The Contribution of National Disparities to International Differences in Mortality Between the United States and 7 European Countries

Objectives. This study examined to what extent the higher mortality in the United States compared to many European countries is explained by larger social disparities within the United States. We estimated the expected US mortality if educational disparities in the United States were similar to those in 7 European countries.Methods. Poisson models were used to quantify the association between education and mortality for men and women aged 30 to 74 years in the United States, Belgium, Denmark, Finland, France, Norway, Sweden, and Switzerland for the period 1989 to 2003. US data came from the National Health Interview Survey linked to the National Death Index and the European data came from censuses linked to national mortality registries.Results. If people in the United States had the same distribution of education as their European counterparts, the US mortality disadvantage would be larger. However, if educational disparities in mortality within the United States equaled those within Europe, mortality differences between the United States and Europe would be reduced by 20% to 100%.Conclusions. Larger educational disparities in mortality in the United States than in Europe partly explain why US adults have higher mortality than their European counterparts. Policies to reduce mortality among the lower educated will be necessary to bridge the mortality gap between the United States and European countries.The United States has lower life expectancy at birth than most Western European countries. In 2009, life expectancy in the United States was 76 years for men and 81 years for women, between 2 and 4 years less than in several European countries.1 The disadvantage is greater for women than for men and originated in the 1980s.2 The US health disadvantage is found not only for life expectancy, but also for self-reported health measures,3,4 biomarkers,3 and many specific causes of death5,6 across the entire life course.3–5,7A recent report by the National Research Council suggests that smoking and obesity explain an important part of the US mortality disadvantage.2,8,9 However, an approach that solely emphasizes behavioral differences is impoverished by ignoring the role of socioeconomic and environmental determinants.10 A substantial body of research suggests that most behavioral risk factors are socially patterned; lower education or income are associated with a higher prevalence of smoking, excessive alcohol consumption, obesity, and poor dietary patterns.11–19 In addition, European countries and the United States differ in many aspects of the physical and social environment that can affect population health and that are in turn socially patterned within each country. For example, the socioeconomic distribution of access to healthy food differs between countries.20 Social environmental factors related to safety, violence, social connections, social participation, social cohesion, social capital, and collective efficacy have also been shown to influence health and in turn differ between countries and socioeconomic groups.21 Indeed, differences in mortality between the United States and Europe are larger among those with a lower educational level,6 suggesting that larger educational disparities in mortality, which partly coincide with differences in behavior, partly explain why Americans have higher mortality than Europeans.The United States is characterized by relatively higher levels of income inequalities,22 residential and racial segregation,23–25 and financial barriers to health care access2,26 than any European country. Social protection policies and benefits are also less comprehensive in the United States than in Europe, including policies on early education and childcare programs,27 access to high-quality education,28 employment protection and support programs,29,30 and housing29,31 and income transfer programs.31,32 A plausible hypothesis is that the more unequal distribution of resources and less comprehensive policies contribute to the more unfavorable risk factor profile and poorer health of lower-educated Americans as compared with corresponding Europeans.4,33,34 A follow-up report by the National Research Council and the Institute of Medicine published in 2013 concluded that there is a lack of evidence on how these factors explain the US health disadvantage.21 The aim of this article is to assess to what extent larger educational disparities in mortality explain why Americans have higher mortality than Europeans.     

An Instrument for Assessing the Quality of Tobacco-Control Policies: The ACT-L Scale

Background.Efforts to prevent and decrease tobacco use and tobacco-related disease include improving the quality of tobacco-control laws to make them more stringent in controlling tobacco advertising, youth access, and exposure to environmental tobacco smoke (ETS). However, because there are no instruments to empirically evaluate the quality of such laws, it has been difficult to demonstrate that their quality is associated with decreased youth access or tobacco-related morbidity. We present the first instrument for empirically assessing the quality of tobacco-control policies.Methods.Recommendations for the content of an ideal, comprehensive tobacco-control policy were used as the 55 items in the Assessment of the Comprehensiveness of Tobacco Laws Scale (ACT-L Scale). Raters evaluated 71 tobacco-control laws with the scale; 70 of these were actual California laws and 1 was a model law from Americans for Non-smokers' Rights (ANR).Results.Interrater (r= 0.64–0.89) and internal-consistency (r= 0.63–0.88) reliability of the scale and subscales were high, and validity was established by demonstrating that the ANR model law received a significantly higher total score (mean = 18.75) than all actual laws (mean = 2.04). California tobacco-control laws were poor in all areas (youth access, ETS, tobacco advertising).Conclusions.The ACT-L scale can be used to compare and evaluate the quality of tobacco-control laws, highlight areas in which further policy efforts are needed, quantify improvement in such policies, and empirically demonstrate the positive health impact of high-quality tobacco-control laws.     

