Contributory Causes Research Articles

Review:The important epidemiology of pre-eclampsia

Hypertensive disorders in pregnancy are responsible for significant mortality and morbidity of which pre-eclampsia is the greatest contributor. More than half of these deaths can be avoided by better understanding the important epidemiology of this disease. By intelligent revision of the final causes of hypertensive death, it is evident that there are only two significant contributory causes, namely cerebral haemorrhage and cardio-respiratory failure, usually manifesting in pulmonary oedema. Accurate measurement and appropriate treatment of blood pressure, seizure prevention, early recognition and referral of women in respiratory distress and monitoring of pulmonary capillary wedge pressure are effective interventions aimed at reducing mortality. The belief that morbidity or mortality associated with pre-eclampsia is confined to the reproductive years is no longer legitimate. The long-term risks of cardiovascular disease, stroke, end-stage renal disease and cognitive decline are increased in women having had one or more pregnancies complicated by this disease. These risks need to be appreciated and addressed by health professionals.

Socioeconomic differentials in cause-specific mortality among 1.4 million South Korean public servants and their dependents

BackgroundA growing number of investigations have explored the contribution of cause of death to socioeconomic inequalities in mortality in Europe and North America, but few such studies have been performed...

Quantifying Alcohol-Related Mortality: Should Alcohol-Related Contributory Causes of Death be Included?

The aim of the study was to assess whether alcohol-related mortality data in the UK should be extended to include contributory as well as underlying cause of death. A total of 101,320 deaths registered in Northern Ireland between 2001 and 2007 were analysed to determine the quantity and characteristics of those with an underlying or contributory alcohol-related cause of death. Alcohol was found to be an underlying cause of death in 1690 cases (1.7% of deaths) and a contributory cause in a further 1105 cases. Analyses show that the addition of alcohol-related contributory causes of deaths would increase the male-female ratio, result in steeper socio-economic gradients and amplify the apparent rate of increase of alcohol-related deaths. The significant contribution of alcohol to external causes of death, such as accidents and suicide, is also more evident. Using only underlying cause of death undoubtedly underestimates the burden of alcohol-related harm and may provide an inaccurate picture of those most likely to suffer from an alcohol-related death, especially among younger men.

Causes of persistent dizziness in elderly patients in primary care.

Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness. We performed a cross-sectional diagnostic study among elderly patients in the Netherlands consulting their family physician for persistent dizziness. All patients underwent a comprehensive evaluation according to a set of diagnostic tests that were developed during an international Delphi procedure. Data for each patient were independently reviewed by a panel consisting of a family physician, a geriatrician, and a nursing home physician, which resulted in major and minor contributory causes of dizziness. From June 2006 to January 2008, we included 417 patients aged 65 to 95 years. Presyncope was the most common dizziness subtype (69%). Forty-four percent of the patients were assigned more than 1 dizziness subtype. Cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than 1 contributory cause of dizziness. Contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.

The diabetic cardiomyopathy

Diabetic cardiomyopathy has been defined as "a distinct entity characterized by the presence of abnormal myocardial performance or structure in the absence of epicardial coronary artery disease, hypertension, and significant valvular disease". The diagnosis stems from the detection of myocardial abnormalities and the exclusion of other contributory causes of cardiomyopathy. It rests on non-invasive imaging techniques which can demonstrate myocardial dysfunction across the spectra of clinical presentation. The presence of diabetes is associated with an increased risk of developing heart failure, and the 75% of patients with unexplained idiopathic dilated cardiomyopathy were found to be diabetic. Diabetic patients with microvascular complications show the strongest association between diabetes and cardiomyopathy, an association that parallels the duration and severity of hyperglycemia. Metabolic abnormalities (that is hyperglycemia, hyperinsulinemia, and hyperlipemia) can lead to the cellular alterations characterizing diabetic cardiomyopathy (that is myocardial fibrosis and/or myocardial hypertrophy) directly or indirectly (that is by means of renin-angiotensin system activation, cardiac autonomic neuropathy, alterations in calcium homeostasis). Moreover, metabolic abnormalities represent, on a clinical ground, the main therapeutic target in the patients with diabetes since the diagnosis of diabetes is made. Since diabetic cardiomyopathy is highly prevalent in the asymptomatic type 2 diabetic patients, screening for its presence at the earliest stage of development can lead to prevent the progression to chronic heart failure. The most sensitive test is standard echocardiogram, while a less expensive pre-screening method is the detection of microalbuminuria.

