaB alpha excludes structural stabilization as the mechanism for protection against proteasomal degradation

BACKGROUND: In recent years, mortality from lung cancer has increased rapidly in Korea, a South East Asian country with a high prevalence of smoking. The objectives of this study are to examine how age, period, and birth cohort effects contributed to trends in lung cancer mortality in Korea 1980-1994, and to predict lung cancer mortality rates for 1995-2004. METHODS: Age- and sex-specific lung cancer mortality rates were obtained from annual reports of the National Office of Statistics in Korea. Poisson regression models were used to estimate age, period and cohort effects. RESULTS: Among men, age-adjusted annual mortality rates from lung cancer (per 100000) increased from 3.7 in 1980 to 17.8 in 1994; corresponding rates for women were 1.4 and 7.0. As age increased, mortality rates from lung cancer increased more rapidly in men than in women. Within the same age group, the mortality of younger cohorts was higher than older cohorts. The average annual number of lung cancer deaths projected for the years 2000-2004 among men and women will be 15441 and 3572 respectively, while the average annual age-adjusted mortality rates from lung cancer (per 100000) will be 65.4 for men and 15.1 for women. These rates correspond to 17.7- and 10.7-fold increases over the 1980 mortality rates in men and women, respectively. CONCLUSION: These results, in conjunction with trends in tobacco consumption, indicate that mortality from lung cancer in both men and women will increase substantially through the early part of the 21st century in Korea.     

Cancer mortality in Italy, 1994, and an overview of trends from 1955 to 1994

BACKGROUND: Data and statistics are presented on cancer death certification in Italy, updating previous publications covering the period 1955-1993. METHODS: Data for 1994 and the quinquennium 1990-94 subdivided into 30 cancer sites are presented in 8 tables, including age- and sex-specific absolute and percentage frequencies of cancer deaths, and crude, age-specific and age-standardized rates, at all ages and truncated for the 35-64 year age group. Trends in age-standardized rates for major cancer sites are plotted from 1955 to 1994. RESULTS: The age-standardized (world standard) death certification rates from all neoplasms steadily declined from the peak of 199.2/100,000 males in 1988 to 186.3 in 1994, and in females from 102.5 in 1989 to 98.6 in 1994. Ever larger was the decline in truncated rates, for males from the peak of 275.1/100,000 in 1983 to 223.2 (-19%) in 1994, and for females from 151.6/100,000 in 1987 to 136.4 (-10%). A major component of the favourable cancer mortality trends in males was lung cancer (accounting for 31,000 deaths in both sexes combined in 1994), whose overall age-standardized rates declined from 60.3 in 1987-89 to 54.6/100,000 males in 1994 (-9%), and from the peak of 96.7 in 1983 at ages 35 to 64 to 72.7 in 1994 (-25%). In contrast, female lung cancer rates have remained stable from 1992 onwards, but have increased from 7.2 to 7.7 at all ages and from 10.6 to 11.0 at age 35-64 between 1985-89 and 1990-94. These different trends in the two sexes reflect the patterns and trends in smoking among Italian males and females. CONCLUSIONS: Cancer mortality trends in Italy over the period 1990-94 were relatively favourable, mainly reflecting the decline in lung cancer rates in males, together with the persistent declines in gastric cancer in both sexes and in cervix uteri for women. Continuous advancements were registered for neoplasms amenable to treatment, essentially testicular cancer, Hodgkin's disease and childhood leukaemias. The major unfavourable trends were observed for non Hodgkin's lymphomas, and require therefore further monitoring, besides a clearer understanding of their determinants. Italy maintains an intermediate level of cancer mortality on a European scale, suggesting that further progress is possible, mostly for tobacco-related neoplasms in males.     

Health difference in eastern Europe: preliminary findings from the Nowa Huta study

This paper reports the findings of a retrospective study of differential mortality trends among men in a cohort of steelworks employees during the period 1974-1993, a period which encompassed the rise of Solidarity, martial law, and the transition to democracy in Poland. The Nowa Huta study traced vital status for 34,141 individuals and found few systematic differences in death rates among the social groupings it compared. However, there was a significant temporary increase in mortality differentials between skilled and unskilled manual workers, as well as between men of manual worker and peasant farmer origin, in 1981. In addition, differences between manual and non-manual workers opened up after 1991 and reached statistical significance in 1993. This paper considers the extent to which employment at the Nowa Huta steelworks, experienced within a specific and changing political context, may have contributed to the pattern of findings revealed by the study. The paper argues that an adequate account of the East-West health divide should include explicit consideration of qualitative differences in the structuring the social distribution of health.     