Smoking and the potential for reduction of inequalities in mortality in Europe

Socioeconomic inequalities in health and mortality remain a widely recognized problem. Countries with smaller inequalities in smoking have smaller inequalities in mortality, and smoking plays an important part in the explanation of inequalities in some countries. We identify the potential for reducing inequalities in all-cause and smoking-related mortality in 19 European populations, by applying different scenarios of smoking exposure. Smoking prevalence information and mortality data come from 19 European populations. Prevalence rates are mostly taken from National Health Surveys conducted around the year 2000. Mortality rates are based on country-specific longitudinal or cross-sectional datasets. Relative risks come from the Cancer Prevention Study II. Besides all-cause mortality we analyze several smoking-related cancers and chronic obstructive pulmonary disease/asthma. We use a newly-developed tool to quantify the changes in population health potentially resulting from modifying the population distribution of exposure to smoking. This tool is based on the epidemiological measure of the population attributable fraction, and estimates the impact of scenario-based distributions of smoking on educational inequalities in mortality. The potential reduction of relative inequality in all-cause mortality between those with high and low education amounts up to 26 % for men and 32 % for women. More than half of the relative inequality may be reduced for some causes of death, often in countries of Northern Europe and in Britain. Patterns of potential reduction in inequality differ by country or region and sex, suggesting that the priority given to smoking as an entry-point for tackling health inequalities should differ between countries.     

The contribution of risk factors to the higher incidence of invasive and in situ breast cancers in women with higher levels of education in the European prospective investigation into cancer and nutrition

The authors investigated the role of known risk factors in educational differences in breast cancer incidence. Analyses were based on the European Prospective Investigation Into Cancer and Nutrition and included 242,095 women, 433 cases of in situ breast cancer, and 4,469 cases of invasive breast cancer. Reproductive history (age at first full-term pregnancy and parity), exposure to endogenous and exogenous hormones, height, and health behaviors were accounted for in the analyses. Relative indices of inequality (RII) for education were estimated using Cox regression models. A higher risk of invasive breast cancer was found among women with higher levels of education (RII = 1.22, 95% confidence interval (CI): 1.09, 1.37). This association was not observed among nulliparous women (RII = 1.13, 95% CI: 0.84, 1.52). Inequalities in breast cancer incidence decreased substantially after adjusting for reproductive history (RII = 1.11, 95% CI: 0.98, 1.25), with most of the association being explained by age at first full-term pregnancy. Each other risk factor explained a small additional part of the inequalities in breast cancer incidence. Height accounted for most of the remaining differences in incidence. After adjusting for all known risk factors, the authors found no association between education level and risk of invasive breast cancer. Inequalities in incidence were more pronounced for in situ breast cancer, and those inequalities remained after adjustment for all known risk factors (RII = 1.61, 95% CI: 1.07, 2.41), especially among nulliparous women.     

Applications of neuroreceptor imaging to psychiatry research

Over the past two decades, there have been significant advances in the ability to study the neurochemistry of the living brain using neuroreceptor radiotracers with Positron Emission Tomography (PET) and Single Photon Emission Computed Tomography (SPECT) imaging modalities. The greater availability of radiotracers for neurotransmitter synthesis/metabolism, enzymes, transporters and receptors, as well as neuromodulators and second messengers has enabled the evaluation of hypotheses regarding neurotransmitter function and regulation that are generated from basic neuroscience studies in animals, and the investigation of the neurochemical substrates of psychiatric disorders and the mechanism of action of psychotropic medications. This review will focus on the status of radiotracer development, on the clinical and methodological considerations regarding neurochemical brain imaging study design and data interpretation. The applications of neurochemical brain imaging methods to the study of specific psychiatric disorders, including schizophrenia, anxiety disorders, depression and Alzheimer's Disease, will be reviewed and potential future directions of research in these areas identified. Finally, the studies of the neurochemical substrates of personality traits will be reviewed. Thus far, fundamental observations have been made with respect to 1). detecting abnormalities in the availability of neurotransmitter transporter and receptor sites in psychiatric patients; 2). evaluating the relationship of these neurochemical measures to symptomatology; and 3). assessing the magnitude of occupancy of the initial target sites of action of psychotropic medication relative to treatment response and drug concentrations. Further advances in instrumentation and radiotracer chemistry will enable investigators to conduct pre-clinical and clinical mechanistic studies focused on other neurotransmitters and neuromodulators. These data will provide important insights into the neurochemical substrates of treatment response variability in psychiatric disorders that will have important implications for the refinement of pharmacotherapy.     

Principles of disaster planning for the pediatric population

Unique physiological, developmental, and psychological attributes of children make them one of the more vulnerable populations during mass-casualty incidents. Because of their distinctive vulnerabilities, it is crucial that pediatric needs are incorporated into every stage of disaster planning. Individuals, families, and communities can help mitigate the effects of disasters on pediatric populations through ongoing awareness and preventive practices. Mitigation efforts also can be achieved through education and training of the healthcare workforce. Preparedness activities include gaining Emergency Medical Services for Children Pediatric Facility Recognition, conducting pediatric disaster drills, improving pediatric surge capacity, and ensuring that the needs of children are incorporated into all levels of disaster plans. Pediatric response can be improved in a number of ways, including: (1) enhanced pediatric disaster expertise; (2) altered decontamination protocols that reflect pediatric needs; and (3) minimized parent-child separation. Recovery efforts at the pediatric level include promoting specific mental health therapies for children and incorporating children into disaster relief and recovery efforts. Improving pediatric emergency care needs should be at the forefront of every disaster planner's agenda.     

