Comparison of risk estimates for selected diseases and causes of death

Lifetime Risk of Death From Firearm Injuries, Drug Overdoses, and Motor Vehicle Accidents in the United States

BACKGROUND

News media and policy makers frequently discuss deaths from firearms, drug overdoses, and motor vehicle accidents. However, this information is generally presented as absolute numbers or annual rates. Cumulative lifetime risk may be an additional useful metric for understanding the impact of these causes of death.

METHODS

Data on all-cause firearm, drug overdose, and motor vehicle accident deaths were obtained from the US Centers for Disease Control and Prevention (CDC) for the year 2018. Age-specific death rates were used to estimate the cumulative risk of firearm, drug overdose, and motor vehicle accident deaths from birth to age 85 after accounting for other causes of death.

RESULTS

The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents was 0.93% (95% confidence interval [CI], 0.92%-0.94%), 1.52% (95% CI, 1.51%-1.53%), and 0.92% (95% CI, 0.91%-0.93%), respectively. Black males had a 2.61% (95% CI, 2.55%-2.66%) lifetime risk of firearm death, indicating that 1 out of 38 black males will die from firearms if current death rates persist. Residents of West Virginia had a 3.54% lifetime risk of drug overdose death, equivalent to 1 out of every 28 residents dying from overdoses.

CONCLUSIONS

The lifetime risk of death from firearms, drug overdoses, and motor vehicle accidents is substantial and varies greatly across demographic subgroups and states.

Contemporary rates and predictors of fast progression of chronic kidney disease in adults with and without diabetes mellitus

Background

Chronic kidney disease (CKD) is highly prevalent but identification of patients at high risk for fast CKD progression before reaching end-stage renal disease in the short-term has been challenging. Whether factors associated with fast progression vary by diabetes status is also not well understood. We examined a large community-based cohort of adults with CKD to identify predictors of fast progression during the first 2 years of follow-up in the presence or absence of diabetes mellitus.

Methods

Within a large integrated healthcare delivery system in northern California, we identified adults with estimated glomerular filtration rate (eGFR) 30–59 ml/min/1.73 m² by CKD-EPI equation between 2008 and 2010 who had no previous dialysis or renal transplant, who had outpatient serum creatinine values spaced 10–14 months apart and who did not initiate renal replacement therapy, die or disenroll during the first 2 years of follow-up. Through 2012, we calculated the annual rate of change in eGFR and classified patients as fast progressors if they lost > 4 ml/min/1.73 m² per year. We used multivariable logistic regression to identify patient characteristics that were independently associated with fast CKD progression stratified by diabetes status.

Results

We identified 36,195 eligible adults with eGFR 30–59 ml/min/1.73 m² and mean age 73 years, 55% women, 11% black, 12% Asian/Pacific Islander and 36% with diabetes mellitus. During 24-month follow-up, fast progression of CKD occurred in 23.0% of patients with diabetes vs. 15.3% of patients without diabetes. Multivariable predictors of fast CKD progression that were similar by diabetes status included proteinuria, age ≥ 80 years, heart failure, anemia and higher systolic blood pressure. Age 70–79 years, prior ischemic stroke, current or former smoking and lower HDL cholesterol level were also predictive in patients without diabetes, while age 18–49 years was additionally predictive in those with diabetes.

Conclusions

In a large, contemporary population of adults with eGFR 30–59 ml/min/1.73 m², accelerated progression of kidney dysfunction within 2 years affected ~ 1 in 4 patients with diabetes and ~ 1 in 7 without diabetes. Regardless of diabetes status, the strongest independent predictors of fast CKD progression included proteinuria, elevated systolic blood pressure, heart failure and anemia.

Risk of ESRD in the United States

BACKGROUND

Although incidence rates of end-stage renal disease (ESRD) in the United States are reported routinely by the US Renal Data System (USRDS), risks (probabilities) are not reported. Short- and long-term risk estimates need to be updated and expanded to minority populations, including Native Americans, Asian/Pacific Islanders, and Hispanics.

STUDY DESIGN

Risk estimation from surveillance data in large populations using life-table methods. A competing-risks framework was applied by constructing a hypothetical cohort followed from birth to death.

SETTING & PARTICIPANTS

Total US population. Incidence and mortality rates of ESRD were obtained from the USRDS; all-cause mortality rates were obtained from CDC WONDER.

PREDICTORS

Age, sex, race/ethnicity, and year.

OUTCOMES

10-year to lifetime risks (cumulative incidence) of ESRD.

