24-year Study Period Research Articles

Preventable diagnostic errors in fatal cervical spine injuries: a nationwide register-based study from 1987 to 2010

BackgroundFall-induced injuries in patients are increasing in number, and they often lead to serious consequences, such as cervical spine injuries (CSI). CSI diagnostics remain a challenge despite improved radiological services. PurposeOur aim is to define the incidence and risk factors for diagnostic errors among patients who died following a CSI. Study Design/SettingA retrospective death certificate-based study of the whole population of Finland was carried out. Patient sampleWe identified 2,041 patients whose death was, according to the death certificate, either directly or indirectly caused by a CSI. Outcome MeasuresDemographics, injury- and death-related data, and adverse event (AE)-related data were the outcome measures. MethodsAll death certificates between the years 1987 and 2010 from Statistics Finland that identified a CSI as a cause death were reviewed to identify preventable AEs with the emphasis on diagnostic errors. ResultsOf the 2,041 patients with CSI-related deaths, 36.5% (n=744) survived at least until the next day. Errors in CSI diagnostics were found in 13.8% (n=103) of those who died later than the day of injury. Those with diagnostic errors were significantly older (median age 79.4 years, 95% confidence interval 75.9–80.1 vs. 74.9, 95% confidence interval 70.2–72.9, p<.001) and the mechanism of injury was significantly more often a fall (86.4%, n=89 vs. 69.7%, n=447, p=.002) compared with those who did not have a diagnostic error. The incidence of diagnostic errors increased slightly during the 24-year study period. ConclusionsCervical spine injury diagnostics remain difficult despite improved radiological services. The majority of the patients subjected to diagnostic errors are fragile elderly people with reduced physical capacity. In our analysis, preventable AEs and diagnostic errors were most commonly associated with ground-level falls.

Impact of Treatment and Insurance on Socioeconomic Disparities in Survival after Adolescent and Young Adult Hodgkin Lymphoma: A Population-Based Study.

Previous studies documented racial/ethnic and socioeconomic disparities in survival after Hodgkin lymphoma among adolescents and young adults (AYA), but did not consider the influence of combined-modality treatment and health insurance. Data for 9,353 AYA patients ages 15 to 39 years when diagnosed with Hodgkin lymphoma during 1988 to 2011 were obtained from the California Cancer Registry. Using multivariate Cox proportional hazards regression, we examined the impact of sociodemographic characteristics [race/ethnicity, neighborhood socioeconomic status (SES), and health insurance], initial combined-modality treatment, and subsequent cancers on survival. Over the 24-year study period, we observed improvements in Hodgkin lymphoma-specific survival by diagnostic period and differences in survival by race/ethnicity, neighborhood SES, and health insurance for a subset of more recently diagnosed patients (2001-2011). In multivariable analyses, Hodgkin lymphoma-specific survival was worse for Blacks than Whites with early-stage [HR: 1.68; 95% confidence interval (CI): 1.14-2.49] and late-stage disease (HR: 1.68; 95% CI, 1.17-2.41) and for Hispanics than Whites with late-stage disease (HR: 1.58; 95% CI, 1.22-2.04). AYAs diagnosed with early-stage disease experienced worse survival if they also resided in lower SES neighborhoods (HR: 2.06; 95% CI, 1.59-2.68). Furthermore, more recently diagnosed AYAs with public health insurance or who were uninsured experienced worse Hodgkin lymphoma-specific survival (HR: 2.08; 95% CI, 1.52-2.84). Our findings identify several subgroups of Hodgkin lymphoma patients at higher risk for Hodgkin lymphoma mortality. Identifying and reducing barriers to recommended treatment and surveillance in these AYAs at much higher risk of mortality is essential to ameliorating these survival disparities.

Landscape fragmentation, severe drought, and the new Amazon forest fire regime.

