Apheis: public health impact of PM10 in 19 European cities

STUDY OBJECTIVE: Apheis is a public health surveillance system that aims to provide European, national, regional, and local decision makers, environmental health professionals, and the general public with up to date and easy to use information on air pollution and public health. This study presents the health impact assessment done in 19 cities of Western and Eastern European countries. DESIGN: Apheis developed guidelines for gathering and analysing data on air pollution and the impact on public health. Apheis has analysed the acute and chronic effects of fine particles on premature mortality using the estimates developed by Aphea2 study and two American cohort studies. This health impact assessment was performed for different scenarios on the health benefits of reducing levels of particles less than 10 microm in size (PM(10)). MAIN RESULTS: PM(10) concentrations were measured in 19 cities (range: 14-73 microg/m(3)). The population covered in this health impact assessment includes nearly 32 million inhabitants. The age standardised mortality rates (per 100 000 people) range from 456 in Toulouse to 1127 in Bucharest. Reducing long term exposure to PM(10) concentrations by 5 microg/m(3) would have "prevented" between 3300 and 7700 early deaths annually, 500 to 1000 of which are associated with short term exposure. CONCLUSIONS: Apheis shows that current levels of air pollution in urban Europe have a non-negligible impact on public health, and that preventive measures could reduce this impact, even in cities with low levels of air pollution.     

Serum vitamin A concentration and the risk of hip fracture among women 50 to 74 years old in the United States: a prospective analysis of the NHANES I follow-up study

BACKGROUND: Recent studies on the association between vitamin A and fracture risk have focused on samples with high vitamin A intake. We analyzed a cohort that was more representative of the overall U.S. population to test the hypothesis that both high and low serum vitamin A concentrations increase the risk of hip fracture. METHODS: We utilized data on 2799 women who were 50 to 74 years of age from the first National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. There were 172 incident hip fractures during the 22-year follow-up period. Using Cox regression analysis, we analyzed the relation between baseline serum vitamin A (retinol and retinyl esters) concentration, as a continuous variable and by quintiles, and hip fracture risk. RESULTS: While there was no linear relation between serum vitamin A concentration and the risk of hip fracture in the multivariate analysis (hazard ratio [HR] per SD increase = 1.0; 95% confidence interval [CI]: 0.9 to 1.2), analysis by quintiles revealed a U-shaped relation between serum vitamin A concentration and hip fracture. Fracture risk was significantly higher among subjects in the lowest (HR = 1.9; 95% CI: 1.1 to 3.3) and highest (HR = 2.1; 95% CI: 1.2 to 3.6) quintiles compared with those in the middle quintiles. CONCLUSION: Both low and high serum vitamin A concentrations may be associated with an increased risk of hip fracture.     

A report from the international consensus on diagnosing and treating the infected diabetic foot

In persons with diabetes, foot infection, that is, invasion and multiplication of microorganisms in tissues accompanied by tissue destruction or a host inflammatory response, usually begins with skin trauma or ulceration 1. While most foot infections remain superficial, they can spread to subcutaneous tissues, including muscle, joints, and bone. Many diabetic foot ulcers eventuate in an amputation; infection plays a role in approximately 60% of cases 2-4. Neuropathy is the main factor leading to skin breaks, while arterial perfusion largely affects infection outcome. Among the factors predisposing diabetic patients to foot infections are ill-defined immunological perturbations 56; foot anatomy may foster proximal spread of infection and ischemic necrosis 78.     

Effect of Interleukin-6 promoter polymorphisms in survivors of myocardial infarction and matched controls in the North and South of Europe. The HIFMECH Study

Elevated plasma IL-6 levels have been implicated in the pathogenesis of coronary heart disease. We have investigated the association of two polymorphisms in the promoter of IL-6 (-572G>C and -174G>C) with levels of inflammatory markers and risk of myocardial infarction (MI) in a European study of MI survivors and age-matched controls from two high-risk centres in the North of Europe, and two low risk centres in the South. IL-6 and CRP levels were similar in controls in both regions, but were higher in cases. For the -174G>C polymorphism the rare -174C allele showed a regional difference in allele frequency, being more common in the North European group (0.43 vs 0.28; p < 0.0005), where -174C allele carriers showed an apparent reduced risk of MI compared to -174GG homozygotes (OR 0.53, 95%CI 0.32, 0.86). No such effect was observed in the South or with the -572G>C in either group. Neither genotype was associated with a significant effect on plasma IL-6 levels in either cases or controls. Furthermore, no regional difference was observed in the frequency of the -572G>C SNP, suggesting that these polymorphisms are unlikely to be contributing to the observed increased risk of cardiovascular disease in Northern Europe.     

Length of stay and antipsychotic treatment costs of patients with acute psychosis admitted to hospital in Spain.

