Physical abuse among depressed women

BACKGROUND: The evidence-based approach to medical care involves the explicit use of evidence on the magnitude of the effects of interventions to inform diagnostic and treatment decisions. This article critiques current mainstream guidelines on the management of hypertension in the elderly (aged 60 years and over) and presents an alternative evidence-based approach. METHODS: Three major national and international guidelines for the management of hypertension from the United Kingdom (UK), the United States (US) and from a joint World Health Organisation/International Society of Hypertension (WHO/ISH) Working Party were appraised and the evidence on which they were based was reviewed. The relevant evidence was also assessed to determine the likely magnitude of risks and benefits of anti-hypertensive treatment in older people and an alternative approach to making treatment decisions, based on the New Zealand guidelines for the management of hypertension, is described. RESULTS: Hypertension management guidelines from the UK, US and WHO/ISH made similar recommendations about which elderly patients should be treated, although there were some ambiguities in their advice. Treatment recommendations were based primarily on blood pressure levels which were set at about 160 mm Hg systolic and/or 90 mm Hg diastolic. The threshold levels were based mainly on the cut-off blood pressure levels used in randomised trials of anti-hypertensive drug treatment, rather than the estimated magnitude of treatment benefit. Each of the guidelines acknowledged the important effect of associated cardiovascular disease (CVD) risk factors on the likely benefits of treatment, but did not expand on the magnitude of this effect. No patient-specific estimates of the likely absolute benefits of treatment were provided in any of the guidelines. In contrast the New Zealand guidelines for the management of hypertension recommend the use of explicit estimates of absolute CVD risks and benefits to inform treatment decisions. They were designed to provide practitioners with estimates of the likely absolute risk of CVD in patients with different risk factor profiles and with estimates of the absolute benefits of treatment. The New Zealand guidelines recommend that drug treatment be considered in patients with a 5-year risk of CVD of about 10-15% or more; approximately 25 patients with a 10-15% risk would require treatment for 5 years to prevent one CVD event. As elderly patients are generally at higher absolute CVD risk than younger people, the New Zealand recommendation give priority to the treatment of older patients. In order to take account of differences in life expectancy and the medical costs of caring for elderly people, absolute risk-based guidelines can be improved by incorporating potential years of life gained from treatment and the cost-effectiveness of treatment expressed as $/quality adjusted life years gained. Preliminary analyses indicate that the cost-effectiveness of treatment is generally greatest in patients in their 60s and early 70s. Treatment in younger people is not usually very cost-effective because of their low absolute risk of CVD and the cost-effectiveness of treatment in people over about 75 years declines because of the increasing cost of non-CVD morbidity. CONCLUSIONS: The explicit assessment of absolute CVD risks and likely treatment benefits in patients with hypertension can usefully inform treatment decisions and provide a more rational basis for initiating therapy than blood pressure levels alone. This approach highlights the generally greater CVD risk and potential treatment benefits in older compared with younger hypertensive patients. The absolute risk-based approach can be further enhanced by providing decision makers with patient-specific data on the potential life years gained from treatment and its cost-effectiveness. (ABSTRACT TRUNCATED)     

The relationship of head and neck irradiation to the subsequent development of thyroid neoplasms

Individuals who have received head and neck radiation for benign conditions have a markedly increased risk of developing thyroid, salivary, and perhaps breast cancer as compared to the general population. Although the relative risk is very high, the absolute risk that any one individual who has had head or neck irradiation will develop a subsequent malignancy is low. Identification of these patients through some type of screening procedure may be beneficial in terms of prevention of subsequent morbidity and perhaps mortality from cancer, especially thyroid and salivary cancer. The risks of any detection or prophylaxis program must be carefully weighed against the probable, but unproved benefits of early detection. A major unresolved question is the natural history of microscopic thyroid carcinoma in the 25 yr-40 yr old radiation exposed population.     

