Cause Of Death Analysis Research Articles

Multiple cause of death analysis in multiple sclerosis: A population-based study.

To gain a better understanding of the complex patterns of causes that contribute to death due to multiple sclerosis (MS) by assessing the relationship between MS and other causes of death listed on death certificates. Multiple cause of death data for all adult deaths (aged ≥18 years) in British Columbia, Canada, between 1986 and 2013 were accessed. All causes, as listed on the death certificate, whether underlying or contributing, were considered "any mention" causes. The associations between mention of MS on the death certificate and mention of other causes of death were examined by logistic regression, adjusted for age, sex, and calendar year (Bonferroni-corrected α level = 0.002). Findings were also sex-stratified. Among 771,288 deaths, MS was mentioned on 2,153 certificates. If MS was mentioned (versus not mentioned), there was a greater chance that specific conditions contributed to the death: respiratory infection (adjusted odds ratio [aOR], 3.03 [95% confidence interval (CI), 2.73-3.36]), aspiration pneumonia (aOR, 7.15 [95% CI, 6.23-8.22]), urinary tract infection (UTI) (aOR, 10.2 [95% CI, 8.7-12.0]), other infection including sepsis (aOR, 1.34 [95% CI, 1.15-1.56]), and skin disease (aOR, 5.06 [95% CI, 3.96-6.46]). Sex differences existed for urinary tract infection (men: aOR, 14.9 [95% CI, 11.5-19.3]; women: aOR, 8.00 [95% CI, 6.53-9.81]) and chronic respiratory disease (men = aOR, 1.36 [95% CI, 1.14-1.63]; women = aOR, 0.97 [95% CI, 0.84-1.13]). Deaths attributed to MS were commonly caused by infection (especially respiratory and urinary tract-related); conditions associated with advanced disability and immobility, such as aspiration pneumonia; and chronic respiratory disease in men. All are potentially modifiable; interventions that reduce the frequency or severity of these complications could improve survival in MS.

Особенности состояния здоровья трудоспособного населения в Сибирском федеральном округе

<span>Доля трудоспособного населения в России постепенно сокращается. По прогнозам, в 2026 г. численность всего населения уменьшится на 4,3%, а трудоспособного</span><span class="myHorizontalScaleForEmDashSpaceBefore"> </span><span>–</span><span class="myHorizontalScaleForEmDashSpaceAfter"> </span><span>на 16,4%, что приведет к снижению доли данной группы в возрастной структуре до 55,1% (в 2008 г. было 63,2%). По этой причине состояние здоровья этой категории граждан, анализ причин смертности и меры по ее снижению приобретают особое значение. Цель настоящего исследования</span><span class="myHorizontalScaleForEmDashSpaceBefore"> </span><span>–</span><span class="myHorizontalScaleForEmDashSpaceAfter"> </span><span>изучение состояния, динамики и особенностей заболеваемости, в том числе профессиональной, и причин смерти трудоспособного населения Сибирского федерального округа (СФО). Опираясь на анализ литературы, посвященной заболеваемости и смертности лиц трудоспособного возраста в СФО и России, а также статистические данные региональных органов управления здравоохранения СФО, авторы сделали выводы, что состояние здоровья трудоспособного населения в Сибири заметно хуже, чем в среднем по России. При этом заболевамость как с впервые в жизни установленным диагнозом, так и общая продолжает расти. Смертность хотя и снижается с течением времени, но медленнее, чем в целом по стране, поэтому за семь лет отставание от общероссийских показателей увеличилось с 14,8 до 17,25%. В структуре смертности отмечается повышенное (относительно РФ в целом) влияние внешних причин, таких как убийства, самоубийства, отравления суррогатами алкоголя и др. Несмотря на существенное снижение числа смертельных несчастных случаев на производстве (на 1000 человек), по этому показателю СФО опережают лишь Дальневосточный и Приволжский федеральные округа.</span>

Long-Term Survival of Young Patients Surviving ICU Admission With Severe Sepsis.