Abstract. Objective: The aim of this study was to describe the length of stay, cost of drug treatment, diagnostic tests and other therapeutic measures in acute psychotic patients admitted to acute in-patient psychiatric units and to analyse the factors associated with these. Methods: A retrospective review was made of medical records of 200 patients admitted for acute psychosis in eight Spanish hospitals. Information was collected concerning the length of stay, cost of drug treatment and diagnostic tests; bivariate and multivariate analysis was made of factors associated with length of stay and cost of antipsychotic drug treatment. Results: The average admission cost ranged between 2,830.29 and 3,624.95 euros, with a wide variability among hospitals. Of this cost, 94.3% corresponded to fixed costs, 3.4% to diagnostic tests and 2.4% to drug treatment (84.2% of this latter cost corresponded to antipsychotic drugs). Age younger than 25 years and a diagnosis of schizophrenia were associated with longer hospital stays; longer length of stay, the presence of aggressiveness/agitation, a diagnosis of schizophrenia, age younger than 25 years and the use of atypical antipsychotics were associated with higher costs in antipsychotic drug treatment. Conclusions: The hospital admission cost of an acute psychotic episode is mostly dependent on the structural costs derived from in-patient treatment. The differences in costs seem to be related to the different length of stay schemes used by the various hospitals rather than to the clinical characteristics of patients or the drugs used.* The Psychosp Group includes: Ana Alvarez Díaz, Sonia Cruz Pardo (Hospital General de Guadalajara), Milagros Anaya Turrientes, Leonor Sanz Vila, Marta Soler (Hospital Ramón y Cajal de Madrid), Alicia Díez del Pino, Sonia González Ponsjoan, Antonia M^a Mejías Corbacho (Hospital Insular de Las Palmas), María Forés Mayán, Juan Rojo, Mónica Suárez (Hospital Conxo de Santiago),Gregorio Gómez, Salvador Peiró (Fundación Instituto de Investigación en Servicios de Salud, Valencia), Iris Guadarrama, Javier Rejas (Pfizer Spain, Madrid), Isabel Martín Herranz, Juan C. Yañez Rubal (Hospital Juan Canalejo de La Coruña), Montserrat Navarro (Hospital de Santa María, Lleida), Amaya Navarte, José Luis Vila Jato (Hospital General de Santiago), Ramón Pla Poblador, Susana Redondo Capafons (Hospital Mutua de Tarrasa), Josep Rivas, Francesc Sorio (Hospital Clinic i Provincial, Barcelona).     

STRIDE 1: effects of the selective ET(A) receptor antagonist, sitaxsentan sodium, in a patient population with pulmonary arterial hypertension that meets traditional inclusion criteria of previous pulmonary arterial hypertension trials

Sitaxsentan (SITAX; Thelin, Encysive Corporation, Bellaire, TX, U.S.A.) is a highly selective oral endothelin-A receptor antagonist. STRIDE-1, a 12-week randomized, doubleblind, placebo-controlled trial of sitaxsentan for pulmonary arterial hypertension showed significant benefit in 6-minute walk distance, functional class and hemodynamics. Pulmonary arterial hypertension clinical trials traditionally limit enrolment to class III/IV patients with idiopathic pulmonary arterial hypertension or pulmonary arterial hypertension related to connective tissue disease, who have a baseline 6-minute walk distance of < 450 m. In contrast, STRIDE-1 included milder cases: class II patients, no baseline 6- minute walk cut-off, and congenital heart disease patients. We now present the STRIDE-1 subset who would have qualified under traditional inclusion criteria. The results were: change for placebo (mean +/- SE) vs change for sitaxsentan (mean +/- SE) vs treatment effect (mean), all statistically significant: 6-minute walk (m): -26 +/- 13, 39 +/- 10, 65; mean right atrial pressure (mmHg): 2.1 +/- 0.8, -1.2 +/- 0.5, -3.3; mean pulmonary arterial pressure (mmHg): 0.4 +/- 1.5, -4.7 +/- 1.5, -5.1; cardiac index (L/min per m): -0.09 +/- 0.09, 0.38 +/- 0.06, 0.47; pulmonary vascular resistance (dyne.s.cm): 85 +/- 60, -274 +/- 47, -359. A 45% improvement in functional class was seen in sitaxsentan-treated patients (P = 0.0005). Thus, in the STRIDE-1 subpopulation that met enrolment criteria of previous pulmonary arterial hypertension trials, improvement in efficacy parameters with sitaxsentan therapy was even greater than seen in the entire STRIDE-1 population.     

Truth telling and truthfulness in the care for patients with advanced dementia: an ethnographic study in Dutch nursing homes

The purpose of this study was to investigate and analyze the moral tension that exists in the care for demented nursing home patients, between the principle of respect for autonomy and the value that is attached to respect for the subjective world of the patient. To this end an ethnographical field study was carried out by two researchers in two Dutch nursing homes. Among the central topics that evolved were the different moral problems that nurses experience concerning truth telling and acting truthfully in relation to demented patients. In situations unrelated to the dementia and its diagnosis, the right to be informed is in principle respected, even if the information is sometimes painful. More specific questions of demented patients about their situation are a regular cause of embarrassment for their carers, who rely on various treatment strategies to deal with such questions. These strategies are often successful. However, when they fail, the nurses are faced with a problem they cannot solve, namely the loss of a common shared world and the resulting unmentionable truth about the diagnosis of dementia, as objective basis and legitimization for their approach to the demented patient. We conclude that in the training and professional support given to nurses, more attention should be paid to (awareness of) the moral problems that arise from this loss of a common shared world, so that they can react to the subjective world of demented patients without feeling that they are deceiving them.     

