Non-accidental Causes Research Articles

Heat, Heat Waves, and Hospital Admissions among the Elderly in the United States, 1992–2006

Background: Heat-wave frequency, intensity, and duration are increasing with global climate change. The association between heat and mortality in the elderly is well documented, but less is known regarding associations with hospital admissions.Objectives: Our goal was to determine associations between moderate and extreme heat, heat waves, and hospital admissions for nonaccidental causes among Medicare beneficiaries ≥ 65 years of age in 114 cities across five U.S. climate zones.Methods: We used Medicare inpatient billing records and city-specific data on temperature, humidity, and ozone from 1992 through 2006 in a time-stratified case-crossover design to estimate the association between hospitalization and moderate [90th percentile of apparent temperature (AT)] and extreme (99th percentile of AT) heat and heat waves (AT above the 95th percentile over 2–8 days). In sensitivity analyses, we additionally considered confounding by ozone and holidays, different temperature metrics, and alternate models of the exposure–response relationship.Results: Associations between moderate heat and hospital admissions were minimal, but extreme heat was associated with a 3% (95% CI: 2%, 4%) increase in all-cause hospital admissions over the subsequent 8 days. In cause-specific analyses, extreme heat was associated with increased hospitalizations for renal (15%; 95% CI: 9%, 21%) and respiratory (4%; 95% CI: 2%, 7%) diseases, but not for cardiovascular diseases. An added heat-wave effect was observed for renal and respiratory admissions.Conclusion: Extreme heat is associated with increased hospital admissions, particularly for renal causes, among the elderly in the United States.Citation: Gronlund CJ, Zanobetti A, Schwartz JD, Wellenius GA, O’Neill MS. 2014. Heat, heat waves, and hospital admissions among the elderly in the United States, 1992–2006. Environ Health Perspect 122:1187–1192; http://dx.doi.org/10.1289/ehp.1206132

ABSTRACT 1005

Background and aims: Abusive head trauma (AHT) is one of the leading causes of death in children. In infants with serious head injury, the high prevalence of non-accidental causes mandates a systematic and thorough approach to investigation. Aims: We studied adherence to our hospital protocol and reasons for any deviation. Methods: A multi-source search strategy identified all children admitted to our tertiary paediatric intensive care unit between 2011 and 2012 with unexplained head injury or abnormal cranial imaging. A retrospective review of case notes was followed by interdisciplinary discussion and analysis of results. Results: 33 case records were reviewed. For 15 children, all aged <12 months, the working diagnosis on admission was AHT (no history or reported assault); 9 had alternative explanations for head trauma.Table: No title available.Conclusions: Overall adherence was poor. Following interdisciplinary discussion the protocol is being revised to improve multi-speciality agreement. Other factors identified included accessibility of the protocol, clarity of wording and layout and practical difficulties. Technological and process-based solutions were introduced, and a re-audit is planned. Making a hospital-wide change in practice requires more than just a new guideline – it needs widespread ongoing consultation with stakeholders and a continuous evaluation of processes to ensure achievement of the original objectives.

G462(P) When guidelines are not enough – reasons for poor adherence to a protocol for investigation of abusive head trauma

AimsAbusive head trauma (AHT) is one of the leading causes of death in children. In infants with serious head injury, the high prevalence of non-accidental causes mandates a systematic and...

Modelling clinical progression and health care utilization of HIV‐positive patients in British Columbia prior to death