Changes in weather and land use are transforming the spatial and temporal characteristics of fire regimes in Amazonia, with important effects on the functioning of dense (i.e., closed-canopy), open-canopy, and transitional forests across the Basin. To quantify, document, and describe the characteristics and recent changes in forest fire regimes, we sampled 6 million ha of these three representative forests of the eastern and southern edges of the Amazon using 24 years (1983-2007) of satellite-derived annual forest fire scar maps and 16 years of monthly hot pixel information (1992-2007). Our results reveal that changes in forest fire regime properties differentially affected these three forest types in terms of area burned and fire scar size, frequency, and seasonality. During the study period, forest fires burned 15% (0.3 million ha), 44% (1 million ha), and 46% (0.6 million ha) of dense, open, and transitional forests, respectively. Total forest area burned and fire scar size tended to increase over time (even in years of average rainfall in open canopy and transitional forests). In dense forests, most of the temporal variability in fire regime properties was linked to El Nino Southern Oscillation (ENSO)-related droughts. Compared with dense forests, transitional and open forests experienced fires twice as frequently, with at least 20% of these forests' areas burning two or more times during the 24-year study period. Open and transitional forests also experienced higher deforestation rates than dense forests. During drier years, the end of the dry season was delayed by about a month, which resulted in larger burn scars and increases in overall area burned later in the season. These observations suggest that climate-mediated forest flammability is enhanced by landscape fragmentation caused by deforestation, as observed for open and transitional forests in the Eastern portion of the Amazon Basin.

(794) - Lung Retransplantation for Early Graft Failure: Trends and Results in 112 Patients Over a 24-Year Period

In this study, we review trends and results of lung retransplantation for early graft failure (EGF) in the United States. Adult patients undergoing lung transplantation between 1987-2010 were identified in the United Network for Organ Sharing database. Patients undergoing redo lung transplantation for EGF (defined as within 90-days of original transplant) were compared to primary lung transplant patients (PLTx) and those undergoing redo lung transplantation for late graft failure (LGF). Trends were identified using three eras (1987-1994, 1995-2004, and 2005-2010). Postoperative complications were also compared between cohorts. Of 20,658 lung transplant recipients in the 24-year study period, 719(3%) were redo transplants (112 EGF, 607 LGF). The mean interval between initial transplant and redo transplant was 18.5±19.2 days for the EGF group and 1502.5±1201.7 days for the LGF group. The EGF cohort had significantly worse overall 1-year survival (49% versus 81% PLTx versus 68% LGF; p<0.001). Although 1-year survival significantly improved over time for the other cohorts (PLTx: 75% to 84%, p<0.001; LGF: 45% to 73%, p<0.001), this was not observed in the EGF patients (48% to 48%, p=0.88). Postoperative rates of renal failure requiring dialysis (31% versus 5% PLTx versus 11% LGF, p<0.001), stroke (5% versus 2% PLTx versus 1% LGF, p=0.05), reoperation (57% versus 19% PLTx versus 24% LGF, p<0.001), and infection (74% versus 44% PLTx versus 57% LGF, p<0.001) were higher in the EGF group. Median days of hospitalization were also longer in EGF (46 versus 24 in PLTx versus 31 in LGF, p<0.001). Redo lung transplant for EGF is associated with significantly high mortality and morbidity risk. Although overall outcomes in lung transplant recipients have improved over the last quarter century, this has not applied to the EGF subset. Judicious patient selection in this challenging cohort remains prudent in the modern era.

Stable incidence of surgical treatment and hospitalisation for humeral shaft fractures among 0- to 16-year-old patients in Finland from 1987 to 2010