RESULTS

Among males, lifetime risks of ESRD from birth using 2013 data were 3.1% (95% CI, 3.0%-3.1%) for non-Hispanic whites, 8.0% (95% CI, 7.9%-8.2%) for non-Hispanic blacks, 3.8% (95% CI, 3.4%-4.9%) for non-Hispanic Native Americans, 5.1% (95% CI, 4.8%-5.4%) for non-Hispanic Asians/Pacific Islanders, and 6.2% (95% CI, 6.1%-6.4%) for Hispanics. Among females, lifetime risks were 2.0% (95% CI, 2.0%-2.1%) for non-Hispanic whites, 6.8% (95% CI, 6.7%-6.9%) for non-Hispanic blacks, 3.6% (95% CI, 3.3%-4.2%) for non-Hispanic Native Americans, 3.8% (95% CI, 3.6%-4.0%) for non-Hispanic Asian/Pacific Islanders, and 4.3% (95% CI, 4.2%-4.5%) for Hispanics. Lifetime risk of ESRD from birth increased from 3.5% in 2000 to 4.0% in 2013 in males and decreased from 3.0% to 2.8% in females.

LIMITATIONS

Standard life-time assumption of fixed age-specific rates over time and possible ESRD misclassification. To be useful in clinical practice, this application will require additional predictors (eg, comorbid conditions and chronic kidney disease stage).

CONCLUSIONS

ESRD risk in the United States varies more than 2-fold among racial/ethnic groups for both sexes.

A high leucine diet mitigates cardiac injury and improves survival after acute myocardial infarction

OBJECTIVE

Evidence suggests that branched chain amino acids (BCAAs) are beneficial in treating human disease. It is unknown, however, what impact BCAAs have on outcomes in acute myocardial infarction (MI). This study was performed to test the hypothesis that the specific BCAA leucine mitigates cardiac injury and improves survival post-MI.

MATERIALS/METHODS

11-12 week old male C57BL/6 mice were subjected to experimental MI or sham procedure, and provided regular chow (RC; 1.5% leucine) or a high leucine diet (HLD; 5% leucine), and followed for 3½ or 28 days. All mice were studied by echocardiography and cardiac catheterization, and all hearts were collected for histologic measurements of hypertrophy, fibrosis and apoptosis. Inflammation, hypertrophic gene expression, signal transduction, and glucose, palmitate and leucine metabolism were also measured in 3½day hearts.

RESULTS

Except for increased leucine and decreased glucose oxidation, an HLD had no effect on measured outcomes in sham mice. With MI, cardiac structure, function, and survival were significantly improved with an HLD. At 3½days post-MI, an HLD increased cardiac hypertrophic signaling and decreased inflammation. Cardiac leucine oxidation was decreased in RC mice post-MI, but significantly increased with an HLD. These changes in metabolism were accompanied by a significant increase in cardiac ATP content in the HLD group. Finally, at both 3½ and 28 days post-MI, an HLD increased compensatory hypertrophy, and attenuated cardiac fibrosis and apoptosis.

CONCLUSIONS

An HLD increases compensatory hypertrophy, attenuates fibrosis and apoptosis, and positively modulates oxidative metabolism to improve cardiac structure, function, and survival post-MI.

Lifetime risk for cancer death by sex and smoking status: the lifetime risk pooling project

BACKGROUND

Understanding how sex and tobacco exposure may modify lifetime risks for cancer mortality is important for effective communication of risk in targeted public health messages.

OBJECTIVE

To determine lifetime risk estimates for cancer death associated with sex and smoking status in the United States.

METHODS

A pooled cohort design using ten well-defined epidemiologic cohorts including middle-aged and older individuals was used to estimate the lifetime risk for cancer death at selected index ages, with death from non-cancer causes as the competing risk, by sex and smoking status.

RESULTS

There were a total of 11,317 cancer-related deaths. At age 45 years, the lifetime risk of cancer death for male smokers is 27.7 % (95 % CI 24.0-31.4 %) compared to 15.8 % (95 % CI 12.7-18.9 %) for male non-smokers. At age 45 years, the lifetime risk of cancer death for female smokers is 21.7 % (95 % CI 18.8-24.6 %) compared to 13.2 % (95 % CI 11.0-15.4 %) for female non-smokers. Remaining lifetime risk for cancer death declined with age, and men have a greater risk for cancer death compared to women. Adjustment for competing risk of death, particularly representing cardiovascular mortality, yielded a greater change in lifetime risk estimates for men and smokers compared to women and non-smokers.

CONCLUSIONS

At the population level, the lifetime risk for cancer death remains significantly higher for smokers compared to non-smokers, regardless of sex. These estimates may provide clinicians with useful information for counseling individual patients and highlight the need for continued public health efforts related to smoking cessation.