A meta-analysis of infant outcomes after breech delivery

OBJECTIVE: To estimate the risks of neonatal morbidity and mortality associated with a trial of labor and with elective cesarean for the term breech infant. DATA SOURCES: Using the terms "breech," "malpresentation," and "external cephalic version," we used the MEDLINE and Health Planning and Administration data bases to search the English-language literature from January 1981 to June 1993. The search was supplemented with a review of the reference lists of key articles and text chapters. METHODS OF STUDY SELECTION: We included randomized trials or cohort studies that specified selection criteria for a vaginal delivery, provided detailed outcome data, and allowed for analysis by intended mode of delivery. DATA EXTRACTION AND SYNTHESIS: Nine studies met the inclusion criteria. We pooled the weighted results from these studies to estimate the risks of birth injuries and perinatal death, and the risk differences between trial of labor and no trial of labor groups. The pooled risk for any injury was 1.00% after a trial of labor and 0.09% after elective cesarean. For any injury or death, the risk was 1.23% after a trial of labor and 0.09% after elective cesarean. The risk differences for injury and injury or death were 0.89 and 1.10%, respectively. These are significantly different from zero, suggesting an increased risk of injury and injury or death after a trial of labor. CONCLUSION: When management decisions are made, the potential increased risk of neonatal morbidity after a trial of labor should be considered along with the increased maternal risk from cesarean delivery.     

Organizing and Evaluating Uncertainty in Geotechnical Engineering

Probabilistic methods are potentially useful in four stages of a typical project: site characterization and evaluation, evaluation of designs, decision making, and construction control. In evaluation of projects, it can be useful to express risk numerically. When uncertainties can be quantified and model errors are understood, reliability theory may be used. Event-tree analysis can be a framework for effectively applying judgment concerning uncertainty. The use of quantified risk in decision making is limited by standards for acceptable risk; good communication with a client is essential. Unless clients or regulators are interested in quantifying risks as part of decision making, engineers will continue to rely on traditional methods. When risks are large and the costs of absolute safety are large, clients are interested in discussing risks. Issues concerning the adequacy of existing structures such as earth dams are stimulating interest in risk assessment, and there will be spin-off from developments in earthquake engineering. More and better examples of applications of probabilistic methods are needed.     

Features of the spike activity of globus pallidus neurons and pallido-thalamic functional interactions during targeted verbally cued movements in humans

OBJECTIVE: To estimate the relative risk and lifetime risk of ovarian cancer in women with various categories of family history. DESIGN: A meta-analysis of all published case-control and cohort studies. METHODS: Pooled relative risk estimates were calculated for the case control studies, using the Mantel-Haenzel method. These estimates were combined with the relative risks from the cohort studies. The pooled estimates of relative risk were used to estimate lifetime risks of ovarian cancer from age 15 up to age 75, for various categories of family history. MAIN OUTCOME MEASURES: Relative risks and lifetime risks of developing ovarian cancer were calculated for the categories of women with 1. an affected first degree relative; 2. an affected mother; 3. an affected sister; and 4. women with more than one affected relative. RESULTS: The relative risk to first degree relatives is 3.1 (95% CI 2.6-3.7). There is some evidence that this relative risk declines with age. The relative risk to mothers of cases 1.1 (95% CI 0.8-1.6) was lower than the relative risks to sisters: 3.8 (95% CI 2.9-5.1), and daughters: 6.0 (95% CI 3.0-11.9); the explanation of this difference is unclear. CONCLUSIONS: Women with a family history of ovarian cancer have a substantially higher risk of developing ovarian cancer compared with women without such a history. However the risk is small for most categories of family history, except for the small number of individuals who have more than one affected relative.     