BackgroundStudies among children experiencing fractures report an increasing trend toward operative management. In the present study, we examined whether the same trend has occurred for humeral shaft fractures in accordance with increasing interest toward intramedullary nailing and other operative treatments. The number, incidence and treatment of all hospitalised 0- to 16-year-old patients with humeral shaft fractures in Finland was assessed over a recent 24-year period.MethodThe study included the entire adolescent (0–16 years) population in Finland during the 24-year period from January 1, 1987, to December 31, 2010. Data on hospitalised patients who sustained humeral shaft fractures were obtained from the nationwide National Hospital Discharge Register (NHDR) of Finland.ResultsDuring the study period, there were a total of 1,165 hospitalisations with a main or secondary diagnosis of humeral shaft fracture. The incidence of hospitalisation due to humeral shaft fractures was 4.8 per 100,000 person-years. The incidence increased only slightly among girls from 3.3 per 100,000 person-years in 1987 to 5.3 per 100,000 person-years in 2010. The incidence of reposition and casting was 1.1 per 100,000 person-years and the incidence of reposition with osteosynthesis, including intramedullary nailing, was 1.4 per 100,000 person-years. The specific incidence of intramedullary nailing remained low with no signs of increased incidence, and the incidence was 0.3 per 100,000 person-years. There were no significant changes in the incidence of surgical treatment during the 24-year study period.ConclusionDespite an overall increasing trend toward operative management of fractures in children, conservative management remains the treatment of choice for humeral shaft fractures based on the low and steady incidence of surgical treatment during the 24-year study period. In addition, the incidence of hospitalisation for fractures remained low without a significant increase during the study period.

Increased incidence of distal humeral fractures and surgical treatment in 0- to 18-year-old patients treated in Finland from 1987 to 2010

Studies of pediatric and adolescent fractures in general report a significant increase in the incidence of upper-extremity fractures as well as in their surgical treatment. The aim of this study was to determine the trends of the incidence and treatment of distal humeral fractures in hospitalized 0- to 18-year-old patients in Finland. The study included the entire pediatric and adolescent (<19years) population in Finland during the 24-year period from 1 January 1987 to 31 December 2010. Data on hospitalized patients were obtained from the nationwide National Hospital Discharge Registry where information is collected from all hospital categories (private, public, and other). Surgical treatment was categorized into three groups; (1) reposition with casting; (2) reposition or reduction and osteosynthesis; (3) reposition or reduction and external-fixation and other fixation methods. Patients were classified into three groups according to age: 0-6years, 7-13years, and 14-18years. Annual incidences were calculated using the annual mid-year population census obtained from the Official Statistics of Finland. During the 24-year study period, there were a total of 12,590 hospitalizations with a main or secondary diagnosis of distal humeral fracture. In children aged 0-12 years the overall incidence of hospitalization increased 30% during the 24-year study period, from 4.5 per 10,000 person-years in 1987 to 5.8 per 10,000 person-years in 2010. There were a total of 5,548 operations. During the study period, surgical treatment by repositioning or reduction with osteosynthesis due to a distal humeral fracture increased by fivefold in patients aged <6years and by twofold in patients aged 7-12years of age. The incidences of fracture and treatment in children older than 13years did not change. The incidence of distal humeral fractures and the incidence of repositioning with osteosynthesis increased remarkably in prepubertal children during the 24-year study period in Finland.

Longitudinal age-and cohort trends in body mass index in Sweden – a 24-year follow-up study

BackgroundThe aim of this longitudinal study was to analyze whether mean Body Mass Index (BMI), assessed at four occasions, changed within different age groups and birth cohorts over time, i.e., between 1980/81 and 2004/05, after adjustment for possible confounders.MethodsA sample of 2728 men and 2770 women aged 16–71 years at study start were randomly drawn from the Swedish Total Population Register and followed from 1980/81 to 2004/05. The same sample was assessed on four occasions during the 24-year study period (i.e., every eighth year). The outcome variable, BMI, was based on self-reported height and weight. A mixed model, with random intercept and random slope, was used to estimate annual changes in BMI within the different age groups and birth cohorts.ResultsMean BMI increased from 24.1 to 25.5 for men and from 23.1 to 24.3 for women during the 24-year study period. The annual change by age group was highest in the ages of 32–39, 40–47 and 48–55 years among men, and in the ages of 24–31, 32–39, and 40–47 years among women. The highest annual changes were found in the youngest birth cohorts for both men and women, i.e., those born 1958–65, 1966–73, and 1974–81. For each birth cohort, the annual change in BMI increased compared to the previous, i.e., older, birth cohort. In addition, age-by-cohort interaction tests revealed that the increase in BMI by increasing age was higher in the younger birth cohorts (1966–1989) than in the older ones.ConclusionsPublic health policies should target those age groups and birth cohorts with the highest increases in BMI. For example, younger birth cohorts had higher annual increases in BMI than older birth cohorts, which means that younger cohorts increased their BMI more than older ones during the study period.