The extent to which clinical progression of HIV-positive patients leads to an increase in health care utilization, especially prior to their death, is unknown. Thus, we modelled trends in CD4 cell count and emergency department utilization and the likelihood of an emergency department visit leading to a transfer to an acute care-level facility prior to a patient's death from nonaccidental causes. Eligible patients initiated highly active antiretroviral therapy (HAART) in British Columbia between August 1996 and June 2006 (n = 457). Patients were followed until their death, which occurred on or before 30 June 2007 (period in which the emergency department visit data were available). Trends were modelled using generalized mixed effects. Patients experienced a significantly steep decline in CD4 cell count and a corresponding increase in the number of emergency department visits and transfers to acute-level facilities in the 5 years prior to death. For every 6-month interval prior to death, the CD4 cell count decreased by 13.22 cells/μL, the risk of experiencing an emergency department visit increased by 9%, and among those ever admitted, the odds ratio of being transferred to an acute care-level facility increased by 3%. We showed that patients experienced a steep decline in CD4 cell count, which was associated with an increase in health care utilization prior to their death. These findings highlight the substantial residual avoidable burden that unsuccessfully managed HIV disease poses, even in the HAART era. Further strategies to enhance sustained and successful engagement in care are urgently needed to mitigate high health care utilization.

Mortality Related to Air Pollution with the Moscow Heat Wave and Wildfire of 2010

Prolonged high temperatures and air pollution from wildfires often occur together, and the two may interact in their effects on mortality. However, there are few data on such possible interactions. We analyzed day-to-day variations in the number of deaths in Moscow, Russia, in relation to air pollution levels and temperature during the disastrous heat wave and wildfire of 2010. Corresponding data for the period 2006-2009 were used for comparison. Daily average levels of PM10 and ozone were obtained from several continuous measurement stations. The daily number of nonaccidental deaths from specific causes was extracted from official records. Analyses of interactions considered the main effect of temperature as well as the added effect of prolonged high temperatures and the interaction with PM10. The major heat wave lasted for 44 days, with 24-hour average temperatures ranging from 24°C to 31°C and PM10 levels exceeding 300 μg/m on several days. There were close to 11,000 excess deaths from nonaccidental causes during this period, mainly among those older than 65 years. Increased risks also occurred in younger age groups. The most pronounced effects were for deaths from cardiovascular, respiratory, genitourinary, and nervous system diseases. Continuously increasing risks following prolonged high temperatures were apparent during the first 2 weeks of the heat wave. Interactions between high temperatures and air pollution from wildfires in excess of an additive effect contributed to more than 2000 deaths. Interactions between high temperatures and wildfire air pollution should be considered in risk assessments regarding health consequences of climate change.

Air quality modeling and mortality impact of fine particles reduction policies in Spain

BackgroundIn recent years, Spain has implemented a number of air quality control measures that are expected to lead to a future reduction in fine particle concentrations and an ensuing positive impact on public health. ObjectivesWe aimed to assess the impact on mortality attributable to a reduction in fine particle levels in Spain in 2014 in relation to the estimated level for 2007. MethodsTo estimate exposure, we constructed fine particle distribution models for Spain for 2007 (reference scenario) and 2014 (projected scenario) with a spatial resolution of 16×16km2. In a second step, we used the concentration–response functions proposed by cohort studies carried out in Europe (European Study of Cohorts for Air Pollution Effects and Rome longitudinal cohort) and North America (American Cancer Society cohort, Harvard Six Cities study and Canadian national cohort) to calculate the number of attributable annual deaths corresponding to all causes, all non-accidental causes, ischemic heart disease and lung cancer among persons aged over 25 years (2005–2007 mortality rate data). We examined the effect of the Spanish demographic shift in our analysis using 2007 and 2012 population figures. ResultsOur model suggested that there would be a mean overall reduction in fine particle levels of 1µg/m3 by 2014. Taking into account 2007 population data, between 8 and 15 all-cause deaths per 100,000 population could be postponed annually by the expected reduction in fine particle levels. For specific subgroups, estimates varied from 10 to 30 deaths for all non-accidental causes, from 1 to 5 for lung cancer, and from 2 to 6 for ischemic heart disease. The expected burden of preventable mortality would be even higher in the future due to the Spanish population growth. Taking into account the population older than 30 years in 2012, the absolute mortality impact estimate would increase approximately by 18%. ConclusionsEffective implementation of air quality measures in Spain, in a scenario with a short-term projection, would amount to an appreciable decline in fine particle concentrations, and this, in turn, would lead to notable health-related benefits. Recent European cohort studies strengthen the evidence of an association between long-term exposure to fine particles and health effects, and could enhance the health impact quantification in Europe. Air quality models can contribute to improved assessment of air pollution health impact estimates, particularly in study areas without air pollution monitoring data.