Critical data‐based re‐evaluation of minocycline as a putative specific microglia inhibitor

Minocycline, a second generation broad‐spectrum antibiotic, has been frequently postulated to be a “microglia inhibitor.” A considerable number of publications have used minocycline as a tool and concluded, after achieving a pharmacological effect, that the effect must be due to “inhibition” of microglia. It is, however, unclear how this “inhibition” is achieved at the molecular and cellular levels. Here, we weigh the evidence whether minocycline is indeed a bona fide microglia inhibitor and discuss how data generated with minocycline should be interpreted. GLIA 2016;64:1788–1794     

Predictors of carotid atherosclerotic plaque progression as measured by noninvasive magnetic resonance imaging

The purpose of this in vivo MRI study was to quantify changes in atherosclerotic plaque morphology prospectively and to identify factors that may alter the rate of progression in plaque burden. Sixty-eight asymptomatic subjects with >or=50% stenosis, underwent serial carotid MRI examinations over an 18-month period. Clinical risk factors for atherosclerosis, and medications were documented prospectively. The wall and total vessel areas, matched across time-points, were measured from cross-sectional images. The normalized wall index (NWI=wall area/total vessel area), as a marker of disease severity, was documented at baseline and at 18 months. Multiple regression analysis was used to correlate risk factors and morphological features of the plaque with the rate of progression/regression. On average, the wall area increased by 2.2% per year (P=0.001). Multiple regression analysis demonstrated that statin therapy (P=0.01) and a normalized wall index >0.64 (P=0.001) were associated with a significantly reduced rate of progression in mean wall area. All other documented risk factors were not significantly associated with changes in wall area. Findings from this study suggest that increased normalized wall index and the use of statin therapy are associated with reduced rates of plaque progression amongst individuals with advanced, asymptomatic carotid atherosclerosis.     

Changes in gastric myoelectric activity during space flight

The purpose of the present study was to examine postprandial myoelectric activity of the stomach and gastric activity associated with space motion sickness using electrogastrography. Three crewmembers participated in this investigation. Preflight, subjects exhibited normal postprandial responses to the ingestion of a meal. Inflight, crewmembers exhibited an abnormal decrease in the power of the normal gastric slow wave after eating on flight day 1, but had a normal postprandial response by flight day 3. Prior to and during episodes of nausea and vomiting, the electrical activity of the stomach became dysrhythmic with 60–80% of the spectral power in the bradygastric and tachygastric frequency ranges. These findings indicate that gastric motility may be decreased during the first few days of space flight. In addition, changes in the frequency of the gastric slow wave associated with space motion sickness symptoms are consistent with those reported for laboratory-induced motion sickness.     

Iron ingestion: an evidence-based consensus guideline for out-of-hospital management

From 1983 to 1991, iron caused over 30% of the deaths from accidental ingestion of drug products by children. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before its distribution to secondary reviewers for comment. The panel then made changes in response to comments received. The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial management of patients with suspected ingestions of iron by 1) describing the manner in which an ingestion of iron might be managed, 2) identifying the key decision elements in managing cases of iron ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to ingestion of iron alone and is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. The panel's recommendations follow; the grade of recommendation is in parentheses. 1) Patients with stated or suspected self-harm or who are victims of malicious administration of an iron product should be referred to an acute care medical facility immediately. This activity should be guided by local poison center procedures. In general, this should occur regardless of the amount ingested (Grade D). 2) Pediatric or adult patients with a known ingestion of 40 mg/kg or greater of elemental iron in the form of adult ferrous salt formulations or who have severe or persistent symptoms related to iron ingestion should be referred to a healthcare facility for medical evaluation. Patients who have ingested less than 40 mg/kg of elemental iron and who are having mild symptoms can be observed at home. Mild symptoms such as vomiting and diarrhea occur frequently. These mild symptoms should not necessarily prompt referral to a healthcare facility. Patients with more serious symptoms, such as persistent vomiting and diarrhea, alterations in level of consciousness, hematemesis, and bloody diarrhea require referral. The same dose threshold should be used for pregnant women, however, when calculating the mg/kg dose ingested, the pre-pregnancy weight of the woman should be used (Grade C). 3) Patients with ingestions of children's chewable vitamins plus iron should be observed at home with appropriate follow-up. The presence of diarrhea should not be the sole indicator for referral as these products are often sweetened with sorbitol. Children may need referral for the management of dehydration if vomiting or diarrhea is severe or prolonged (Grade C). 4) Patients with unintentional ingestions of carbonyl iron or polysaccharide-iron complex formulations should be observed at home with appropriate follow-up (Grade C). 5) Ipecac syrup, activated charcoal, cathartics, or oral complexing agents, such as bicarbonate or phosphate solutions, should not be used in the out-of-hospital management of iron ingestions (Grade C). 6) Asymptomatic patients are unlikely to develop symptoms if the interval between ingestion and the call to the poison center is greater than 6 hours. These patients should not need referral or prolonged observation. Depending on the specific circumstances, follow-up calls might be indicated (Grade C).