African American kidney transplantation survival: the ability of immunosuppression to balance the inherent pre- and post-transplant risk factors

Among organ transplant recipients, the African American population historically has received special attention. This is because secondary to their disposition to certain disease states, for example hypertension, an African American patient has a propensity to reach end-stage renal disease and require renal replacement earlier than a Caucasian patient. Regardless of the initiative to replace dialysis therapy with organ transplantation, the African American patient has many barriers to kidney transplantation, thus extending their time on dialysis and waiting time on the organ transplant list. These factors are among the many negative causes of decreased kidney graft survival, realized before kidney transplantation. Unfortunately, once the African American recipient receives a kidney graft, the literature documents that many post-transplant barriers exist which limit successful outcomes. The primary post-transplant barrier relates to designing proper immunosuppression protocols. The difficulty in designing protocols revolves around (i) altered genetic metabolism/lower absorption, (ii) increased immuno-active cytokines and (iii) detrimental effects of noncompliance. Based on the literature, dosing of immunosuppression must be aggressive and requires a diligent practitioner. Research has indicated that, despite some success with proven levels of immunosuppression, the African American recipient usually requires a higher 'dose per weight' regimen. However, even with aggressive immunosuppressant dosing, African Americans still have worse outcomes than Caucasian recipients. Additionally, many of the targeted sites of action that immunosuppression exerts its effects on have been found to be amplified in the African American population. Finally, noncompliance is the most discouraging inhibitor of long-term success in organ transplantation. The consequences of noncompliance are biased by ethnicity and affect the African American population more severely. All of these factors are discussed further in this review in the hope of identifying an ideal healthcare model for caring for the African American transplant recipient, from diagnosing chronic kidney disease through to successful kidney graft outcomes. An indepth review of the literature is described and organized in a fashion that highlights all of the issues affecting success in African Americans. The compilation of the literature in this review will enable the reader to get closer to understanding the caveats of kidney transplantation in the African American patient, but falls short of delivering an actual 'equation' for post-transplant care in an African American kidney recipient.

Protective effects of epigallocatechin gallate on colon preneoplastic lesions induced by 2-amino-3-methylimidazo[4,5-f ] quinoline in mice

Epigallocatechin gallate (EGCG), a key active ingredient in green tea, has multiple anticarcinogenic effects. The aim of the present study was to investigate if EGCG could prevent the formation of colon aberrant crypt foci (ACF) induced by 2-amino-3-methylimidazo[4,5-f ]quinoline (IQ) and to explore possible mechanisms for resultant effects. Sixty male BALB/cA nude, immunodeficient mice were divided into six groups including a normal unexposed control, mice induced with IQ alone, three groups treated with varying doses of EGCG post-IQ induction, and a EGCG-treated control population. Six weeks later, the mice were killed, and tissues subjected to hematoxylin-eosin (H&E) and 0.2% methylene blue staining to observe histopathological alterations of colon mucus and the formation of ACF, respectively. Protein expression of NF-E2-related factor 2 (Nrf2) was assessed via immunohistochemistry (IHC) and Western analysis, and mRNA levels of Nrf2 and uridine 5'-diphosphate-glucuronosyltransferase (UGT)1A10 were determined in colon tissues. Our results demonstrate that, compared with IQ-induced controls, the degree of atypical hyperplasia decreased and the number of total ACF and total AC also decreased significantly (P < 0.05 and P < 0.01, respectively) in mice belonging to all EGCG dosing groups. At the same time, the protein levels of Nrf2 detected by IHC and Western blotting increased (both P < 0.01 compared with IQ group), and the mRNA levels of Nrf2 and UGT1A10 increased (both P < 0.01 compared with IQ group). In conclusion, EGCG had preventive effects on preneoplastic lesions induced by IQ. Our observations suggest that this effect may be the result of activation of the Nrf2-UGT1A10 signaling pathway.

Risk estimates of hysterectomy and selected conditions commonly treated with hysterectomy

PURPOSE

This study presents corrected rates and probability (risk) estimates of experiencing a hysterectomy and of selected conditions commonly treated with hysterectomy.

METHODS

Analyses are based on hysterectomy prevalence data from the Behavior Risk Factor Surveillance Survey (calendar years 2000-2006), hysterectomy incidence data from the National Hospital Discharge Survey (2001-2005), and population estimates from the U.S. Census Bureau (2001-2005). The correction involved removing those women without a uterus from the denominator in the rate calculation.

RESULTS

Corrected hysterectomy incidence rates per 1000 women were greater than the uncorrected rates for women ages 18-44 years (6.0 vs. 5.0), 45-64 years (10.4 vs. 7.1), and 65 years and older (4.9 vs. 2.6). Correcting the rates had a comparatively larger impact in the South. Incidence rates of selected conditions associated with the female reproductive system were greater after correction for hysterectomy prevalence. For example, corrected compared with uncorrected rates of uterine fibroids per 1000 women were 2.9 vs. 2.7 for ages 18-44 and 5.0 vs. 3.4 for ages 45-64. The uncorrected and corrected 10-year risk of being diagnosed with uterine fibroids among women aged 50 who have not previously had fibroids is 3.87 (1 in 26) and 4.54 (1 in 22), respectively.

CONCLUSIONS

The correction method employed produces greater incidence and age-conditional-risk estimates of hysterectomy and of conditions commonly treated with hysterectomy. Corrected rates and age-conditional risk estimates may allow women with intact uteri to better assess their probability of undergoing a hysterectomy and certain other conditions of the reproductive system.