Risk assessment for cardiovascular and respiratory mortality due to air pollution and synoptic meteorology in 10 Canadian cities

Synoptic weather and ambient air quality synergistically influence human health. We report the relative risk of mortality from all non-accidental, respiratory-, and cardiovascular-related causes, associated with exposure to four air pollutants, by weather type and season, in 10 major Canadian cities for 1981 through 1999. We conducted this multi-city time-series study using Poisson generalized linear models stratified by season and each of six distinctive synoptic weather types. Statistically significant relationships of mortality due to short-term exposure to carbon monoxide, nitrogen dioxide, sulphur dioxide, and ozone were found, with significant modifications of risk by weather type, season, and mortality cause. In total, 61% of the respiratory-related mortality relative risk estimates were significantly higher than for cardiovascular-related mortality. The combined effect of weather and air pollution is greatest when tropical-type weather is present in the spring or summer.

Hearts over Time: Cardiovascular Mortality Risk Linked to Long-Term PM 2.5 Exposure

Adverse respiratory effects and short-term hospital admissions have been linked to acute exposure to fine particulate matter (PM2.5), but few studies have examined mortality risks associated with chronic exposure. Now, in Canada’s first national-level cohort study of the subject, investigators report an association between cardiovascular mortality and long-term exposure to PM2.5 [EHP 120(5):708–714; Crouse et al.]. Most research examining associations between ambient air pollution and human health has used data generated by ground-based air-pollution monitors over short periods of time. But in the current study, researchers also calculated long-term exposure levels using satellite-based estimates of ground-level PM2.5. Study subjects consisted of 2.1 million adults who were included in the 1991–2001 Canadian census mortality follow-up study. For residents of cities with ground-based air monitors, the investigators calculated average mean annual concentrations of PM2.5 for the period 1987–2001 and assigned exposure levels to individuals based on their residence during that time. They also calculated exposure estimates for the whole cohort for the period 2001–2006 based on satellite remote sensing observations. The team linked the census and exposure data to national mortality data to estimate increased risk of death from ischemic heart disease, cerebrovascular disease, cardiovascular disease, circulatory disease, and all nonaccidental causes for each 10-µg/m3 increase in PM2.5. The largest estimated increase in mortality was for ischemic heart disease (31%), followed by deaths from nonaccidental causes, circulatory diseases, and cardiovascular disease (each estimated to increase by 15–16%). In contrast, cerebrovascular disease was not clearly associated with PM2.5 exposure. Strengths of the study include the large sample size and the use of remote sensing satellite data, which allowed exposure estimates to be calculated for subjects living in areas without air-pollution monitors. Limitations include a lack of information on smoking and obesity—two of the primary risk factors for cardiovascular disease—and the inability to account for address changes during the follow-up period. However, with a mean estimated exposure of 8.7 µg/m3 (range 1.9–19.2 µg/m3), the findings suggest that exposure even to very low amounts of PM2.5 over long periods may pose a greater risk to human health than originally assumed.