Microalbuminuria independently predicts all-cause and cardiovascular mortality in a British population: The European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) population study

BACKGROUND: In patients with diabetes or hypertension, raised albuminuria is independently associated with an increased risk of all mortality, cardiovascular morbidity and mortality, and renal insufficiency. The role of albuminuria in the general population is still controversial. We therefore undertook this study to examine the relationship between albuminuria and all-cause, cardiovascular disease (CVD) and non-CVD mortality in the general population. METHODS: Prospective population-based cohort study of 20 911 individuals aged 40-79 years recruited in 1993-1997 for the EPIC-Norfolk Study (UK) and followed-up for an average of 6.3 years. Random spot urine specimens were collected at baseline and the albumin-to-creatinine ratio measured. Participants were categorized into normoalbuminuria, microalbuminuria, and macroalbuminuria ordered groups. At follow-up, vital status and cause of death were obtained from the UK Office for National Statistics. RESULTS: During follow-up, 934 deaths were registered. Age-adjusted all-cause mortality rate increased significantly across categories of baseline albuminuria (5.3, 5.2, and 6.3/1000 person years (pyrs) across tertiles of normoalbuminuria, 8.7/1000 pyrs for microalbuminuria, and 18.4/1000 pyrs for macroalbuminuria, P < 0.001 for trend); CVD, 1.6, 1.7, 2.1, 4.3, 12.6/1000 pyrs (P < 0.001); and non-CVD, 3.7, 3.5, 4.2, 4.4, 5.8/1000 pyrs (P = 0.052) respectively. The multivariate hazard ratio for all-cause mortality associated with microalbuminuria was 1.48 (95% CI: 1.20, 1.79), and CVD 2.03 (95% CI: 1.55, 2.67). The association with non-CVD mortality was only significant in men. CONCLUSIONS: The significant increased risk of all-cause mortality especially from CVD associated with microalbuminuria, suggest that this may be a useful indicator in identifying those in the population at greatest absolute risk of fatal CVD events alongside conventional CVD risk factors.     

Surveillance of influenza in Apulia, Italy, 1999-2000, 2000-2001, 2001-2002, and 2002-2003 seasons

BACKGROUND: The objective of this study was to evaluate, within the Italian National Influenza Epidemiological and Virological Surveillance, the rate of vaccination coverage, the incidence of Influenza Like-Illness (ILI), the incidence of Acute Respiratory Illness (ARI), and to identify the virus strains circulating in Apulia from 1999 to 2003. METHODS: Vaccination coverage rates were calculated based on the number of doses administered to individuals > 65 years of age. Every week, sentinel physicians reported ILI and ARI cases having occurred among their patients. Voluntary general practitioners (GPs) and paediatricians (Ps) collected oropharyngeal swab samples from patients suspected with ILI. Influenza viruses were isolated and identified by cell culture (MDCK cells) and RT-PCR. Virological surveillance was carried out by the ISS, in collaboration with a network of peripheral laboratories. RESULTS: In Apulia, vaccination coverage progressively increased to 68.6% during the 2002-2003 season. The analysis of ILI cases showed higher incidence rates during the 1999-2000 and 2002-2003 seasons. ARI rates appeared to have a more constant trend. ILI and ARI incidence rates were higher in the 0-14 year age group. CONCLUSION: The increase in vaccination coverage rates and implementation of the network of clinical, and epidemiological and virological surveillance are fundamental for the control and prevention of influenza.     

A combination of serum low albumin and above-average cholesterol level was associated with excess mortality

BACKGROUND: There is no population-based prospective study concerning the relation between serum albumin and mortality in a non-Western population, and few previous studies included the subgroup analysis stratified by serum cholesterol level. METHODS: A 13.7-year cohort study was conducted on 6,957 males and females aged 30-59 years from 300 randomly selected areas throughout Japan, who participated in the National Survey on Circulatory Disorders in 1980. RESULTS: In the group with median and above of total cholesterol, one standard deviation (SD) increment of serum albumin (2.6 g/L for males and 2.4 g/L for females) was inversely associated with all-cause mortality for both males and females (relative risk RR = 0.68 and 0.81: 95% confidence interval CI = 0.53-0.87 and 0.68-0.98), and with cancer mortality for females (RR = 0.74; 95% Cl = 0.57-0.96);and the lowest category of serum albumin (< or = 43 g/L) showed the highest cardiovascular mortality for males (RR = 5.04; 95% CI = 1.04-24.5) among the three albumin categories. These relationships were not evident in the group with total cholesterol level below median. CONCLUSION: A combination of a low albumin level and above average cholesterol level, even both within the clinical normal range,is associated with excess mortality in the Japanese general population.