Lifetime risk of stroke and dementia: current concepts, and estimates from the Framingham Study

The main neurological causes of morbidity and mortality are stroke and dementia. We contend that the most relevant and readily communicated risk estimate for stroke and dementia is lifetime risk, which is the probability of someone of a given age and sex developing a condition during their remaining lifespan. Lifetime risk estimates describe the population burden; however, they can be refined with risk-stratified models to enable individual risk prediction. Community-based data on a group of North Americans of European descent indicate that the lifetime risk of stroke for a middle-aged woman is 1 in 5 and for a middle-aged man is 1 in 6. The lifetime risk of stroke was equal to the lifetime risk of dementia and equal to or greater than the lifetime risk of Alzheimer's disease (1 in 5 and 1 in 10 for women and men, respectively), and the lifetime risk of stroke or dementia was greater than 1 in 3. Thus, the lifetime burden attributable to common neurological disease is immense.

Sucrose, glucose and fructose have similar genotoxicity in the rat colon and affect the metabolome

We have shown previously that a high sucrose intake increases the background level of somatic mutations and the level of bulky DNA adducts in the colon epithelium of rats. The mechanism may involve either glucose or fructose formed by hydrolysis of sucrose. Male Big Blue rats were fed 30% sucrose, glucose, fructose or potato starch as part of the diet. Mutation rates and bulky DNA adduct levels were determined in colon and liver. The concentration of short-chain fatty acids and pH were determined in caecum, C-peptide was determined in plasma, biomarkers for oxidative damage and proliferation were determined in colon, and a metabonomic analysis was performed in plasma and urine. The sugars increased the mutation rates in colon and the bulky adduct levels in colon and liver to a similar extent. All sugars decrease the caecal concentration of acetic acid and propionic acid. The metabonomic studies indicated disturbed amino acid metabolism and decrease in plasma and urinary acetate as a common feature for all sugars and confirmed triglyceridemic effects of fructose. In conclusion, the genotoxicity may be related to the altered chemical environment in the caecum and thereby also in the colon but we found no related changes in insulin resistance or oxidative stress.

Inhibition of epigallocatechin gallate on orthotopic colon cancer by upregulating the Nrf2-UGT1A signal pathway in nude mice

Epigallocatechin gallate (EGCG), a key active ingredient in green tea, has many anti-carcinogenic activities. The aim of the present study was to investigate whether EGCG could prevent the occurrence or metastases of orthotopic colon cancer and probe the underlined mechanisms. We observed the inhibition of EGCG on growth and metastases of colon tumor implanted orthotopically in the cecum of nude mice. Immunohistochemistry and Western-blotting analysis were used to detect NF-E2-related factor 2 (Nrf2) protein expressions. RT-PCR was also applied to detect the mRNA levels of Nrf2, uridine 5'-diphosphate-glucuronosyltransferase (UGT) 1A, UGT1A8 and UGT1A10 in colon tumors. As a result, the inhibition rates on tumor growth in the 3 EGCG groups were significantly different (all p < 0.001) compared with the control group. In addition, different doses of EGCG were able to inhibit liver and pulmonary metastases to varying degrees. The protein level of Nrf2 and the mRNA levels of Nrf2, UGT1A, UGT1A8 and UGT1A10 significantly increased in EGCG-treated mice in comparison with the control group (all p < 0.01). The results demonstrated that EGCG has a preventive effect on the growth and liver and pulmonary metastases of orthotopic colon cancer in nude mice, and this anticancer effect could be partly caused by activating the Nrf2-UGT1A signal pathway.

Eating Behaviors and Health History of Rural Midlife to Older Women in the Midwestern United States

This study was conducted to examine daily energy, food group, and nutrient intakes of late midlife to older women living in the rural Midwestern United States compared with recommended intakes for the US population, and to describe their physical measures and health history. Random-digit dialing was used to recruit 225 community-dwelling women aged 50 to 69 years from a rural Midwestern area of the United States. Participants completed online food intake and health history surveys. Nearly half of the women had energy intakes in excess of their Estimated Energy Requirement. Mean daily servings of fruits, grains, and dairy products were below target levels identified in the 2000 Dietary Guidelines for Americans. Mean calcium and dietary fiber intakes were below recommended levels, while percent calories from fat (39.0%+/-6.8%) were well above recommendations. Eighty percent were overweight or obese and 76% were prehypertensive or hypertensive, yet only 33.5% indicated their health care provider had discussed dietary factors with them in the previous year. Late midlife and older rural Midwestern women, aged 50 to 69 years, need more guidance than they currently receive to learn how to make changes to meet dietary recommendations, particularly with a focus on establishing a more healthful dietary pattern that will be suitable for their older years.

CKD risk factors reported by primary care physicians: do guidelines make a difference?