Assessing the relationship between maternal opiate use and neonatal mortality

We undertook a number of meta-analyses to estimate more precisely the relationship between neonatal mortality and use of opiates in three groups of women. First, women who continued to use illicit heroin throughout pregnancy; secondly, women stabilized on methadone at the time of conception or shortly after and thirdly, women who use heroin well into pregnancy with late entry into methadone treatment, or who continued to use illicit heroin during pregnancy while receiving methadone. FINDINGS: The pooled estimates of the relative risks of neonatal mortality for separate heroin and methadone use were both near unity: 1.47 (95% CI 0.88-2.33) and 1.75 (95% CI 0.60-4.59), respectively. The result for heroin may be due to the inclusion in the meta-analysis of a particularly large study, which, unlike the two other smaller studies included found a relative risk near unity. When this study was excluded from the meta-analysis the pooled estimate of the relative risk of neonatal mortality for heroin use was 3.27 (95% CI 0.95-9.60). In contrast to the results for use of methadone only, the pooled relative risk associated with heroin and methadone use was 6.37 (95% CI 2.57-14.68). CONCLUSIONS: The increased relative risk for neonatal mortality associated with women using heroin and methadone during pregnancy, compared to those stabilized on methadone, is probably due to the chaotic and high-risk life-style associated with illicit heroin use and not solely to the use of heroin and methadone per se. It is recommended tht women who use heroin well into pregnancy with late entry into methadone treatment, or who continue to use illicit heroin during pregnancy while receiving methadone, receive special attention over and above that provided to women stabilized on methadone.     

Rationale for systematic reviews

Systematic literature reviews including meta-analyses are invaluable scientific activities. The rationale for such reviews is well established. Health care providers, researchers, and policy makers are inundated with unmanageable amounts of information; they need systematic reviews to efficiently integrate existing information and provide data for rational decision making. Systematic reviews establish whether scientific findings are consistent and can be generalised across populations, settings, and treatment variations, or whether findings vary significantly by particular subsets. Meta-analyses in particular can increase power and precision of estimates of treatment effects and exposure risks. Finally, explicit methods used in systematic reviews limit bias and, hopefully, will improve reliability and accuracy of conclusions.     

Genetic and non-genetic basis of essential hypertension: maladaptation of human civilization to high salt intake

A controlled laboratory experiment was used to assess the efficacy of the cognitive processes that underlie risk taking decision making in young and elderly people. Thirty-six participants took part in the study: half the subjects were elderly (mean age of 74) and the other half were young adults (mean age of 19). The elderly participants made equivalent decisions to those of the control young adults. Both age-groups of participants systematically and comparably changed their behavior as a function of risk levels. Furthermore, the elderly participants, relative to young adults, did not exhibit any slowing down in the speed of processing the information involved in making risk taking decisions, reflecting that healthy elderly people are cognitively apt to making risk taking decisions. Both age-groups took comparably less time on the easy trials (trials with either low or high levels of risk) and comparably more time on the difficult trials (trials with medium levels of risk).     

Maternal and neonatal lead exposure in southern Italy

BACKGROUND: Over the past 20 years, there has been remarkable improvement in the chances of survival of patients treated in burn centers. A simple, accurate system for objectively estimating the probability of death would be useful in counseling patients and making medical decisions. METHODS: We conducted a retrospective review of all 1665 patients with acute burn injuries admitted from 1990 to 1994 to Massachusetts General Hospital and the Shriners Burns Institute in Boston. Using logistic-regression analysis, we developed probability estimates for the prediction of mortality based on a minimal set of well-defined variables. The resulting mortality formula was used to determine whether changes in mortality have occurred since 1984, and it was tested prospectively on all 530 patients with acute burn injuries admitted in 1995 or 1996. RESULTS: Of the 1665 patients (mean [+/-SD] age, 21+/-20 years; mean burn size, 14+/-20 percent of body-surface area), 1598 (96 percent) lived to discharge. The mean length of stay was 21+/-29 days. Three risk factors for death were identified: age greater than 60 years, more than 40 percent of body-surface area burned, and inhalation injury. The mortality formula we developed predicts 0.3 percent, 3 percent, 33 percent, or approximately 90 percent mortality, depending on whether zero, one, two, or three risk factors are present. The results of the prospective test of the formula were similar. A large increase in the proportion of patients who chose not to be resuscitated complicated comparisons of mortality over time. CONCLUSIONS: The probability of mortality after burns is low and can be predicted soon after injury on the basis of simple, objective clinical criteria.     