Sepsis remains a disease with a high mortality rate. The study goal was to assess long-term survival of severe sepsis in young patients. Retrospective cohort study. Patients admitted with sepsis to ICUs in seven tertiary hospitals between 2003 and 2011. A total of 409 patients less than 45 years who survived to hospital discharge were age and sex matched with 818 patients with infectious disease without sepsis selected from internal medicine or surgical department admissions. None. The median age in sepsis patients and the comparison group was 31 and 32 years, respectively. The proportions of patients surviving after hospital discharge were significantly lower in the sepsis group compared with the control group; among survivors, 6-month, 1-year, and 3-year mortality rates were 0.7% versus 0%, 4.5% versus 0.7%, 7.9% versus 1.2%, and 10.8% versus 1.8%, respectively (p < 0.001 for all). In a multivariate Cox proportional hazards regression model, sepsis was associated with an increased risk of mortality (hazard ratio, 3.79; 95% CI, 2.27-6.32), while controlling for age, Charlson Comorbidity Index, history of stroke, and congestive heart failure. Past the 24-month landmark, sepsis was not found to be an independent risk for mortality (hazard ratio, 1.79; 95% CI, 0.67-4.79). Based on cause of death analysis, chronic underlying comorbidities might explain the excess mortality in patients with sepsis. Young patients experiencing an episode of severe sepsis continue to be at higher risk of long-term mortality. The highest mortality rates were observed during the first 24 months following discharge.

Asthma-related mortality in the United States, 1999 to 2015: A multiple causes of death analysis

BackgroundAsthma mortality based on the underlying cause of death (UCOD) underestimates disease burden. ObjectiveTo analyze asthma mortality in the United States from 1999 to 2015 and the pattern of reporting of asthma and its comorbidities in death certificates, using multiple cause of death (MCOD) records. MethodsAll 156,517 death certificates with any mention of asthma were analyzed for 1999 to 2015. Asthma was defined by International Classification of Diseases, 10th Revision code J45 based on the UCOD or MCOD. Annual age-adjusted asthma death rates were computed according to age, sex, and race/ethnicity. The 6,304 MCOD coded status asthmaticus cases (J46) were also examined. ResultsFrom 1999 to 2015 a total of 59,067 deaths with a UCOD of asthma occurred; 37,832 deaths occurred in females and 21,235 in males (female-male ratio = 1.78). A total of 156,517 deaths with MCOD of asthma occurred; 101,371 deaths occurred in females and 55,146 in males (female-male ratio = 1.83). Hence, 37.7% of deaths with any mention of asthma had asthma as the UCOD (37.3% in females and 38.45% in males). Of these deaths, 41.7% occurred in non-Hispanic blacks and 36% in non-Hispanic whites. Between 1999 and 2015, age-adjusted MCOD death rates changed as follows: 38.1% in Hispanic white females, 34.1% in non-Hispanic black females, 15.1% in non-Hispanic white females, 28.5% in Hispanic white males, 21.3% in non-Hispanic black males, and 25.0% in non-Hispanic white males. Non-Hispanic black females and males had the highest MCOD and UCOD rates throughout the period. ConclusionAmong deaths with any mention of asthma, asthma was chosen as the UCOD most often in non-Hispanic black males and least often in non-Hispanic white females. Age-adjusted MCOD rates decreased most in non-Hispanic white males and least in non-Hispanic white females.

Distinct mortality profile in systemic sclerosis: a death certificate study in Rio de Janeiro, Brazil (2006-2015) using a multiple causes of death analysis.