BACKGROUND

End-stage renal disease is epidemic within the United States among certain high-risk groups. The National Kidney Disease Education Program examined the awareness of chronic kidney disease (CKD) risk factors among primary care physicians who treat high-risk populations, such as African Americans, persons with diabetes, persons with hypertension, and family members of dialysis patients.

METHODS

We conducted a survey of 465 primary care physicians in 4 communities with high-risk populations. Respondents were asked to score 9 potential CKD risk factors on a 4-point scale graded from "Does not increase risk at all" to "Increases risk greatly." Potential risk factors included African-American race, diabetes, hypertension, and family history of CKD.

RESULTS

Respondents saw a mean of 414 +/- 222 (SD) patients/mo. Primary care physicians were more likely to report that diabetes and hypertension were significant risk factors for CKD. Conversely, 34.4% did not consider family history of kidney disease to increase the risk for CKD, and 22% of respondents did not consider African-American race a CKD risk factor.

CONCLUSION

Primary care physicians need targeted education to increase awareness of populations at high risk for CKD.

Racial/ethnic patterns in lifetime and age-conditional risk estimates for selected cancers

BACKGROUND

Estimates of the probability of developing or dying from cancer, either over a lifetime or over a specified number of years, are useful summary measures of the burden of cancer in a population.

METHODS

The authors used publicly available DevCan software and new, detailed, racial/ethnic data bases that were developed in the Surveillance Research Program of the National Cancer Institute to produce risk estimates for selected major cancers among American Indian/Aleut/Eskimo, black, Chinese, Filipino, native Hawaiian, Japanese, white (total, non-Hispanic), and Hispanic populations.

RESULTS

Japanese and non-Hispanic white men had the highest lifetime risk for developing cancer (47.94% and 47.41%, respectively), and the American Indian/Eskimo/Aleut population (excluding Alaska) had the lowest lifetime risk among men (24.30%). Among women, white and American Indian/Eskimo/Aleut (in Alaska) populations had higher lifetime risks than Japanese women, whereas American Indian/Eskimo/Aleut (excluding Alaska) women had the lowest risk. The age-conditional probabilities of developing cancer within the next 10 years among men and women age 60 years and the lifetime probabilities of dying from cancer also were reported by racial/ethnic group.

CONCLUSIONS

Racial/ethnic disparities in the lifetime risk of cancer may be because of differences in cancer incidence rates, but they also may reflect differential mortality rates from causes other than the cancer of interest. Furthermore, because cross-sectional incidence and mortality rates are used in calculating the DevCan lifetime risk estimates, results must be interpreted with caution when events, such as the widespread and rapid implementation of a new screening test, are known to have influenced disease rates.

Linkage Analysis for Complex Diseases Using Variance Component Analysis

Variance component linkage analysis has become one of the most popular tools for the analysis of poly genic phenotypes. In particular for cardiovascular disease, such as coronary artery disease and myocardial infarction, variance component analysis holds some unique advantages. This analysis approach is versatile, affording the user the ability to incorporate the interplay between risk factors, genetic susceptibility, the effect of environmental factors, or the joint analysis of multiple phenotypes in the analysis. In this chapter, we present as an introduction the statistical background of variance component analysis as implemented in the genetic analysis package SOLAR.

Prevalence of family history of kidney disease and perception of risk for kidney disease: a population-based study

BACKGROUND

A family history of kidney disease is associated with an increased risk for end-stage renal disease (ESRD). However, it is unclear whether blacks are more likely to have a family history of ESRD than other groups independently of kidney disease risk factors. Moreover, their risk perception for kidney disease is unknown.

METHODS

The association of race with family history of ESRD and perception of risk for kidney disease was examined in a representative random sample of 402 Georgia residents who completed a telephone interview. Logistic regression analysis was used to derive adjusted odds ratios and 95% confidence intervals for the association between race and family history of ESRD, controlling for age, sex, education level, being a Georgia native, diabetes, hypertension, and personal history of kidney disease. A multinomial logit model was used to derive adjusted estimates for the association between race and perception of risk for kidney disease.

RESULTS

Mean age was 43.2 years, 41.0% of respondents were men, 20.1% were black, 6.6% had diabetes, 21.4% had hypertension, 1.6% had a personal history of kidney disease, and 3.7% reported a family member with ESRD. Although blacks were more likely to report a family history of ESRD (odds ratio, 6.43; 95% confidence interval, 2.02 to 20.43), their perception of risk was not greater.

CONCLUSION

Although blacks are approximately 6 times as likely to report a family history of ESRD independently of a personal history of kidney disease, diabetes, or hypertension, they do not perceive themselves as more vulnerable for kidney disease.

A public health action plan is needed for chronic kidney disease

In 2005, chronic kidney disease (CKD) meets all criteria for classification as a public health problem in the United States. It imposes a large burden on society that is increasing despite ongoing efforts to control the disease. The burden is unevenly distributed by race and economic status, whereas evidence suggests that preventive strategies could substantially reduce the burden. Finally, there are indications that such strategies are not yet in place. A broad and coordinated public health approach to the burgeoning health, economic, and societal challenges of CKD is needed to complement present clinical approaches, increase awareness, promote early detection, and facilitate prevention and treatment.