Effect of prenatal alcohol and cigarette exposure on two- and six-month-old infants'' adrenocortical reactivity to stress

Biologic data on benzene metabolite doses, cytotoxicity, and genotoxicity often show that these effects do not vary directly with cumulative benzene exposure (i.e., concentration times time, or c x t). To examine the effect of an alternate exposure metric, we analyzed cell-type specific leukemia mortality in Pliofilm workers. The work history of each Pliofilm worker was used to define each worker's maximally exposed job/department combination over time and the associated long-term average concentration associated with the maximally exposed job (LTA-MEJ). Using this measure, in conjunction with four job exposure estimates, we calculated SMRs for groups of workers with increasing LTA-MEJs. The analyses suggest that a critical concentration of benzene exposure must be reached in order for the risk of leukemia or, more specifically, AMML to be expressed. The minimum concentration is between 20 and 60 ppm depending on the exposure estimate and endpoint (all leukemias or AMMLs only). We believe these analyses are a useful adjunct to previous analyses of the Pliofilm data. They suggests that (a) AMML risk is shown only above a critical concentration of benzene exposure, measured as a long-term average and experienced for years, (b) the critical concentration is between 50 and 60 ppm when using a median exposure estimate derived from three previous exposure assessments, and is between 20 and 25 ppm using the lowest exposure estimates, and (c) risks for total leukemia are driven by risks for AMML, suggesting that AMML is the cell type related to benzene exposure.     

Socioeconomic differences in risk of myocardial infarction 1971-1994 in Sweden: time trends, relative risks and population attributable risks

BACKGROUND: The general trend in incidence of myocardial infarction (MI) in the Stockholm area changed from increasing to decreasing around 1980. The objective of this study is to examine time trends in incidence in major socioeconomic strata, relative risk between socioeconomic groups and population risk attributable to socioeconomic differences during this period. METHODS: All cases of MI from 1971 to 1986 were identified from hospital discharge and cause-of-death registers. Person-years for each year of follow-up were calculated from the population register in the Stockholm region 1971-1986. Census registers were used for information on socioeconomic status. Register information was individually linked through the Swedish personal identification number. Supplementary information for 1992-1994 was taken from the case-control study SHEEP (Stockholm Heart Epidemiology Program). RESULTS: The decline in MI risk among male high- and middle-level employees started in 1976 and in male manual workers in 1981. For women incidence increased from 1971 to 1986 among manual workers and decreased among high- and middle-level employees. The increase over time of the relative risk from low socioeconomic position continued into the 1990s. Despite the reduction of the category of manual workers, the population attributable risk from socioeconomic differences also increased over time. The process of social change influencing the size of the socioeconomic groups contributes to the change in time trends of MI morbidity. CONCLUSIONS: The increase over time of relative and population attributable risks of MI from low socioeconomic status add to the public health importance of social inequity.     

Perceptions of absolute versus relative differences between personal and comparison health risk.