The objective of this study was to assess the mortality profile related to SSc in the state of Rio de Janeiro, Brazil. We retrospectively examined all registered deaths in the region (2006-2015 period) in which the diagnosis of SSc was mentioned on any line of the death certificates (underlying cause of death [UCD], n = 223; non-UCD, n = 151). Besides the analysis of gender, age, and the causes of death, we also compared the mortality from UCDs between individuals whose death causes included SSc (cases) and those whose death causes did not include SSc (deceased controls). For the latter comparison, we used the mortality odds ratio to approximate the cause-specific standardized mortality ratio. We identified 1495 death causes among the 374 SSc cases. The mean age at death of the SSc cases (85% women) was significantly lower than that of the controls (n = 1,294,117) (58.7 vs. 65.5years, respectively). The main death causes were circulatory system diseases, infections, and respiratory diseases (36%, 34%, and 21% of SSc cases, respectively). Compared to the deceased controls, there were proportionally more deaths among the SSc cases from pulmonary arterial hypertension, lung fibrosis, septicemia, gastrointestinal hemorrhage, other systemic connective tissue diseases, and heart failure (for death age < 50years). We confirmed the high burden of cardiovascular, respiratory, and infectious causes in thispredominantly non-Caucasian sample of SSc patients. Of interest, the percentage of infection-related deaths in our report was about three times higher than that in SSc studies with predominantly Caucasian populations.

Fracture-related mortality in southern Sweden: A multiple cause of death analysis, 1998–2014

PurposeTo assess fracture-related mortality among adults (aged ≥20years) in southern Sweden using multiple causes of death approach. MethodsAll death certificates (n=201 488) in adults recorded in the region of Skåne from 1998 to 2014 were examined. We identified fracture-related deaths and computed mortality rates by sex, age group, and fracture site. Temporal trends were evaluated using joinpoint regression and associated causes were identified by age- and sex-adjusted observed/expected ratios. ResultsFractures were mentioned on 6 226 (3.1%) death certificates, with majority of these occurred among women (60%) and those aged≥80years (77%). While hip was the most common site overall (61% of all fracture-related deaths), skull was the most common site in people <60years (60% of all fracture-related deaths). Proportion of death certificates mentioning fracture was stable in women but increased by 0.4% (95% CI: 0.1 to 0.6) in men between 1998–2002 and 2010–2014. The mean age at death was higher in death certificates mentioning fracture than those without and this gap widened over time. The mean age-standardized fracture-related mortality rate was 18.8 (14.0) per 100 000 person-year in men (women) and declined by 1.5% (1.3%) per year during 1998–2014. Injuries (84.6%) and cardiovascular disorders (64.6%) were the most common comorbidities on death certificates mentioning fracture. ConclusionsFracture is a contributing cause of death in more than 3% of all deaths in southern Sweden with hip in lead among older and skull fracture among younger people. There was a slight increase in proportion of deaths associated with fracture in men but not women during the study period.

Fall-related mortality in southern Sweden: a multiple cause of death analysis, 1998–2014

ObjectivesTo investigate temporal trend in fall mortality among adults (aged ≥20 years) in southern Sweden using multiple cause of death data.MethodsWe examined all death certificates (DCs, n=2 01 488) in...

Impact of an Age-Adjusted Co-morbidity Index on Survival of Patients With Heart Failure Implanted With Cardiac Resynchronization Therapy Devices

Age is an adverse prognostic factor in patients with heart failure. We aimed to assess the impact of age and noncardiac co-morbidities in the outcome of patients undergoing cardiac resynchronization therapy (CRT), and determine which of these two factors is the most important predictor of survival. The study involved a single-center retrospective assessment of 697 consecutive CRT implants during a 12-year period. Patient co-morbidity profile was assessed using the Charlson Co-morbidity Index (CCI) and the Charlson Age-Co-morbidity Index (CACI). Predictors of survival free from heart transplantation were assessed. CRT-related complications and cause of death analysis were assessed within tertiles of the CACI. During a mean follow-up of 1,813 ± 1,177 days, 347 patients (49.9%) died and 37 (5.3%) underwent heart transplantation. On multivariate Cox regression, female gender (HR = 0.78, 95% confidence interval [CI] 0.62 to 0.99, p = 0.041), estimated glomerular filtration rate (HR per ml/min = 0.99, 95% CI 0.98 to 0.99, p < 0.001), left ventricular ejection fraction (HR per % = 0.99, 95% CI 0.98 to 1.00, p = 0.022), New York Heart Association class (HR = 1.83, 95% CI 1.53 to 2.20, p < 0.001), presence of left bundle branch block (HR = 0.70, 95% CI 0.56 to 0.87, p = 0.001), and CACI tertile (HR = 1.37, 95% CI 1.18 to 1.59, p < 0.001) were independent predictors of all-cause mortality or heart transplantation. Compared with age and the CCI, the CACI was the best discriminator of all-cause mortality. Inappropriate therapies occurred less frequently in higher co-morbidity tertiles. In conclusion, patient co-morbidity profile adjusted to age impacts on mortality after CRT implantation. Use of the CACI may help refine guideline criteria to identify patients more likely to benefit from CRT.