Epidemiology and risk factors for chronic kidney disease

Kidney disease is highly prevalent in the United States population and groups at high risk for increased prevalence of CKD include individuals with a family history of ESRD, diabetes, hypertension, and cardiovascular disease. Despite the increased risk of ESRD observed for blacks compared with whites, racial disparities in the prevalence of kidney disease have not been consistently demonstrated in the United States population. Although the reasons for discrepancy in risk of ESRD and CKD have not been established, clinicians should be aware that more rapid progression of CKD among blacks is a possible explanation for this observation and that closer monitoring and intensive care of risk factors associated with progressive renal injury is warranted for blacks with CKD and in other high-risk groups. Therapeutic interventions that delay or prevent progressive kidney disease are well established and incorporated into widely disseminated clinical practice guidelines. These interventions include aggressive blood pressure control with agents that block the renin-angiotensin system, reduction of dietary protein to recommended levels for the American diet, weight loss, smoking cessation, and control of hyperlipidemia. These interventions also reduce the risk of cardiovascular disease and should be regarded as essential components of care of CKD. Achieving high levels of medically appropriate care of CKD patients and reduction in risk of progression to ESRD may be delayed by barriers created by individual and regional poverty.

Non-suicidal deaths following hospital-treated self-poisoning

OBJECTIVE

To quantify the non-suicidal mortality subsequent to hospital treated self-poisoning, and to identify risk factors for non-suicidal death.

METHOD

A prospective longitudinal cohort design was used, with data-linkage between the Hunter Area Toxicology Service database and the National Death Index. All patients with deliberate self-poisoning for a 10-year period (1991-2000) were studied and the first episode in the period was used as the index episode. The outcomes were: accidental, 'natural' and non-suicidal death, with follow-up for the study duration.

RESULTS

There were 4044 patients studied, and 170 (4.2%) of these had non-suicidal death; 64 were accidental and 106 were 'natural' cause deaths. The standardized mortality ratio (95% CI) for non-suicidal death for males, females and combined were 4.98 (4.08-6.07), 3.78 (3.0-4.75) and 4.20 (3.62-4.88), respectively. The increased mortality was apparent for both males and females, and was more marked in the younger age groups. For non-suicidal death the adjusted hazard ratio (95% CI) for increased risk were: increasing age 1.07 (1.06-1.08), male gender 1.77 (1.24-2.52), psychiatric diagnosis of substance related disorder 1.49 (1.03-2.16), prescription of a respiratory drug 2.69 (1.31-5.55), and prescription of an anti-diabetic drug 1.95 (0.93-4.07), while psychiatric diagnosis of adjustment disorder 0.64 (0.38-1.053) was associated with decreased risk.

CONCLUSIONS

Patients who present with self-poisoning have increased mortality from accidental and 'natural' causes. Long-term treatment goals for these patients need to address non-suicide mortality in addition to suicide mortality.

Sucrose and IQ induced mutations in rat colon by independent mechanism

Sucrose-rich diets have repeatedly been observed to have co-carcinogenic actions in colon and liver of rats and to increase the number of 2-amino-3-methylimidazo[4,5-f]quinoline (IQ) induced aberrant crypt foci in rat colon. To investigate a possible interaction between sucrose and IQ on the genotoxicity in rat liver and colon, we gave Big Blue rats a diet containing sucrose (0%, 3.45% or 13.4% w/w) and/or IQ (70 ppm) for a period of 3 weeks. Sucrose and IQ increased the mutation frequency in the colon. The effect of combined treatments with IQ and sucrose on the mutation frequencies was additive indicating that sucrose and IQ act independently. This was supported by the mutation spectra where sucrose expands the background mutations in the colon, whereas IQ, in other studies, more specifically has induced G:C --> T:A transversions. In the liver IQ increased the mutation frequency, whereas addition of sucrose reduced the effect of IQ in a dose-dependent manner. The level of bulky DNA adducts in liver and colon was increased in animals exposed to either sucrose or IQ. In animals exposed to IQ, addition of sucrose had marginal effects on the level of bulky DNA adducts. Markers of oxidative damage and DNA repair were generally unaffected by the treatments. In conclusion, sucrose and IQ in the diet induced mutations in the colon by independent mechanisms, whereas an interaction was observed in liver leading to a decrease in mutations by the combined treatment.