The Effects of the 2004 Reduction in the Price of Alcohol on Alcohol-Related Harm in Finland – a Natural Experiment Based on Register Data

Changes in alcohol pricing have been documented as inversely associated with changes in consumption and alcohol-related problems. Evidence of the association between price changes and health problems is nevertheless patchy and is based to a large extent on cross-sectional state-level data, or time series of such cross-sectional analyses. Natural experimental studies have been called for. There was a substantial reduction in the price of alcohol in Finland in 2004 due to a reduction in alcohol taxes of one third, on average, and the abolition of duty-free allowances for travellers from the EU. These changes in the Finnish alcohol policy could be considered a natural experiment, which offered a good opportunity to study what happens with regard to alcohol-related problems when prices go down. The present study investigated the effects of this reduction in alcohol prices on (1) alcohol-related and all-cause mortality, and mortality due to cardiovascular diseases, (2) alcohol-related morbidity in terms of hospitalisation, (3) socioeconomic differentials in alcohol-related mortality, and (4) small-area differences in interpersonal violence in the Helsinki Metropolitan area. Differential trends in alcohol-related mortality prior to the price reduction were also analysed. A variety of population-based register data was used in the study. Time-series intervention analysis modelling was applied to monthly aggregations of deaths and hospitalisation for the period 1996-2006. These and other mortality analyses were carried out for men and women aged 15 years and over. Socioeconomic differentials in alcohol-related mortality were assessed on a before/after basis, mortality being followed up in 2001-2003 (before the price reduction) and 2004-2005 (after). Alcohol-related mortality was defined in all the studies on mortality on the basis of information on both underlying and contributory causes of death. Hospitalisation related to alcohol meant that there was a reference to alcohol in the primary diagnosis. Data on interpersonal violence was gathered from 86 administrative small-areas in the Helsinki Metropolitan area and was also assessed on a before/after basis followed up in 2002-2003 and 2004-2005. The statistical methods employed to analyse these data sets included time-series analysis, and Poisson and linear regression. The results of the study indicate that alcohol-related deaths increased substantially among men aged 40-69 years and among women aged 50-69 after the price reduction when trends and seasonal variation were taken into account. The increase was mainly attributable to chronic causes, particularly liver diseases. Mortality due to cardiovascular diseases and all-cause mortality, on the other hand, decreased considerably among the-over-69-year-olds. The increase in alcohol-related mortality in absolute terms among the 30-59-year-olds was largest among the unemployed and early-age pensioners, and those with a low level of education, social class or income. The relative differences in change between the education and social class subgroups were small. The employed and those under the age of 35 did not suffer from increased alcohol-related mortality in the two years following the price reduction. The gap between the age and education groups, which was substantial in the 1980s, thus further broadened. With regard to alcohol-related hospitalisation, there was an increase in both chronic and acute causes among men under the age of 70, and among women in the 50-69-year age group when trends and seasonal variation were taken into account. Alcohol dependence and other alcohol-related mental and behavioural disorders were the largest category in both the total number of chronic hospitalisation and in the increase. There was no increase in the rate of interpersonal violence in the Helsinki Metropolitan area, and even a decrease in domestic violence. There was a significant relationship between the measures of social disadvantage on the area level and interpersonal violence, although the differences in the effects of the price reduction between the different areas were small. The findings of the present study suggest that that a reduction in alcohol prices may lead to a substantial increase in alcohol-related mortality and morbidity. However, large population group differences were observed regarding responsiveness to the price changes. In particular, the less privileged, such as the unemployed, were most sensitive. In contrast, at least in the Finnish context, the younger generations and the employed do not appear to be adversely affected, and those in the older age groups may even benefit from cheaper alcohol in terms of decreased rates of CVD mortality. The results also suggest that reductions in alcohol prices do not necessarily affect interpersonal violence. The population group differences in the effects of the price changes on alcohol-related harm should be acknowledged, and therefore the policy actions should focus on the population subgroups that are primarily responsive to the price reduction.