Natural mortality and cause of death analysis of the captive chimpanzee (Pan troglodytes): A 35-year review.

We present the spontaneous causes of mortality for 137 chimpanzees (Pan troglodytes) over a 35-year period. A record review of the pathology database was performed and a primary cause of mortality was determined for each chimpanzee. The most common causes of mortality were as follows: cardiomyopathy (40% of all mortalities), stillbirth/abortion, acute myocardial necrosis, chimpanzee-induced trauma, amyloidosis, and pneumonia. Five morphologic diagnoses accounted for 61% of mortalities: cardiomyopathy, hemorrhage, acute myocardial necrosis, amyloidosis, and pneumonia. The most common etiologies were degenerative, undetermined, bacterial, traumatic, and neoplastic. The cardiovascular system was most frequently involved, followed by the gastrointestinal, respiratory, and multisystemic diseases. Degenerative diseases were the primary etiological cause of mortality of the adult captive chimpanzee population. Chimpanzee-induced trauma was the major etiological cause of mortality among the perinatal and infant population. This information should be a useful resource for veterinarians and researchers working with chimpanzees.

Growing burden of sepsis-related mortality in northeastern Italy: a multiple causes of death analysis.

BackgroundFew population-based data are available on mortality due to sepsis. The aim of the study was to estimate sepsis-related mortality rates and to assess the associated comorbidities.MethodsFrom multiple causes of death data (MCOD) of the Veneto Region (northeastern Italy), all deaths with sepsis mentioned anywhere in the death certificate were retrieved for the period 2008–2013. Among these deaths the prevalence of common chronic comorbidities was investigated, as well as the distribution of the underlying cause of death (UCOD), the single disease selected from all condition mentioned in the certificate and usually tabulated in mortality statistics. Age-standardized mortality rates were computed for sepsis selected as the UCOD, and for sepsis mentioned anywhere in the certificate.ResultsOverall 16,906 sepsis-related deaths were tracked. Sepsis was mentioned in 6.3 % of all regional deaths, increasing from 4.9 in 2008 to 7.7 % in 2013. Sepsis was the UCOD in 0.6 % of total deaths in 2008, and in 1.6 % in 2013. Age-standardized mortality rates increased by 45 % for all sepsis-related deaths, and by 140 % for sepsis as the UCOD. Sepsis was often reported in the presence of chronic comorbidities, especially neoplasms, diabetes, circulatory diseases, and dementia. Respiratory tract and intra-abdominal infections were the most frequently associated sites of infection.ConclusionsMCOD analyses provide an estimate of the burden of sepsis-related mortality. MCOD data suggest an increasing importance attributed to sepsis by certifying physicians, but also a real increase in mortality rates, thus confirming trends reported in some other countries by analyses of hospital discharge records.

Clostridium difficile Infection: An Emerging Cause of Death in the Twenty-First Century

ABSTRACTEnterocolitis due to Clostridium difficile is major emerging cause of death in the U.S. Between 1999 and 2012, C. diff. deaths rose by a staggering almost ten-fold amount, to 7,739 from 793. This article has three goals. First, we present a demographic description of C. diff. mortality in the U.S. since 1999. Second, we test a hypothesis that the increase in C. diff. deaths is due to population aging. We find that the emergence of this cause of death follows a proportional hazard pattern above age 40. Thus, population aging is not the only factor responsible for the increase in C. diff. deaths. This, combined with a contributory cause of death analysis, points towards health care–based strategies to combat C. diff. Third, we demonstrate a simple weighted least squares technique for estimating Gompertz models that gives parameter estimates that are closer to full maximum likelihood than conventional approaches.