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Spatial and spatial–temporal clustering analysis of hemorrhagic disease in white-tailed deer in the southeastern USA: 1980–2003

We used the space-time K function and Kulldorff's scan statistic to analyze the spatial and spatial–temporal clustering of hemorrhagic disease (HD) in white-tailed deer in Alabama, Georgia, South Carolina, North Carolina, and Tennessee. The HD occurrence data were binary presence/absence data acquired annually on a county basis from 1980 to 2003. Space-time K function was employed to globally examine the existence of spatial–temporal clustering in the HD data. Three approaches of Kulldorff's scan statistic, i.e., spatial clustering analysis for the entire period, spatial–temporal clustering analysis, and spatial clustering analysis by individual years, were applied to detect potential HD clusters. Statistically significant spatial clusters and spatial–temporal clusters were detected in the five southeastern states during the 24-year study period. Some clusters were observed in multiple years. Clusters were most evident in west Alabama, south Alabama, central South Carolina, and along the border between South Carolina and North Carolina. The identification of HD clusters may provide a means to better understand the causal factors related to the HD outbreaks. Results also have potential application in improving or designing effective surveillance programs for this disease.

Age-dependent care and long-term (20 year) mortality of 14,434 myocardial infarction patients: Changes from 1985 to 2008

ObjectivesTo determine whether age-dependent inequalities in care and outcome changed over a 24year period for patients admitted with a myocardial infarction (MI). MethodsWe examined four age groups (<55, 55–65, 65–75, and >75years) and treatment and mortality in 14,434 consecutive patients admitted for MI to an intensive coronary care unit from 1985 to 2008. Temporal trend analyses were performed by comparing decades of admission (1985–1990 vs. 1990–2000 vs. 2000–2008). ResultsA total of 2040 (14%) of the patients were >75years of age. Older patients more often were female and less often presented with an ST-segment elevation MI (STEMI). Systematic differences in care were present between the age groups: older patients were less likely to receive evidence-based medical care and reperfusion therapy during the last 24years, although the differences became smaller over time. In 2000–2008, 30-day (adjusted OR 0.28, 95%CI: 0.23–0.34) and 5-year (adjusted HR 0.61, 95%CI: 0.54–0.68) mortality were lower compared to 1985–1990. These temporal trends were equal across all age groups. Hence, the change in mortality over the 24-year study period is similar among the spectrum of ages. Patients aged <55, 55–65, 65–75, and >75years had a 20-year mortality of 38, 63, 87 and >95%, respectively. ConclusionsOlder patients with an MI remained less likely to receive evidence-based care during 24years of observation. Temporal reductions in mortality were similar among all age groups. The application of proven MI therapies to appropriate patients regardless of age may even further improve these outcomes.

Neonatal acute kidney injury in a tertiary center in a developing country

Acute kidney injury (AKI) is a common contributor to morbidity and mortality in newborns, with prevalences varying by population and hospital. A study of AKI in newborns in tertiary care centers in Thailand, a developing country with limited resources, has not been conducted yet. The aim of this study was to determine the prevalence of AKI in newborns in a tertiary care hospital in southern Thailand and to investigate the etiology, mortality and risk factors of mortality. The records of patients aged <30 days with high serum creatinine, admitted from 1984 to 2007, were retrospectively reviewed. Eighty-eight boys and 51 girls were enrolled; 61.4% were premature and 56.5% had a birth weight <2500 g. The prevalence of newborn AKI increased from 0.9 to 6.3% during the 24-year study period. Thirty-nine and 65% had renal failure within 2 and 7 days post-birth, respectively. Sepsis was the most common cause of AKI (30.9%) followed by hypovolemia (18.7%), kidney, ureter and bladder (KUB) anomalies (12.2%), congestive heart failure (12.2%) and birth asphyxia (11.5%). Indomethacin caused AKI in 24.4% with gestational age <32 weeks. Sepsis-induced AKI had the highest mortality rate (65.1%) with an overall mortality rate of 38.8% and nearly 14 times the risk of death compared to hypovolemia-induced AKI. The prevalence of newborn AKI in our Thai tertiary center over 24 years was 6.3% of admitted newborns. Sepsis was the most common cause of AKI and sepsis-induced AKI is the most common cause of death. Disease etiology was the only risk factor for mortality.