An evaluation of the impact of a large reduction in alcohol prices on alcohol-related and all-cause mortality: time series analysis of a population-based natural experiment

We examined the effect of a large reduction in the price of alcohol that occurred in Finland in 2004 on alcohol-related and all-cause mortality, and mortality due to cardiovascular diseases (CVDs) from which alcohol-attributable cases were excluded. Time series intervention analysis modelling was applied to the monthly aggregations of deaths in Finland for the period 1996-2006 to assess the impact of the reduction in alcohol prices. Alcohol-related mortality was defined using information on both underlying and contributory causes of death. Analyses were carried out for men and women aged 15-39, 40-49, 50-69 and >69 years. Alcohol-related deaths increased in men aged 40-49 years, and in men and women aged 50-69 years, after the price reduction when trends and seasonal variation were taken into account: the mean rate of alcohol-related mortality increased by 17% [95% confidence interval (CI) 1.5, 33.7], 14% (95% CI 1.1, 28.0) and 40% (95% CI) 7.1, 81.7), respectively, which implies 2.5, 2.9 and 1.6 additional monthly deaths per 100,000 person-years following the price reduction. In contrast to alcohol-related mortality, CVD and all-cause mortality decreased: among men and women aged >69 years a decrease of 7 and 10%, respectively, in CVD mortality implied 19 and 25 fewer monthly deaths per 100,000 person-years, and a decrease of 7 and 14%, respectively, in all-cause mortality similarly implied 42 and 69 fewer monthly deaths. These results obtained from the time series analyses suggest that the reduction in alcohol prices led to an increase in alcohol-related mortality, except in persons <40 years of age. However, it appears that beneficial effects in older age, when CVD deaths are prevalent, counter-balance these adverse effects, at least to some extent.

Diverse Placental Pathologies as the Main Causes of Fetal Death

To estimate the occurrence of placental causes of fetal death in relation to different gestational ages and their clinical manifestations during pregnancy. In a prospective cohort study conducted from 2002 to 2006, we studied 750 couples with singleton intrauterine fetal death after 20 weeks of gestation. Cause of death was classified according to the Dutch Tulip cause of death classification for perinatal mortality. Differences between groups for categorical data were evaluated by the Fisher exact test or chi test. The main causes were placental pathology (64.9%), congenital anomaly (5.3%), infection (1.9%), other (4.8%), and unknown (23.1%). The contribution of causes differed over gestational age periods. At lower gestational age, placental and unknown were the most dominant causes of death (34.8% and 41.7%, respectively); at higher gestational age, the relative importance of an unknown cause decreased and a placental cause increased (16.5% and 77.6%) (P<.001). Placental bed pathology was observed in 33.6% of all fetal deaths, with the highest occurrence between 24 0/7 and 31 6/7 weeks and a strong decline after 32 weeks. In contrast, contribution of developmental placental pathology (17.6%) increased after 32 weeks of gestation (P<.001), as did umbilical cord complications (5.2%) and combined placental pathology (5.4%). Solitary placental parenchyma pathology was less frequent (3.1%). Hypertension-related disease was observed in 16.1% (95% confidence interval [CI] 13.6-19.0) of the cohort, small for gestational age fetuses in 37.9% (95% CI 34.1-41.7), and diabetes-related disease in 4.1% (95% CI 2.8-5.8). Most fetal deaths were caused by a variety of placental pathologies. These were related to gestational age, and their clinical manifestations varied during pregnancy. II.