Objective: To explain inconsistent results in previous attempts to determine whether, when presented with health risk information, people focus primarily on information about their own risk status or on a comparison with others. Design: A randomized between-groups experiment in which participants were presented with hypothetical cardiac risk information. We examined whether affective responses were primarily sensitive to the relative difference between personal and comparison risk, rather than the absolute difference. Main Outcome Measures: Participants' negative affective response to the risk information. Results: When relative differences were held constant, participants' responses were independently influenced by both personal risk and comparative standing, effects that were greatly attenuated when absolute differences were held constant. When maintaining constant absolute differences, personal and comparison risk information appeared to interact. Conclusion: Previous studies tended to maintain constant absolute risk differences and so may have underestimated the impact of personal risk information. Participants' responses were sensitive to the way the risk difference was constructed. Basing experimental design decisions on assumptions about the information participants will respond to can lead to misinterpretations of the basis of risk judgments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Socioeconomic inequalities in morbidity and mortality in western Europe. The EU Working Group on Socioeconomic Inequalities in Health

BACKGROUND: Previous studies of variation in the magnitude of socioeconomic inequalities in health between countries have methodological drawbacks. We tried to overcome these difficulties in a large study that compared inequalities in morbidity and mortality between different countries in western Europe. METHODS: Data on four indicators of self-reported morbidity by level of education, occupational class, and/or level of income were obtained for 11 countries, and years ranging from 1985 to 1992. Data on total mortality by level of education and/or occupational class were obtained for nine countries for about 1980 to about 1990. We calculated odds ratios or rate ratios to compare a broad lower with a broad upper socioeconomic group. We also calculated an absolute measure for inequalities in mortality, a risk difference, which takes into account differences between countries in average rates of illhealth. FINDINGS: Inequalities in health were found in all countries. Odds ratios for morbidity ranged between about 1.5 and 2.5, and rate ratios for mortality between about 1.3 and 1.7. For men's perceived general health, for instance, inequalities by level of education in Norway were larger than in Switzerland or Spain (odds ratios [95% CI]: 2.57 [2.07-3.18], 1.60 [1.30-1.96], 1.65 [1.44-1.88], respectively). For mortality by occupational class, in men aged 30-44, the rate ratio was highest in Finland (1.76 [1.69-1.83]), although there was no large difference in the size of the inequality in those countries with data. For men aged 45-59, for whom France did have data, this country had the largest inequality (1.71 [1.66-1.77]). In the age-group 45-64, the absolute risk difference ranked Finland second after France (9.8% [9.1-10.4], 11.5% [10.7-12.4]), with Sweden and Norway coming out more favourably than on the basis of rate ratios. In a scatter-plot of average rank scores for morbidity versus mortality. Sweden and Norway had larger relative inequalities in health than most other countries for both measures; France fared badly for mortality but was average for morbidity. INTERPRETATION: Our results challenge conventional views on the between-country pattern of inequalities in health in western European countries.     

The prognostic value of the QT interval and QT interval dispersion in all-cause and cardiac mortality and morbidity in a population of Danish citizens

AIMS: To evaluate the prognostic value of the QT interval and QT interval dispersion in total and in cardiovascular mortality, as well as in cardiac morbidity, in a general population. METHODS AND RESULTS: The QT interval was measured in all leads from a standard 12-lead ECG in a random sample of 1658 women and 1797 men aged 30-60 years. QT interval dispersion was calculated from the maximal difference between QT intervals in any two leads. All cause mortality over 13 years, and cardiovascular mortality as well as cardiac morbidity over 11 years, were the main outcome parameters. Subjects with a prolonged QT interval (430 ms or more) or prolonged QT interval dispersion (80 ms or more) were at higher risk of cardiovascular death and cardiac morbidity than subjects whose QT interval was less than 360 ms, or whose QT interval dispersion was less than 30 ms. Cardiovascular death relative risk ratios, adjusted for age, gender, myocardial infarct, angina pectoris, diabetes mellitus, arterial hypertension, smoking habits, serum cholesterol level, and heart rate were 2.9 for the QT interval (95% confidence interval 1.1-7.8) and 4.4 for QT interval dispersion (95% confidence interval 1.0-19-1). Fatal and non-fatal cardiac morbidity relative risk ratios were similar, at 2.7 (95% confidence interval 1.4-5.5) for the QT interval and 2.2 (95% confidence interval 1.1-4.0) for QT interval dispersion. CONCLUSION: Prolongation of the QT interval and QT interval dispersion independently affected the prognosis of cardiovascular mortality and cardiac fatal and non-fatal morbidity in a general population over 11 years.     