Chemopreventive effects of vanadium toward 1,2-dimethylhydrazine-induced genotoxicity and preneoplastic lesions in rat colon

In the present study, we have evaluated the antitumor effects of vanadium by monitoring DNA damage and chromosomal aberrations (CAs) during the early preneoplastic stage of 1,2-dimethylhydrazine (1,2-DMH)-induced colon cancer in male rats. Treatment with 20 mg/kg 1,2-DMH for 6 weeks resulted in the formation of aberrant crypt foci (ACF), a putative preneoplastic lesion associated with colon cancer development, while cotreatment with ammonium monovanadate (0.5 ppm in the drinking water) reduced ACF formation by 50% (P < 0.001). The 6-week treatment with 1,2-DMH also resulted in significantly higher levels of DNA damage in rat colon as measured by the Comet assay (higher mean values for length-to-width ratios (L:W) of DNA mass (P < 0.01) and mean frequencies of cells with comets (P < 0.001)). The vanadium cotreatment reduced DNA damage in colon cells by 32% (P < 0.02 and P < 0.001 for L:W and tailed cells, respectively). 1,2-DMH treatment also produced a 10-fold increase in the frequency of CAs in rat colon (P < 0.001), while cotreatment with vanadium resulted in a reduction in CAs after 2, 4, and 6 weeks of 1,2-DMH exposure (P < 0.01). Analysis of antioxidant defense enzyme activity in colonic mucosa indicated that glutathione reductase and catalase activities were increased in 1,2-DMH-treated rats; cotreatment with vanadium reduced these activities when compared to the carcinogen control (P < 0.001 and P < 0.02). These results demonstrate that the early protective effect of vanadium in chemically induced rat colon carcinogenesis may be mediated by a reduction of carcinogen-induced DNA damage.

Effects of dairy products on heterocyclic aromatic amine-induced rat colon carcinogenesis

Heterocyclic aromatic amines (HAA) are initiating agents of colon carcinogenesis in animals and are suspected in the aetiology of human colon cancer. In the context of prevention, it seems interesting to test possible protective compounds, such as fermented milk, against HAA food carcinogens. Male F344 rats were used in a model of HAA-induced colon carcinogenesis. The HAA, 2-amino-3-methylimidazo[4,5-f]quinoline (IQ), 2-amino-3,4-dimethylimidazo[4,5-f]quinoline (MeIQ) and 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) (ratio 1:1:1) were administered in food for a 7 week induction period, with a cumulative dose of 250 mg of the HAA, per kg body weight. Four different diets were given to four rat groups: supplemented with 20% water, 30% non-fermented milk, 30% Bifidobacterium animalis DN-173 010 fermented milk and 30% Streptococcus thermophilus DN-001 158 fermented milk. Fecal mutagenicity was quantified during the induction period. At the end of the treatment, DNA lesion levels were determined in the liver and colon using the number of 8-oxo-7,8-dihydro-2'desoxyguanosine (8-oxodGuo) oxidized bases, "3D Test" and comet assay. The metabolic activity of hepatic and colon cytochrome P450 (CYP450) 1A1 and 1A2 was also evaluated. Aberrant colon crypts were scored, 8 weeks after the last HAA treatment. The results showed that dairy products decreased the incidence of aberrant crypts in rats: 66% inhibition with the milk-supplemented diet, 96% inhibition with the B.animalis fermented milk-supplemented diet and 93% inhibition with the S.thermophilus fermented milk-supplemented diet. Intermediate biomarkers showed that there was a decrease in HAA metabolism, fecal mutagenicity and colon DNA lesions. These results demonstrate the early protective effect of milk in the carcinogenesis process. This effect being more pronounced in the case of milk fermented by lactic acid bacteria.

Measuring the public health burden of cancer in the United States through lifetime and age-conditional risk estimates

PURPOSE

Effects of an aging population in the United States on lifetime and age-conditional risk estimates of developing site-specific cancers are identified and the potential role these statistics play in monitoring disease burden discussed.

METHODS

Risk estimates were derived by applying cross-sectional population-based incidence rates of cancer and mortality rates from other causes to a hypothetical cohort. The cohort was aged through a double decrement life table to determine the expected proportion of the population that would develop the disease.

RESULTS

Despite black men having higher invasive cancer incidence rates than white men, and black and white women having similar rates, because of the better life expectancy among whites lifetime risk estimates of developing cancer are higher for whites than blacks: 45.5% in white men, 40.4% in black men, 39.2% in white women, and 32.4% in black women based on 1995-97 data. White men experience higher 10-year cancer risk than black men in only bladder cancer, non-Hodgkin's lymphomas (NHL), and leukemia. White women tended to show a greater risk than black women for cancers of the breast, corpus uteri, ovary, NHL, and leukemia. For both whites and blacks, the 10-year risk of lung cancer ranks first among men aged 40, ranks second to prostate cancer for men aged 50, 60, and 70, and ranks second to breast cancer for women aged 40, 50, 60, and 70.

CONCLUSIONS

Lifetime and age-conditional risk measures reflect both changes in the disease incidence rates and age distribution over calendar time such that they are useful for monitoring the disease burden in the population. Even if cancer rates remain stable or fall, it is possible for the cancer burden, as reflected by lifetime and age-conditional risk estimates, to increase due to the aging population.