O5-5.6 Evaluation of the compression expansion and dynamic equilibrium theories using western Australian linked hospital morbidity and mortality data

IntroductionThree hypotheses have been advanced to predict changes in population health in countries experiencing low birth and death rates, and increasing expectation of life. Determining which of these best accounts...

Climate Stabilization Wedges in Action: A Systems Approach to Energy Sustainability for Hawaii Island

Pacala and Socolow developed a framework to stabilize global greenhouse gas levels for the next fifty years using wedges of constant size representing an increasing use of existing technologies and approaches for energy efficiency, carbon free generation, renewables, and carbon storage. The research presented here applies their approach to Hawaii Island, with modifications to support local scale analysis and employing a "bottom-up" methodology that allows for wedges of various sizes. A discretely bounded spatial unit offers a testing ground for a holistic approach to improving the energy sector with the identification of local options and limitations to the implementation of a comprehensive energy strategy. Nearly 80% of total primary energy demand across all sectors for Hawaii Island is currently met using petroleum-based fuels.The Sustainable Energy Plan scenario included here presents an internally consistent set of recommendations bounded by local constraints in areas such as transportation efficiency, centralized renewable generation (e.g., geothermal, wind), reduction in transmission losses, and improved building efficiency. This scenario shows thatthe demand for primary energy in 2030 could be reduced by 23% through efficiency measures while 46% could be met by renewable generation, resulting in only 31% of the projected demand being met by fossil fuels. In 2030, the annual releases of greenhouse gases would be 3.2 Mt CO2-eq/year under the Baseline scenario, while the Sustainable Energy Plan would reduce this to 1.2 Mt CO2-eq/year--an annual emissions rate 40% below 2006 levels and 10% below 1990 levels. The total for greenhouse gas emissions during the 24-year study period (2007 to 2030) is 59.9 Mt CO2-eq under the Baseline scenario and 32.5 Mt CO2-eq under the Sustainable Energy Plan scenario. Numerous combinations of efficiency and renewable energy options can be employed in a manner that stabilizes the greenhouse gas emissions of Hawaii Island.

Esophageal and Gastric Cardia Cancers on 4238 Chinese Patients Residing in Municipal and Rural Regions: A Histopathological Comparison During 24‐Year Period

Nutrition deficiencies or poverty traditionally have been recognized to be related with increased risk for esophageal cancer (EC) in rural regions at junction of Henan, Hebei, and Shanxi provinces in northern China--the highest incidence area for esophageal squamous cell carcinoma (ESCC) and gastric cardia adenocarcinoma (GCA). Since the 1980s, economic and nutrition condition in these areas have been improved greatly. However, the histopathological types, staging pattern, and occurrence of ESCC and GCA, especially for esophageal adenocarcinoma (EAC), which have been rarely examined in the Chinese population during the past decades in these areas have not been well characterized to date. Yearly diagnosed new esophageal cancer (ESCC and EAC) and GCA patients from Beijing Tongren Hospital (in municipal low-risk region) and Cixian People Hospital (in rural high-risk region) during 24-year period (1982-2005) were studied retrospectively. Only local resident patients with surgical resection were included. Age at diagnosis, tumor stage and site, and histopathological pattern were recorded for each patient from the tumor registry database in these hospitals. This study demonstrated that the common ESCC sites were different in municipal (chiefly in lower third of the esophagus) and in rural (chiefly in middle third of the esophagus) regions. The peak age of ESCC, EAC, and GCA patients in rural region was 10 years younger than in municipal region. Eighty-six percent of ESCC and 90% of GCA in municipal region were diagnosed at middle and advanced stage; similarly, more than 95% of ESCC and GCA in rural region were diagnosed at middle and advanced stage during the 24-year study period. An increasing tendency in number of yearly diagnosed new patients with ESCC and GCA was observed in municipal region, but not in rural region. However, an increasing tendency for EAC was observed both in municipal and rural regions during the past 24-year period. The present results demonstrate the difference in municipal and rural regions of ESCC, ECA, and GCA in histopathological types, and suggest that there may be different etiological factors involved in esophageal and gastric cardia carcinogenesis in these different areas.