Risk of Nonaccidental and Cardiovascular Mortality in Relation to Long-term Exposure to Low Concentrations of Fine Particulate Matter: A Canadian National-Level Cohort Study

Background: Few cohort studies have evaluated the risk of mortality associated with long-term exposure to fine particulate matter [≤ 2.5 μm in aerodynamic diameter (PM2.5)]. This is the first national-level cohort study to investigate these risks in Canada.Objective: We investigated the association between long-term exposure to ambient PM2.5 and cardiovascular mortality in nonimmigrant Canadian adults.Methods: We assigned estimates of exposure to ambient PM2.5 derived from satellite observations to a cohort of 2.1 million Canadian adults who in 1991 were among the 20% of the population mandated to provide detailed census data. We identified deaths occurring between 1991 and 2001 through record linkage. We calculated hazard ratios (HRs) and 95% confidence intervals (CIs) adjusted for available individual-level and contextual covariates using both standard Cox proportional survival models and nested, spatial random-effects survival models.Results: Using standard Cox models, we calculated HRs of 1.15 (95% CI: 1.13, 1.16) from nonaccidental causes and 1.31 (95% CI: 1.27, 1.35) from ischemic heart disease for each 10-μg/m3 increase in concentrations of PM2.5. Using spatial random-effects models controlling for the same variables, we calculated HRs of 1.10 (95% CI: 1.05, 1.15) and 1.30 (95% CI: 1.18, 1.43), respectively. We found similar associations between nonaccidental mortality and PM2.5 based on satellite-derived estimates and ground-based measurements in a subanalysis of subjects in 11 cities.Conclusions: In this large national cohort of nonimmigrant Canadians, mortality was associated with long-term exposure to PM2.5. Associations were observed with exposures to PM2.5 at concentrations that were predominantly lower (mean, 8.7 μg/m3; interquartile range, 6.2 μg/m3) than those reported previously.

Climate Change may Reduce Annual Temperature-Dependent Mortality in Subarctic: A Case Study of Archangelsk, Russian Federation

The impact of increasing temperatures on age- and cause-specific mortality has been examined for the city of Archangelsk in Russian Subarctic, paying equal attention to heat and cold stress. Projections of future daily temperatures and temperature waves were made for IPCC A2 CO2 emission scenario using regional downscaling of the selected ensemble of nine General Circulation Models. Relative changes in annual mortality attributed to climate warming were negative for five studied causes of mortality: all external causes, all non-accidental causes, coronary, cerebrovascular and respiratory diseases in two age groups: 30-64 and ?65 years. For most causes, the estimated relative changes were significant at 95% level. The benefits of reduced cold-related mortality will most likely outweigh the negative impacts of higher heat-related mortality. The relative input of heat and cold waves in the resultant change in annual mortality is several times smaller than the input of smooth temperature-mortality relationships.

Coarse particles and mortality in three Chinese cities: The China Air Pollution and Health Effects Study (CAPES)

Evidence concerning the health risks of coarse particles (PM 10-2.5) is limited. There have been no multi-city epidemiologic studies of PM 10-2.5 in developing Asian countries. We examine the short-term association between PM 10-2.5 and daily mortality in three Chinese cities: Beijing, Shanghai, and Shenyang. PM 10-2.5 concentrations were estimated by subtracting PM 2.5 from PM 10 measurements. Data were analyzed using the over-dispersed generalized linear Poisson models. The average daily concentrations of PM 10-2.5 were 101 μg/m 3 for Beijing (2007–2008), 50 μg/m 3 for Shanghai (2004–2008), and 49 μg/m 3 for Shenyang (2006–2008). In the single-pollutant models, the three-city combined analysis showed significant associations between PM 10-2.5 and daily mortality from both total non-accidental causes and from cardiopulmonary diseases. A 10-μg/m 3 increase in 1-day lagged PM 10-2.5 was associated with a 0.25% (95% CI: 0.08 to 0.42) increase in total mortality, 0.25% (95% CI: 0.10 to 0.40) increase in cardiovascular mortality, and 0.48% (95% CI: 0.20 to 0.76) increase in respiratory mortality. However, these associations became statistically insignificant after adjustment for PM 2.5. PM 2.5 was significantly associated with mortality both before and after adjustment for PM 10-2.5. In conclusion, there were no statistically significant associations between PM 10-2.5 and daily mortality after adjustment for PM 2.5 in the three Chinese cities.