The Puzzle of Gender‐equal Political Participation in Sweden: The Importance of Norms and Mobilization

Political participation is higher among men than women in most parts of the world. However, earlier research has shown that this does not hold true in Scandinavia, including Sweden, where gender differences are remarkably small. This article studies the causes of the Swedish situation. A conventional hypothesis is formulated based on research from other parts of the world. It assumes that gender‐equal participation in Sweden can be explained by the lack of gender differences in certain political resource and motivational factors that are often analyzed. However, this hypothesis is not supported by the data, which instead indicates a female disadvantage with regard to both resources and motivation. Two alternative hypotheses are developed and shown as empirically viable. The first assumes that women more often adhere to norms that emphasize the importance of being politically active, which promotes their participation in politics. The second focuses on collective mobilization based on interests specific to women. In line with this hypothesis, only women are shown to be members of women's organizations and hold more radical opinions on issues related to gender equality and reproduction. These factors have a positive impact on women's participation, and together they explain a noticeable amount of the male advantage with regard to conventional explanatory factors. Therefore they are important contributory causes of gender‐equal participation in Sweden, although other factors, not discussed here, also contribute. Quantitative methods are used in the analyses, and the study material is the 1997 Swedish Citizenship Survey.

Language-group mortality differentials in Finland in 1988-2004: assessment of the contribution of cause of death, sex and age

The higher mortality among Finnish-speaking than Swedish-speaking Finns is well established and has been shown to be very persistent. However, the most recent comprehensive documentation on the language-group differential extends only to the mid-1980s. We study recent trends in sex- and age-specific language-group mortality from 1988 to 2004, focusing on the relative contribution of the main causes of death and differences in sociodemographic structure. The register data are based on an 11% sample of Finns aged > or =30 years at the end of 1987--which further includes an oversample of deaths covering 80% of all deaths in the period 1988-2004. Finnish-speaking men had 19% and women 11% higher age-adjusted mortality rates than the Swedish speakers. Further adjustments for sociodemographic composition explained 47% and 36%, respectively, of these differences. Age group-specific analyses showed the steepest differences in the young and middle-aged groups (30-49 years) in both men and women. The cause-specific differences were most pronounced in alcohol-related diseases, suicide and other external causes, for which a slight increase in differentials was also observed. The relative difference in mortality between the two main language groups in Finland persists, with a slight narrowing of the gap among women. Moreover, the largest differences and indications of diverging trends were found among the youngest age groups. The causes of death in which the difference is greatest highlight the importance of health-related behaviour and cultural differences in lifestyle.

Causes of mortality in diabetes mellitus: data from a tertiary teaching hospital in India

Background:Mortality studies can show the relative contribution of diabetes to mortality in the total population, and they can provide important descriptions of the changes in causes and frequency of diabetes...

Increased Mortality for Neurological and Mental Diseases following Early Bilateral Oophorectomy

Background: The effects of oophorectomy on brain aging remain uncertain. Methods: We conducted a cohort study with long-term follow-up of women in Olmsted County, Minn., USA, who underwent either unilateral or bilateral oophorectomy before the onset of menopause from 1950 through 1987. Each member of the oophorectomy cohort was matched by age to a referent woman from the same population who had not undergone any oophorectomy. We studied underlying and contributory causes of death in 1,274 women with unilateral oophorectomy, 1,091 women with bilateral oophorectomy, and 2,383 referent women. Results: Mortality for neurological or mental diseases was increased in women who underwent bilateral oophorectomy before age 45 years compared with referent women (hazard ratio = 5.24; 95% confidence interval = 2.02–13.6; p < 0.001). Within this age stratum, mortality was similar in women who were or were not treated with estrogen from the time of oophorectomy through age 45 years, and in women who had bilateral oophorectomy for prophylaxis or for treatment of a benign ovarian condition. Mortality was also increased in women who underwent unilateral oophorectomy before age 45 years without concurrent hysterectomy. Conclusions: Bilateral oophorectomy performed before age 45 years is associated with increased mortality for neurological or mental diseases.

