Urban-rural disparities in old-age mortality vary systematically with age: evidence from Germany and England & Wales

OBJECTIVES

Population aging - which tends to be more pronounced in rural than in urban areas - poses important challenges for facilitating equal opportunities for aging well and 'aging in place.' Unmet health care needs among the older rural population may result in poorer health and higher mortality, but the scientific evidence of a systematic rural mortality disadvantage at older ages is scarce. We argue that systematic urban-rural mortality differences by age may be found if the confounding effect of life expectancy is considered.

STUDY DESIGN

Nationwide population-based study.

METHODS

We draw on age- and sex-specific data for the population aged 60+ years in NUTS-3 regions in Germany (2016-2018) and LAU-1 regions in England & Wales (2017-2019). To account for the confounding effect of life expectancy, we compare age-specific mortality only across urban and rural regions with similar life expectancy levels. We quantify statistical uncertainty with bootstrapping.

RESULTS

The results show a remarkable shift from higher mortality in urban regions to higher mortality in rural regions with increasing age, when controlling for the confounding effect of life expectancy. That is, the urban mortality disadvantage is strongest for the population aged 60-79 years, whereas the pattern shifts toward a rural mortality disadvantage for the population aged 80 years and older. This pattern is present at all levels of life expectancy, for both sexes and in both countries.

CONCLUSION

The shift from urban to rural excess mortality over age suggests that regions may vary in their capability to respond to arising health issues across older ages. This systematic mortality disadvantage is of high public health relevance and should be considered in designing policies to reduce regional mortality disparities.

Low CO2 Sensitivity of Microzooplankton Communities in the Gullmar Fjord, Skagerrak: Evidence from a Long-Term Mesocosm Study

Ocean acidification is considered as a crucial stressor for marine communities. In this study, we tested the effects of the IPCC RPC6.0 end-of-century acidification scenario on a natural plankton community in the Gullmar Fjord, Sweden, during a long-term mesocosm experiment from a spring bloom to a mid-summer situation. The focus of this study was on microzooplankton and its interactions with phytoplankton and mesozooplankton. The microzooplankton community was dominated by ciliates, especially small Strombidium sp., with the exception of the last days when heterotrophic dinoflagellates increased in abundance. We did not observe any effects of high CO₂ on the community composition and diversity of microzooplankton. While ciliate abundance, biomass and growth rate were not affected by elevated CO₂, we observed a positive effect of elevated CO₂ on dinoflagellate abundances. Additionally, growth rates of dinoflagellates were significantly higher in the high CO₂ treatments. Given the higher Chlorophyll a content measured under high CO₂, our results point at mainly indirect effects of CO₂ on microzooplankton caused by changes in phytoplankton standing stocks, in this case most likely an increase in small-sized phytoplankton of <8 μm. Overall, the results from the present study covering the most important part of the growing season indicate that coastal microzooplankton communities are rather robust towards realistic acidification scenarios.

Asthma from the perspective of the patient

BACKGROUND

The published literature is lacking in data on the frequency and severity of medication side effects in the general asthma population.

METHODS

Questionnaires regarding asthma severity, treatment, and medication side effects were answered by 1230 and 604 pediatric and adult asthmatics, respectively, 70% to 75% of whom were consulting a specialist.

RESULTS

Most respondents (58%-79%) reported unwanted side effects from their bronchodilators, most of which had been racemic albuterol prescribed in either generic or name brand form. Side effects were most common in nebulizer users of all ages and in pediatric patients using oral medications. The most common troublesome side effects were jitteriness (58%), restlessness (57%), tachycardia (56%) and cough (56%) in the pediatric patients and tachycardia (64%), jitteriness (60%), shaky hands (43%), and restlessness (42%) in the adult respondents. Most patients had spoken to their physicians about their side effects, and the most common response was to change brands within the same class of medication, adjust the dose, or advise the patients to tolerate the side effects because the medications were necessary and side effects were to be expected. Fewer than 4% of all respondents viewed their physicians as "caring/sympathetic/willing to listen/discuss their bronchodilator side effects." Twenty-five to thirty percent of patients had reduced their bronchodilator dose on their own, and 14% to 24% had skipped doses to avoid unwanted side effects. Hospitalizations were infrequent and were most commonly seen in the nebulizer users, who were also rated by their physicians as more likely to have severe asthma. Other markers of asthma control (such as emergency room visits, unscheduled doctor visits, and being sent home from school/work for asthma symptoms) were not only common in the nebulizer user group but also in children who used oral medications. This group was more likely to have been classified by their physicians as having mild asthma, suggesting perhaps a need for more intensive asthma education in this group.

CONCLUSION

Medication side effects are common in individuals with asthma and are most often ascribed by the patients to their bronchodilators. There is a need for new, rapid-acting bronchodilators with fewer side effects.