Worse Long-term Patient Survival and Higher Cancer Rates in Liver Transplant Recipients With a History of Smoking.

This study is a retrospective review of liver transplant (LT) recipients to determine the impact of tobacco exposure on 10-year survival and de novo cancer (CA) incidence. The records of 1275 consecutive LT patients were reviewed (2001 to 2011). Patients were categorized as current, previous, or never smokers (NS) at listing for LT. Additionally, smokers were stratified by pack-years of tobacco exposure. Events included patient death, cardiovascular events, and de novo cancers. Cox regression analysis was used to evaluate survival. A complete cause of death analysis is provided, as well as a detailed tumor registry. Current (n = 279) and previous smokers (n = 323) were more likely to have hepatocellular carcinoma (HCC) at transplant (25%, 29% vs 18% [NS], P < 0.001), and these 2 groups had higher HCC recurrence rates (21%, 14% vs 11% [NS], P = 0.18). De novo non-HCC CA was higher for current and previous smokers, compared to NS (18%, 16% vs 12% [NS], P = 0.05). Among those with de novo CA (n = 180), the 2 smoking groups were more likely to have non-skin CA (60%, 54% vs 27% [NS], P < 0.001). Patient survival at 10 years was worse for current smokers than the other study groups (55% vs 70%, P < 0.01). These results were largely mirrored with increased tobacco exposure. The LT outcomes are uniformly worse for patients with a history of smoking, and the risk of negative events increases with increasing tobacco use. Smokers have higher rates of HCC and recurrence, de novo cancer, and worse long-term survival. This study summarizes the clinical outcomes for 1275 LT patients over 10 years, analyzing the impact of pre transplant recipient tobacco use. There are 47% of patients with a history of smoking. Because of demonstrated higher cancer rates and decreased survival, patients with a significant smoking history should be carefully scrutinized for liver transplantation.

Multiple causes of death analysis of chronic diseases: the example of diabetes.

BackgroundIdentifying a single disease as the underlying cause of death (UCOD) is an oversimplification of the clinical-pathological process leading to death. The multiple causes of death (MCOD) approach examines any mention of a disease in death certificates. Taking diabetes as an example, the study investigates: patterns of death certification, differences in mortality figures based on the UCOD and on MCOD, factors associated to the mention of diabetes in death certificates, and potential of MCOD in the analysis of the association between chronic diseases.MethodsThe whole mortality archive of the Veneto Region-Italy was extracted from 2008 to 2010. Mortality rates and proportional mortality were computed for diabetes as the UCOD and as MCOD. The position of the death certificate where diabetes was mentioned was analyzed. Conditional logistic regression was applied with chronic liver diseases (CLD) as the outcome and diabetes as the exposure variable. A subset of 19,605 death certificates of known diabetic patients (identified from the archive of exemptions from medical charges) was analyzed, with mention of diabetes as the outcome and characteristics of subjects as well as other diseases reported in the certificate as predictors.ResultsIn the whole mortality archive, diabetes was mentioned in 12.3 % of death certificates, and selected as the UCOD in 2.9 %. The death rate for diabetes as the UCOD was 26.8 × 105 against 112.6 × 105 for MCOD; the UCOD/MCOD ratio was higher in males. The major inconsistencies of certification were entering multiple diseases per line and reporting diabetes as a consequence of circulatory diseases. At logistic regression the mention of diabetes was associated with the mention of CLD (mainly non-alcohol non-viral CLD). In the subset of known diabetic subjects, diabetes was reported in 52.1 %, and selected as the UCOD in 13.4 %. The probability of reporting diabetes was higher with coexisting circulatory diseases and renal failure and with long duration of diabetes, whereas it was lower in the presence of a neoplasm.ConclusionsThe use of MCOD makes the analysis of mortality data more complex, but conveys more information than usual UCOD analyses.