Soft tissue modeling for the esthetic single-tooth implant restoration

In 1994, stroke was responsible for the death of 4,994 men and 7,601 women in the Netherlands, corresponding to 7.5% of all deaths in men and 11.4% in women. Age-adjusted stroke mortality declined by 39% for men and by 45% for women between 1972 and 1994. However, the decline in mortality levelled off after 1987. In contrast to mortality, age-adjusted discharge rates increased by 47% for men and by 28% for women during the study period. The decline in mortality was equally distributed over the age groups, while the increase in the number of hospital admissions was more pronounced in the older age groups. The analyses by diagnostic subgroups of stroke showed the importance of increasing diagnostic capabilities in the hospital setting. The use of diagnostic subgroups in national mortality data was of limited value, illustrated by the fact that 70% of all stroke deaths in 1994 belonged to the ill-defined type of stroke.     

Effects of a long-term hypertension control program on stroke incidence and prevalence in a rural community in northeastern Japan

BACKGROUND AND PURPOSE: Although randomized clinical trials have demonstrated the benefit of antihypertensive treatment in preventing stroke, the effectiveness of community-based programs is largely unknown. We investigated long-term community-based prevention activities. METHODS: In rural northeastern Japan, people aged > or = 30 years numbered 3219 in the full intervention community and 1468 in the minimal intervention community in 1965. Systematic blood pressure screening and health education began in 1963. Stroke was registered through 1987. RESULTS: More than 80% of people aged 40 to 69 years were screened in both communities in the 1960s. One community charged for screening services after 1968, whereas the other community intensified intervention; subsequently, screening rates and the follow-up of hypertensive individuals declined in the minimal intervention community, especially in men. In men, stroke incidence declined more (P < 0.001) in the full intervention (42% in the period 1970 to 1975, 53% in the period 1976 to 1981, and 75% in the period 1982 to 1987) than in the minimal intervention community (5% increase, 20% decrease, and 29% decrease, respectively); in women, the stroke incidence declined about 45% to 65% in both communities. Changes in stroke prevalence paralleled those in stroke incidence. Trends in systolic blood pressure levels tend to explain the differential stroke rates in men. CONCLUSIONS: Delivery of hypertension control services through intensive, free, community-wide screening and health education was effective in prevention of stroke for men in a community.     

Changes in subarachnoid hemorrhage mortality, incidence, and case fatality in New Zealand between 1981-1983 and 1991-1993

BACKGROUND AND PURPOSE: As with total stroke, mortality rates from subarachnoid hemorrhage (SAH) have declined in New Zealand since the mid-1970s. Data from the Auckland Region Stroke studies allow an understanding of reasons for the change, as SAH incidence and 28-day case fatality rates were measured as part of population-based stroke registers. METHODS: National death registrations were used to describe the trends in mortality rates from SAH (International Classification of Diseases [ICD] code 430) among men and women in New Zealand. Changes in incidence and case fatality rates were determined from 2 large-scale population-based stroke registries carried out in 1981-1983 and 10 years later in Auckland. Similar methodology and case ascertainment techniques were used in both studies. RESULTS: The mortality rates from SAH declined in both men and women after the mid-1970s. The mortality rate remained higher among women than men. The incidence of SAH was lower in 1991-1993 (11.3 per 100,000) compared with 1981-1983 (14.6 per 100,000). In the younger age groups, the decrease was mostly due to a lower incidence among men, whereas in the older age groups women older than 65 years had a lower incidence. There was no consistent change in case fatality rates between the 2 periods in either men or women. CONCLUSIONS: Mortality rates from SAH have decreased in both men and women. This decrease may be explained by a decrease in the incidence of SAH, because case fatality rates showed no change.     

Rate control and sinus rhythm maintenance in atrial fibrillation: national trends in medication use, 1980-1996

BACKGROUND: Little is known about national patterns of pharmacological treatment of atrial fibrillation, in particular, use of medications for ventricular rate control and for restoration and maintenance of sinus rhythm. METHODS: We analyzed 1555 visits by patients with atrial fibrillation to randomly selected office-based US physicians included in National Ambulatory Medical Care surveys conducted in 1980, 1981, 1985, and 1989 through 1996. To determine national trends, we evaluated the proportion of atrial fibrillation visits with reported use of rate control medications (digoxin and antiarrhythmics in classes II and IV) and sinus rhythm medications (classes IA, IC, and III). RESULTS: The use of rate control agents decreased from 79% of atrial fibrillation visits in 1980-1981 to 62% in 1994-1996. Declining use was noted for both digoxin (76% in 1980-1981 to 53% in 1994-1996) and beta-blockers (19%-13%). After their introduction, the use of verapamil hydrochloride and diltiazem hydrochloride increased to 15% of atrial fibrillation visits in 1994-1996. Sinus rhythm agent use decreased from 18% of visits in 1980-1981 to 4% in 1992-1993 and then rose to 13% in 1994-1996. The use of class IA agents declined from 18% in 1980-1981 to 3.5% in 1992-1993 and then increased to 8% in 1994-1996. Quinidine remained the most widely used sinus rhythm medication, despite its declining share of this category. Newly available sotalol hydrochloride and amiodarone hydrochloride were used in 3.6% of visits in 1994-1996. CONCLUSIONS: Despite changes in the treatment of atrial fibrillation, digoxin remains the dominant rate control medication. Medications for sinus rhythm maintenance are not widely used. Quinidine use declined prominently in the 1980s, possibly because of concerns about proarrhythmic effects. The use of sinus rhythm agents, however, is now rising.     