Elderly suicide rates in the United Kingdom: Trends from 1979 to 2002

The proportion of elderly in the population is increasing due to a falling birth rate and increased life expectancy, and suicide rates increase with age. Trends in elderly suicide rates over a 24-year period, 1979 to 2002, were examined. Differences in suicide rates between elderly men and women and between the age-bands 65 to 74 years and 75+ years were examined. Data was ascertained from the WHO website. Suicide rates for men and women for the age-bands 65 to 74 years and 75+ years declined over the 24-year study period. Suicide rates were higher in men than women for both the age bands. In men, suicide rates were higher in the 75+ age-band than in the 65 to 74 years age-band. Various national initiatives may have contributed to the decline in suicide rates. The challenge will be to sustain the decline, given that the population is ageing and suicide rates generally increase with age.

Use of Western Australian linked hospital morbidity and mortality data to explore theories of compression, expansion and dynamic equilibrium

Three hypotheses have been advanced to predict changes in population health in countries experiencing low birth and death rates, and increasing expectation of life. Determining which of these best accounts for changing patterns of illness and death is an important step in understanding both the public health and economic impacts of health interventions in an ageing population. The aim of this study was to use the WA Data Linkage System to evaluate the compression, expansion and dynamic equilibrium theories in Western Australia. Changes in life expectancy, average age at first-time hospitalisation and time spent in chronic disabling or activity limiting states were used to evaluate the competing hypotheses. Life expectancy increased by 4.0 and 2.6 years over the 24-year study period in males and females, respectively. However, average time spent with a diagnosed chronic disabling condition increased by 9.2 and 9.4 years in males and females, respectively. These results suggest that an increase in the "medicalisation of more serious morbidity" may be in operation in Australia.

Rapidly declining fine‐scale spatial genetic structure in female red deer

A growing literature now documents the presence of fine-scale genetic structure in wild vertebrate populations. Breeding population size, levels of dispersal and polygyny--all hypothesized to affect population genetic structure--are known to be influenced by ecological conditions experienced by populations. However the possibility of temporal or spatial variation in fine-scale genetic structure as a result of ecological change is rarely considered or explored. Here we investigate temporal variation in fine-scale genetic structure in a red deer population on the Isle or Rum, Scotland. We document extremely fine-scale spatial genetic structure (< 100 m) amongst females but not males across a 24-year study period during which resource competition has intensified and the population has reached habitat carrying capacity. Based on census data, adult deer were allocated to one of three subpopulations in each year of the study. Global F(ST) estimates for females generated using these subpopulations decreased over the study period, indicating a rapid decline in fine-scale genetic structure of the population. Global F(ST) estimates for males were not different from zero across the study period. Using census and genetic data, we illustrate that, as a consequence of a release from culling early in the study period, the number of breeding females has increased while levels of polygyny have decreased in this population. We found little evidence for increasing dispersal between subpopulations over time in either sex. We argue that both increasing female population size and decreasing polygyny could explain the decline in female population genetic structure.

Trends in the etiology of infectious corneal ulcers at the F. I. Proctor Foundation.