Comparison of two methods based on cross-sectional data for correcting corpus uterine cancer incidence and probabilities

BACKGROUND

Two methods are presented for obtaining hysterectomy prevalence corrected estimates of invasive cancer incidence rates and probabilities of the corpus uterine.

METHODS

The first method involves cross-sectional hysterectomy data from the Utah Hospital Discharge Data Base and mortality data applied to life-table methods. The second involves hysterectomy prevalence estimates obtained directly from the Utah Behavior Risk Factor Surveillance System (BRFSS) survey.

RESULTS

Hysterectomy prevalence estimates based on the first method are lower than those obtained from the second method through age 74, but higher in the remaining ages. Correction for hysterectomy prevalence is greatest among women ages 75-79. In this age group, the uncorrected rate is 125 (per 100,000) and the corrected rate based on the life-table method is 223 using 1995-97 data, 243 using 1992-94 data, and 228 from the survey method. The uncorrected lifetime probability of developing corpus uterine cancer is 2.6%; the corrected probability from the life-table method using 1995-97 data is 4.2%, using 1992-94 data is 4.5%; and based on prevalence data from the survey method is 4.6%.

CONCLUSIONS

Both methods provide reasonable hysterectomy prevalence estimates for correcting corpus uterine cancer rates and probabilities. Because of declining trends in hysterectomy in recent decades, corrected estimates from the life-table method are less pronounced than those based on the survey method. These methods may be useful for obtaining corrected uterine cancer rates and probabilities in areas of the world that do not have sufficient years of hysterectomy data to directly compute prevalence.

Prevalence corrected hysterectomy rates and probabilities in Utah

PURPOSE

A life table method is used for correcting hysterectomy rates and probabilities for prevalent cases of hysterectomies in the population. Both corrected and conventional hysterectomy rates and probabilities are reported.

METHODS

Hysterectomy prevalence estimates are derived from cross-sectional hysterectomy and mortality using a life table method. Analysis is based on the Utah Hospital Discharge Data Base and State death certificates.

RESULTS

Hysterectomy rates are strongly influenced by age, reaching 150 per 10,000 for ages 45-49 years. The corresponding corrected hysterectomy rate is 196. Differences between the corrected and uncorrected cause-specific hysterectomy rates tend to be most pronounced at their peaks, particularly later in life where the prevalence of hysterectomy is greatest. Probability of hysterectomy approaches slightly above 35% over the life span, whereas the corrected hysterectomy probability approaches 43%. Probability of hysterectomy in the next 10 years is 12.9% for women aged 35 years and 11.7% for women aged 45 years. Corresponding corrected hysterectomy probabilities are 14.3 and 15.1. Higher prevalence of hysterectomy in later ages explains the reverse in magnitude of the rates when the correction is applied to the hysterectomy rates.

CONCLUSIONS

Conventional hysterectomy rates are underestimated, particularly in older age groups. A prevalence correction of the rates and probabilities is necessary to fully understand the potential health related consequences and impact of this medical procedure in the population.

Interactive multimedia and risk communication

As our understanding of risk factors and their interaction with individual susceptibility to disease improves, general messages designed to communicate risk seem increasingly ineffective and often misleading. Risk messages communicated through the mass media cannot convey an individual's personal susceptibility to preventable diseases or the seriousness of these diseases. The advent of new media technologies allows us to better reach the public with programs tailored to the needs and interests of individual users. Although similar in outward appearance to mass media, programs delivered through the Internet, CD-ROM, and computer kiosks offer the potential for vastly improved efficacy in communicating risk. This paper outlines the potential uses of interactive multimedia within the traditional goals of risk communication. A significant research endeavor, coupled with stronger avenues for dissemination, is recommended to achieve the potential of new media in a timely manner.

Pharmacoeconomic considerations in the management of hypertension

Hypertension is highly prevalent in developed and developing countries (more than 30% of the adult population when a threshold value of 140/90 mm Hg is selected). It constitutes one of the major cardiovascular risk factors and accounts for more than 5% of total deaths worldwide. The economic impact of hypertension is enormous, representing $US23.74 billion in the US in 1995 and approximately $US1685 million in Spain in 1994. Direct costs amount to more than 50% of the total costs of hypertension, and almost 70% of these are attributable to drug treatment. Furthermore, hypertensive patients use medical services 50% more than normotensive individuals, and hypertension represents one of the 3 leading causes of visits to primary healthcare centres. When considering the cost effectiveness of hypertension treatment, there is no doubt that it is cost effective in comparison with other interventions, although some controversies exist, mainly with respect to mild-to-moderate hypertension and to the long term versus short term benefits. The controversy about the absolute risk of hypertension influences the cost-effectiveness analysis. Because of the limitations of the available cost-effectiveness analyses, it is currently impossible to recommend the use of any particular antihypertensive drug for all patients with hypertension. Consequently, the choice of antihypertensive in any patient should be guided by clinical experience and the recommendations of the present international guidelines.