Who died of what in rural KwaZulu-Natal, South Africa: a cause of death analysis using InterVA-4

Background For public health purposes, it is important to see whether men and women in different age groups die of the same causes in South Africa. Objective We explored sex- and age-specific patterns of causes of deaths in a rural demographic surveillance site in northern KwaZulu-Natal in South Africa over the period 2000–2011. Design Deaths reported through the demographic surveillance were followed up by a verbal autopsy (VA) interview using a standardised questionnaire. Causes of death were assigned likelihoods using the publicly available tool InterVA-4. Cause-specific mortality fractions were determined by age and sex. Results Over the study period, a total of 5,416 (47%) and 6,081 (53%) deaths were recorded in men and women, respectively. Major causes of death proportionally affecting more women than men were (all p<0.0001): human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (20.1% vs. 13.6%), other and unspecified cardiac disease (5.9% vs. 3.2%), stroke (4.5% vs. 2.7%), reproductive neoplasms (1.7% vs. 0.4%), diabetes (2.4% vs. 1.2%), and breast neoplasms (0.4% vs. 0%). Major causes of deaths proportionally affecting more men than women were (all p<0.0001) assault (6.1% vs. 1.7%), pulmonary tuberculosis (34.5% vs. 30.2%), road traffic accidents (3.0% vs. 1.0%), intentional self-harm (1.3% vs. 0.3%), and respiratory neoplasms (2.5% vs. 1.5%). Causes of death due to communicable diseases predominated in all age groups except in older persons. Conclusions While mortality during the 2000s was dominated by tuberculosis and HIV/AIDS, we found substantial sex-specific differences both for communicable and non-communicable causes of death, some which can be explained by a differing sex-specific age structure. InterVA-4 is likely to be a valuable tool for investigating causes of death patterns in other similar Southern African settings.

Trends in Sri Lankan cause-specific adult mortality 1950-2006.

BackgroundAlthough all-cause mortality in Sri Lanka decreased significantly from 1950 to 1970, subsequent declines have been more modest with divergent trends by age and sex. This study investigates these trends through cause of death analysis for 1950–2006 in adults aged 15–64 years.MethodsDeaths were obtained from the World Health Organisation (WHO) mortality database for 1950 to 2003, and the Department of Census and Statistics Sri Lanka for 1992–95 and 2004–06 where WHO data was unavailable. Adult deaths were categorised by age (15–34 and 35–64 years) and sex into: infectious diseases; external-causes; circulatory diseases; cancers; digestive diseases; respiratory diseases; pregnancy-related; ill-defined; and other-causes. Cause-specific mortality rates were directly age-standardised to the 2001 Sri Lankan Census population.ResultsMortality declined in females aged 15–34 years by 85% over 1950–2006, predominantly due to sharp declines in infectious disease and pregnancy-related mortality over 1950–70. Among males aged 15–34 years the mortality decline was less at 47%, due to a rise in external-cause mortality during 1970–2000. In females aged 35–64 years mortality declined by 67% over 1950–2006, predominantly due to a sharp decline in infectious disease, ill-defined and other cause mortality over 1950–70. Among males aged 35–64 years, decline in mortality is evident to 1960 (19%) from decline in infectious disease mortality, followed by increased mortality from circulatory diseases and external cause mortality, despite continued decline in infectious disease mortality. All-cause mortality in males 35–64 years has stagnated since 1970, with fluctuating increases. Circulatory diseases were the leading cause of death among adults 35–64 years in 2002–06, with the male rate almost three times higher than females.ConclusionsSignificant disparities are demonstrated in Sri Lankan cause-specific adult mortality by sex and age group for 1950–2006. Female mortality progressively declined while male mortality demonstrated periods of increase and stagnation. Among males aged 15–34 years this coincides with periods of civil conflict over 1970–2000. Among males aged 35–64 years the increased mortality from non-communicable disease and external causes are the main reasons for stagnation in all-cause mortality since the 1970’s.