We analyzed laboratory results from corneal ulcers seen from 1976 to 1999 at the Francis I. Proctor Foundation, a referral center in San Francisco, to determine the relative frequencies of pathogens and to analyze for trends in frequencies of the most common pathogens. The results were compared with a previous study of corneal ulcers seen from 1948 to 1976 at the same institution. Ulcers presenting to the Proctor Foundation were Gram stained and cultured using standard techniques. Herpetic corneal ulcers were excluded from the study. Organisms were isolated from 427 ulcers, 38% of all cases. Two hundred seventy-eight (59%) isolates were gram-positive bacteria, 145 (31%) gram-negative bacteria, 16 (3%) Acanthamoeba spp., and 36 (8%) fungi. Staphylococcus aureus was the most common organism, composing 20% of all isolates, followed by viridans group streptococci (12%), Streptococcus pneumoniae (11%), Pseudomonas aeruginosa (6%), Moraxella spp. (5%), and Serratia marcescens (4%). Over the 24-year study period the proportion of positive cultures decreased and the incidence of S. marcescens increased significantly. Comparing the period of 1948-1976 to 1976-1999, the frequency of S. pneumoniae and P. aeruginosa decreased, and that of S. marcescens increased significantly. The common pathogens associated with corneal ulcers have changed over the past 50 years in Northern California, with S. pneumoniae and P. aeruginosa being isolated relatively less often and S. marcescens being isolated with increasing frequency. The decrease in isolation of organisms over the 1976-1999 period may have resulted from increasing empiric antibiotic treatment by referring ophthalmologists.

Metastasectomy for recurrent stage IV melanoma.

Many patients undergoing complete surgical resection of distant metastatic melanoma (American Joint Committee on Cancer [AJCC] stage IV) develop recurrent disease. We examined whether a second metastasectomy could prolong the survival of patients with recurrent stage IV melanoma. Retrospective review of our 8,750-patient melanoma database identified 211 patients who were rendered clinically free of disease by surgical resection of stage IV metastases during the 24-year study period (January 1971 through December 1995). Our study population comprised the 131 patients who developed recurrent stage IV disease and were followed for at least 24 months or until death. The median disease-free interval prior to recurrent stage IV disease was 8 months (range 0.6-91.8 months). There were 131 tumor-involved anatomic sites; the median number was one (range 1-3). Of these sites, 71 (54.2%) were soft tissue, 35 (26.7%) were pulmonary, 28 (21.4%) were gastrointestinal, 23 (17.6%) were cerebral, 13 (9.9%) were skeletal, and 2 (1.5%) were gynecologic. Median survival following treatment for recurrent stage IV melanoma was 18.2 months after complete metastasectomy, compared with 12.5 months or 5.9 months after a palliative surgical procedure or nonsurgical management, respectively. The 5-year survival rate was 20.0% (8/40) for patients in the complete surgical metastasectomy group, compared with 7.0% (3/43) and 2.1% (1/48) for those in the palliative surgical and nonsurgical groups, respectively. By multivariate analysis, the two most important prognostic factors for survival following diagnosis of recurrent stage IV melanoma were a prolonged disease-free interval to recurrence (P = 0.0001) and complete surgical metastasectomy of the recurrence (P = 0.0001). Metastasectomy can prolong the survival of patients with recurrent stage IV melanoma if all clinically evident tumor can be resected.

Alcohol, Firearms, and Suicide Among Youth

The death certificates and coroners' reports for all suicides, undetermined causes of death, and questionable accidents were obtained from the Pennsylvania Department of Vital Statistics for 10- to 19-year-old residents of Allegheny County, Pennsylvania, from 1960 to 1983. During the 24-year study period, 159 cases of definite suicide and 38 cases of likely suicide were noted. The suicide rate increased markedly among youth during the study period, particularly among white males aged 15 to 19 years, and was not due to changes in classification procedures over time. The suicide rate by firearms increased much faster than the suicide rate by other methods (2.5 vs 1.7-fold). The proportion of suicide victims who had detectable blood alcohol levels rose 3.6-fold from 12.9% in 1968 to 1972 to 46.0% in 1978 to 1983. Suicide victims who used firearms were 4.9 times more likely to have been drinking than were those who used other methods of suicide. The availability of firearms and the increased use of alcohol among youth may have made a significant contribution to the increase in the suicide rate among the young.