Morbidity and mortality among a cohort of HIV-infected adults in a programme for community home-based care, in the Kilimanjaro Region of Tanzania (2003–2005)

Community home-based care (CHBC) plays an integral role in the care of HIV-infected patients living in resource-limited regions. A longitudinal cohort study has recently been conducted, in the Kilimanjaro Region of northern Tanzania, in order to identify the components of an effective CHBC programme. Structured questionnaires were administered to clients over two census rounds, one in October 2003-February 2004 and the other in January 2005-October 2005. In the second round, follow-up interviews were completed for 226 (87.9%) of the 257 clients included in the first round. The clients included in the first round had a median (range) age of 38 (20-66) years and 182 (75.2%) of them were female. Although only 27 (12.9%) of them were using antiretroviral therapy (ART) when first interviewed, 108 (44.6%) were taking trimethoprim-sulfamethoxazole (SXT) prophylaxis. By the time of the follow-up interviews, 102 (45.1%) of the clients included in the first round had died, giving a mortality of 51/100 person-years of observation. The primary cause of death for 87 (85.3%) of the clients who had died was respiratory and/or gastro-intestinal infection, and the most common contributory causes of death were malnutrition (81.4%) and anaemia (42.2%). On bivariable analysis, the following first-round conditions were found to be significantly associated with death by the second census round: weakness for >1 month [odds ratio (OR)=2.64; P=0.008]; oral thrush (OR=2.31; P=0.015); painful swallowing (OR=2.02; P=0.036); staying in bed for part of the day over most of the previous month (OR=1.94; P=0.017); fever for >1 month (OR=1.95; P=0.016); and severe bacterial infections (OR=1.80; P=0.036). The high mortality was associated with advanced, symptomatic HIV disease for which antiretroviral therapy was indicated. Clients who were in the advanced stages of HIV disease (as defined by the World Health Organization's criteria) in the first census round were significantly more likely to have died by the time of the second round than the other clients investigated (log-rank chi(2)=8.115; P=0.044). The high level of morbidity observed in this study, and the causes of mortality that were identified, emphasise the need for CHBC programmes to provide HIV-infected patients with improved access to basic resources such as SXT and isoniazid prophylaxis, clean water, oral rehydration therapy, and micronutrient supplementation, in addition to increased access to ART.

Monitoring oral health and dental attendance in an outpatient psychiatric population

Impaired mental health has been associated with an increased need for dental care. Population surveys have indicated that people with enduring mental health problems make less frequent planned visits to the dentist and report a greater number of missing teeth than the general population. The study aims to examine oral health status, attendance to dental care, and medication in an outpatient psychiatric sample. A descriptive study combining a structured interview with a visual oral examination carried out in 113 outpatients under psychiatric care. Dental health was described in terms of sound, missing and/or filled teeth, and showed a relation between these categories and types of psychiatric diagnosis, age and numbers of antidepressant and neuroleptic drugs. Oral hygiene was found to be more neglected among men and in patients with the diagnosis of schizophrenia. The need of dental treatment was widespread, although regular dental visits were commonly reported. In order to maintain good oral health, regular dental check-ups should be encouraged for patients under psychiatric care. Further studies are required to reveal contributory causes for/to decreased oral health. The difficulty such individuals have in maintaining additional self-efficacy raises questions about the necessity for oral health interventions in outpatient psychiatric services.