Trends in mortality from chronic liver disease

PurposeMortality from liver cirrhosis has sharply declined in most countries in the last few decades, but includes only a fraction of deaths due to chronic liver disease. MethodsMortality records for liver cirrhosis, liver cancer, viral hepatitis, and the three disease categories combined were extracted for the period 1995 to 2010 in the Veneto Region (northeastern Italy). The presence of a birth cohort effect was assessed by fitting Poisson regression models. The alcoholic or viral etiology was retrieved through multiple causes of death analysis for the years 2008 to 2010. ResultsLiver cirrhosis mortality represented only one-third of all liver disease deaths; this proportion was even smaller for deaths with a viral etiology and among elderly people. Through the study period, age-standardized rates declined by 50% for liver cirrhosis, and by 30% (world standard) or by 25% (regional standard) for all liver diseases; the reduction in proportional mortality was limited to 11%. Mortality rates started to decline in subjects born after the early 1920s. ConclusionsThe decline in mortality was smaller than that reported by standard statistics for chronic liver disease; these statistics should routinely include viral hepatitis and liver cancer deaths. When available, multiple causes of death data should be analyzed.

Editorial Commentary: Determining the Effect of Hepatitis C on Mortality: Sorting the Signal From the Noise

Pinchoff et al examined surveillance data for hepatitis C reporting, and compared it to cause-of-death data obtained from death certificates from 2000 to 2011 in New York City (NYC). Theyevaluated the effect of hepatitis C on age of death and cause of death (COD), as well as the effect of coinfection with human immunodeficiency virus (HIV) compared with the population without these diseases. This was a well-designed study taking advantage of NYC having several robust disease surveillance registries that were able to be cross-matched and then compared with mortality data. By doing the study in NYC, they were able to evaluate a large, well-defined, and diverse population with a particularly high incidence of this disease [5]. This study adds to the literature as it helps to delineate the natural history of hepatitis C in the real world. The authors were able to convincingly demonstrate an increased risk of premature mortality (age <65) in patients infected with HCV, stressing the importance of early identification and potential treatment of this disease. The study also attempted to further evaluate the cause of death in this population from a review of death certificate data. It is very important to understand when and how people are being diagnosed with the disease and, ultimately, their specific cause of death. There are, however, some weaknesses in the study that need to be discussed. Unlike a true cohort, this study only captured people who died in NYC. Patients who were diagnosed and treated in NYC would not be included in the COD analysis if they were to die outside the city limits. Although the study implies that earlier diagnosis and treatment would likely decrease premature mortality, the study was not able to evaluate the subset of people who were treated for hepatitis C, and with what regimen. Overall, the study does an excellent job demonstrating the associated mortality with HCV, but causation is much more difficult to prove. Last, the utilization of death certif

Cohorts in chronic disease research: experiences from the PRO-LIFE cohort, Varkala, South India

This study demonstrates the setting up of a cohort study in a resource poor setting. The study began as an initial survey in 2001 conducted at Varkala, Kerala by Health Action by People, a non-profit research group. It was a cross sectional study of all households in seven Panchayaths and an urban segment coming under the ICDS (Integrated Child Development Scheme) block. Eventually with multiple funding sources, the study was extended as a cohort study, in the form of a registry for births, deaths and major health events in the community from 20022006. The cohort was named PRO-LIFE (Population registry of lifestyle diseases) with the objectives of setting up a community registry for coronary disease, hypertension, stroke, COPD & type 2 diabetes and to initiate community level action for prevention of these diseases. The study was conducted by trained grass root level workers of the ICDS programme and the comprehensive survey included socio-demographic characteristics, food frequency information, detailed lifestyle attributes and information on births and deaths. A cause of death analysis was also conducted during the period 2002-2006 which showed a similarity with USA except neoplasms. However the age standardised death rates were much higher than USA. Other findings include a high suicide rate among the young population, higher prevalence of diabetes in the affluent group and a reduced relative risk for mortality from coronary heart disease in more physically active men and women. The follow up was stopped after 2006 due to lack of funds and unreliable collection of information. It is currently proposed to resurvey the project population including anthropometry and biochemical profile with periodic follow up and fool proof system of reporting births, deaths and major events. The experience showed that full support of the local self government and political units is very important. Existing health workers need to be carefully selected for long term follow up. Discussion points included the reasons for high suicide rate among young females and the social gradient of non-communicable diseases. The high rate of suicide among youngsters may be due to their high aspirations and pressures such as entrance examinations. The higher prevalence of noncommunicable diseases in the affluent classes may be due to their lifestyle, however it may change very soon as we move from a situation of food scarcity to plenty of food.