The efficacy and safety of exercise programs in cardiac rehabilitation

Physical activity performed by patients with coronary heart disease is a two-edged sword. A number of biological changes produced by regular exercise may reduce the risk of future cardiac events, while the increase in cardiac work produced by this same exercise can predispose the patient to sudden cardiac death. Data from observational studies as well as randomized clinical trials demonstrate a lower cardiac mortality rate for men participating in exercise rehabilitation programs vs nonparticipants. Overall, exercise program participants appear to experience a reduction of approximately 25% in cardiac and all-cause mortality, but no single study has provided definitive results. During medically supervised exercise, the risk of cardiac death based on reports of programs in the United States is approximately one event in every 60,000 participant-hours of exercise. At this rate, a typical rehabilitation program that has 95 patients exercising 3 h.wk-1 could expect a sudden cardiac death during an exercise session once every 4 yr. No data have been published on the morbidity or mortality benefits or risks of home-based exercise or for women participants. Also, the contribution of continuous electrocardiographic monitoring to the safety of exercise training of cardiac patients is yet to be defined.     

Cholesterol management in high-risk patients without heart disease. When is lipid-lowering medication warranted for primary prevention?

A particularly important question for primary prevention of CHD is when to initiate cholesterol-lowering drugs in patients at risk. The two most important factors to consider are the serum LDL cholesterol level and the absolute risk, based on the presence or absence of other risk factors. The intensity of therapy can be modified according to the other risks at play. For example, diabetes mellitus is a particularly powerful risk factor for morbidity and mortality from CHD. Therefore, middle-aged or elderly diabetic patients can reasonably be treated as if they already have established CHD. Other risk factors are less dangerous, but when a patient has several such factors, intensive cholesterol-lowering therapy often is indicated. Except for patients at highest risk, a 3- to 6-month trial of nondrug therapy is warranted in an effort to achieve the target of therapy without drugs or with low doses of drugs. If patients are appropriately selected for therapy, cholesterol management for primary prevention of CHD should rival secondary prevention in reducing the burden this disorder imposes on society.     

Predictor combination in binary decision-making situations.

Professional psychologists are often confronted with the task of making binary decisions about individuals, such as predictions about future behavior or employee selection. Test users familiar with linear models and Bayes's theorem are likely to assume that the accuracy of decisions is consistently improved by combination of outcomes across valid predictors. However, neither statistical method accurately estimates the increment in accuracy that results from use of additional predictors in the typical applied setting. It was demonstrated that the best single predictor often can perform better than do multiple predictors when the predictors are combined using methods common in applied settings. This conclusion is consistent with previous findings concerning G. Gigerenzer and D. Goldstein's (1996) "take the best" heuristic. Furthermore, the information needed to ensure an increment in fit over the best single predictor is rarely available. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficacy of screening mammography among women aged 40 to 49 years and 50 to 69 years: comparison of relative and absolute benefit

In randomized controlled trials, screening mammography has been shown to reduce mortality from breast cancer about 25% to 30% among women aged 50 to 69 years after only five to six years from the initiation of screening. Among women aged 40 to 49 years, trials have reported no reduction in breast cancer mortality after seven to nine years from the initiation of screening; after 10 to 14 years there is a 16% reduction in breast cancer mortality. Given that the incidence of breast cancer for women aged 40 to 49 years is lower and the potential benefit from mammography screening smaller and delayed, the absolute number of deaths prevented by screening women aged 40 to 49 years is much less than in screening women aged 50 to 69 years. Because the absolute benefit of screening women aged 40 to 49 years is small and there is concern that the harms are substantial, the focus should be to help these women make informed decisions about screening mammography by educating them of their true risk of breast cancer and the potential benefits and risks of screening.