The Cusp of a New Era in Long-term Mechanical Circulatory Support

The Cusp of a New Era in Long-term Mechanical Circulatory Support

Field disease investigation—A differentiating and integrative approach to problems in animal populations

The economically important diseases of agricultural animals are those that affect groups of animals to result in impaired productivity or mortality. Herd and flock disease result from complex interactions between inciting agents (or other etiologies), and factors such as management systems, nutrition, environment and other contributory causes. For these reasons herd and flock disease problems must be addressed, researched, and taught, in the areas where they occur—on the farm and in the field. For political and educational reasons this needs to be on farms throughout the state or region represented by a veterinary school. Like most studies, this type of study needs to have a multidisciplinary input but these inputs often involve disciplines that are different from those that address clinical disease in individual animals in the veterinary teaching hospital setting. Clinical departments in veterinary schools have not traditionally found funds to support this approach to agricultural animal disease. This talk will discuss the establishment of a conjoint program between the College of Veterinary Medicine and the College of Agriculture at Washington State University (Field Disease Investigation Unit) to address these requirements and its activities over the past 25 years.

Changes in Alcohol-Related Mortality and its Socioeconomic Differences After a Large Reduction in Alcohol Prices: A Natural Experiment Based on Register Data

The authors examined the effect of a large reduction in the price of alcohol in Finland in 2004 on alcohol-related mortality by age and socioeconomic group. For this register-based study of Finns aged >or=15 years, data on independent variables were extracted from the employment statistics of Statistics Finland. Mortality follow-up was carried out for 2001-2003 (before the price reduction) and 2004-2005 (after). Alcohol-related causes were defined using both underlying and contributory causes of death. Alcohol-related mortality increased by 16% among men and by 31% among women; 82% of the increase was due to chronic causes, particularly liver diseases. The increase in absolute terms was largest among men aged 55-59 years and women aged 50-54 years. Among persons aged 30-59 years, it was biggest among the unemployed or early-age pensioners and those with low education, social class, or income. The relative differences in change between the education and social class subgroups were small. The employed and persons aged <35 years did not suffer from increased alcohol-related mortality during the 2 years after the change. These results imply that a large reduction in the price of alcohol led to substantial increases in alcohol-related mortality, particularly among the less privileged, and in chronic diseases associated with heavy drinking.

Effects of poverty on cognitive function

Mental retardation is one of the most prevalent neurologic disorders globally. Surveys in high-income countries show 3 to 5 per 1,000 with severe intellectual disability, i.e., IQ below 55. Estimates from developing countries, however, have found prevalence rates from 5 to as much as 22 per 1,000. Protein-energy malnutrition, dietary micronutrient deficiencies, environmental toxins, and lack of early sensory stimulation or the ability to profit from it may contribute to neurodevelopmental disabilities. Tropical diseases such as parasitosis with resultant anemia, malaria, and other infections are major contributory causes. Reduction of poverty and its effects would reduce the present and future burden of mental retardation and cognitive dysfunction, especially in developing countries.

Why Do People Become Terrorists?: A Prosecutor's Experiences

Undeniably the marginalization suffered by many Islamic emigrants (particularly from North Africa) and the consequent difficulties in fitting in the land of adoption, constitute contributory causes — of a socio-economic nature — of their drift into terrorism. However, a distorted view of the principles of Islam and a violent and criminal interpretation of the obligation of Jihad constitute the main factor of their drive. Statements made in the course of interrogation by arrested terrorists (especially by supergrasses, referred to in Italy as ‘repenters’) as well as ideological documents disseminated internationally on the internet or items seized in the course of various judicial enquiries consistently show that the religious view of the world, obviously in the distorted perspective specific to terrorists, constitutes the main reason for their behaviour, whereas practically no importance attaches to the aspiration to liberate specific occupied territories or oppressed peoples. Another possible motivation, at least for suicidal acts, is linked with those of an economic nature: in connection with various judicial investigations it has emerged that sums of money collected as voluntary contributions from the ‘faithful’ serves not to finance the ‘terrorist act’ as such, but to guarantee a future for family members of a suicide attacker, or someone who died in the course of a terrorist action.

What to do … When the treatment does not work: polymyositis

Although patients with polymyositis or dermatomyositis may respond to treatment with corticosteroids alone, in many cases a combination of steroids and an immunosuppressive agent is required to achieve satisfactory disease...