California Pregnancy-Associated Mortality Review: Mixed Methods Approach for Improved Case Identification, Cause of Death Analyses and Translation of Findings

After several decades of declining rates, maternal mortality climbed in California from a three-year moving average of 9.4 deaths per 100,000 live births in 1999-2001 to a high of 14.0 deaths per 100,000 live births in 2006-2008 (p < 0.001). The Maternal, Child and Adolescent Health Division of the California Department of Public Health developed a mixed method approach to identify and investigate maternal deaths to inform prevention strategies. This paper describes the methodology of the California Pregnancy-Associated Mortality Review (CA-PAMR) and its advantages for improved surveillance, cause of death analysis, and translation of findings. From 2002 to 2004, 1,598,792 live births occurred in California and 555 women died while pregnant or within one year of pregnancy. A screening algorithm identified cases for review that were likely to be pregnancy-related. Medical records were then abstracted and reviewed by a multidisciplinary committee to determine cause of death, contributing factors, and opportunities for quality improvement. Mixed methods were used to analyze, synthesize and translate Committee recommendations for improved care. Of 211 cases selected for review, 145 deaths were determined to be pregnancy-related. CA-PAMR methods corrected misclassification of cases and more accurately identified the leading causes of death. Cardiovascular disease emerged as the leading cause of pregnancy-related deaths (20%), and African-American women were disproportionately represented among cardiovascular deaths. Overall, the chance to prevent the fatal outcome appeared good or strong in 40% of cases reviewed. The CA-PAMR methodology resulted in additional case finding, improved accuracy of the causes of pregnancy-related deaths, and evidence to guide development of prevention and quality improvement efforts.

Radiation therapy for clinically node-positive prostate adenocarcinoma is correlated with improved overall and prostate cancer-specific survival

Purpose: To evaluate the effect of radiation therapy on prostate cancer-specific and overall survival with node-positive cancer in a retrospective Surveillance, Epidemiology and End Results (SEER) population based study.Methods and Materials: The survival of subjects with cT1-T4,cN1,M0 prostate adenocarcinoma diagnosed between 1988 and 2006 were compared with univariate and multivariate Cox regression analysis.Results: A total of 1100 subjects, with a median age of 69 years and median follow-up time of 90 months, were identified. The 10-year cancer-specific survival for men who had no definitive therapy was 50.3% and for those who had radiation therapy 62.7%. This was significantly different favoring radiation therapy (hazard ratio [HR] = 0.66, 95% confidence interval [CI] = 0.54 to 0.82, P ≤ .01). On multivariate analysis evaluating age, histologic grade, T stage, year of diagnosis, marital status, SEER registry and radiation therapy, radiation therapy (HR = 0.67, 95% CI = 0.54 to 0.84, P ≤ .01), year of diagnosis (HR = 0.96, 95% CI = 0.93 to 0.99, P = .01), and low and intermediate grade disease were correlated with improved CSS. The number needed to treat to prevent 1 prostate cancer-specific death at 10 years was 8 persons. A cause of death analysis revealed non-prostate cancer deaths were not statistically different in the comparison groups.Conclusions: Radiation therapy is correlated with a clinically significant reduction in all cause and prostate cancer-specific death.