Time trends in long-term survival after stroke: the Northern Sweden Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) study, 1985-1994

BACKGROUND AND PURPOSE: Stroke mortality rates and case fatality of stroke have declined since the beginning of the 1970s in Sweden, but the incidence of stroke has been stable. The aim of this study was to analyze trends in long-term survival after stroke. METHODS: Within the framework of the population-based WHO Multinational Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Project, all acute stroke events were recorded in the age group 25 to 74 years in northern Sweden during the period 1985 to 1994. All first-ever stroke patients were followed for information on vital status (minimum follow-up time was 1 year). Survival time was related to time period of stroke onset, stroke diagnosis, and concomitant diseases. RESULTS: Survival times for a total of 6819 first-ever stroke patients (4057 men and 2762 women) were analyzed. Age-adjusted odds ratio for death within 1 year after stroke was 0.70 (95% confidence interval [CI], 0.55 to 0.88) in the period 1993 to 1994 as compared with the period 1985 to 1986 in men and 0.69 (95% CI, 0.53 to 0.90) in women. Corresponding odds ratios were 0.73 in men and 0.70 in women among those who survived the first 28 days. Similar improvements were seen for 3- and 5-year survival. Improvements in survival over time were most marked among patients with ischemic stroke. There was no improvement in survival over time among patients with the most severe deficits at onset. CONCLUSIONS: Gradually improved survival, both short and long term, was observed during the 10-year study period. The improvements are not explained by changes in known confounding prognostic factors.     

Trends of morbidity and mortality in chronic heart failure in Catalonia

INTRODUCTION: The epidemiology of chronic heart failure, specifically its morbidity and mortality, is insufficiently known, despite the fact that it has an important economic impact because of the pharmacological treatment and the high hospitalization rate. OBJECTIVE: To analyze the trends of mortality and morbidity of chronic heart failure in Catalonia during the periods 1975-1994 and 1989-1994 respectively. PATIENTS AND METHODS: Specific mortality and morbidity rates (ages 45-65, and older than 65) were calculated for both sexes. Standardised mortality rates were also calculated for mortality rates using the European population as the reference. RESULTS: The trend of mortality of chronic heart failure in the population of 45-65 is stable, the rates being higher for men than for women. The trend in the age group older than 65 shows an important increase from 1983 on, higher in women than in men. Morbidity (hospitalization discharge rates) increases slightly in the population of 45-65 years, especially in men; in the population older than 65 an important increase is observed for both sexes. CONCLUSIONS: Trend of mortality is increasing specifically in women older than 65, while trends of morbidity are clearly increasing for both age groups.     

The recent decline in mortality from coronary heart disease, 1980-1990. The effect of secular trends in risk factors and treatment

OBJECTIVE: To examine whether secular trends in risk factor levels and improvements in treatment can account for the observed decline in coronary heart disease mortality in the United States from 1980 to 1990 and to analyze the proportional contribution of these changes. DATA SOURCES: Literature review, US statistics, health surveys, and ongoing clinical trials. STUDY SELECTION: Data representative of the US situation nationwide reported in adequate detail. DATA EXTRACTION: A computer-simulation state-transition model of the US population between the ages of 35 and 84 years was developed to forecast coronary mortality. The input variables were estimated such that the combination of values led to an adequate agreement with reported coronary mortality figures. Subsequently, secular trends were modeled. DATA SYNTHESIS: Actual coronary mortality in 1990 was 34% (127,000 deaths) lower than would be predicted if risk factor levels, case-fatality rates, and event rates in those with and without coronary disease remained the same as in 1980. When secular changes in these factors were included in the model, predicted coronary mortality in 1990 was within 3% (10,000 deaths) of the observed mortality and explained 92% of the decline; only 25% of the decline was explained by primary prevention, while 29% was explained by secondary reduction in risk factors in patients with coronary disease and 43% by other improvements in treatment in patients with coronary disease. CONCLUSIONS: These results suggest that primary and secondary risk factor reductions explain about 50% of the striking decline in coronary mortality in the United States between 1980 and 1990 but that more than 70% of the overall decline in mortality has occurred among patients with coronary disease.