ASSOCIATIONS BETWEEN GREENSPACE AND MORTALITY IN A POPULATION-BASED COHORT STUDY OF 574, 834 ADULTS IN ONTARIO, CANADA

Background: Access and exposure to green space is associated with a wide range of potential health benefits. Few studies have examined the direct impact of exposure to greenspaces on mortality. We investigated the association between greenspaces and mortality using a population-based cohort design. Methods: A cohort of 574,834 adults who were residents in one of 10 urban areas in Ontario, Canada in the early 1980s was assembled using income tax records. Vital status was determined through record linkage to the Canadian Mortality Data Base until the end of 2004. Six-character postal codes, representing a block face or large apartment building, from income tax records were used to identify the geographical coordinates for subjects’ place of residence. To these locations we assigned the Normalized Difference Vegetation Index (NDVI) as a measure of greenspaces. The NDVI is derived from Landsat Thematic Mapper (TM) data at 30m x 30m resolution for the years 1989-1997. Rate ratios for mortality were estimated using the Cox model and adjusted for income, marital status, neighbourhood characteristics, ambient PM2.5, and smoking prevalence estimates from the 1990 Ontario Health Survey. Mortality endpoints studied included: all non-accidental causes, cardiopulmonary disease, ischemic heart disease, and stroke. Results: A total of 181,107 non-accidental deaths occurred in the cohort. An inverse association was observed across increasing quartiles categories of ‘greenspace’. For all non-accidental causes of death, the risks in the upper three quartiles relative to the lowest greenness quartile were: 0.95 (95% CI=0.94 – 0.96), 0.95 (95% CI=0.94 – 0.96), and 0.93 (95% CI=0.92 – 0.95). The corresponding risks for cardio-pulmonary mortality were: 0.95 (95% CI= 0.93 – 0.96), 0.94 (95% CI= 0.92 – 0.96), and 0.92 (95% CI=0.90 – 0.94). Inverse associations were also observed with ischemic heart disease, and stroke mortality. Conclusions: Our study suggests that greenspace in urban environments is associated with lower rates of mortality.

Toward a Quantitative Estimate of Future Heat Wave Mortality under Global Climate Change

BackgroundClimate change is anticipated to affect human health by changing the distribution of known risk factors. Heat waves have had debilitating effects on human mortality, and global climate models predict an increase in the frequency and severity of heat waves. The extent to which climate change will harm human health through changes in the distribution of heat waves and the sources of uncertainty in estimating these effects have not been studied extensively.ObjectivesWe estimated the future excess mortality attributable to heat waves under global climate change for a major U.S. city.MethodsWe used a database comprising daily data from 1987 through 2005 on mortality from all nonaccidental causes, ambient levels of particulate matter and ozone, temperature, and dew point temperature for the city of Chicago, Illinois. We estimated the associations between heat waves and mortality in Chicago using Poisson regression models.ResultsUnder three different climate change scenarios for 2081–2100 and in the absence of adaptation, the city of Chicago could experience between 166 and 2,217 excess deaths per year attributable to heat waves, based on estimates from seven global climate models. We noted considerable variability in the projections of annual heat wave mortality; the largest source of variation was the choice of climate model.ConclusionsThe impact of future heat waves on human health will likely be profound, and significant gains can be expected by lowering future carbon dioxide emissions.

Extreme temperature episodes and mortality in Yakutsk, East Siberia

Although the health impacts of heat waves and, to a lesser extent, cold spells in big cities in moderate climates have been well documented, little is known about the same impacts in the circumpolar region. An epidemiological study in an Arctic town presents considerable difficulties for the statistician because of small population sizes. When daily mortality counts are mostly 0, 1 or 2, they are not normally distributed and do not fit the independence assumption. The aim of this study was to take these difficulties into account and assess the impacts of extreme temperature events on mortality rates in Yakutsk, a city with a strongly continental climate, situated near the north pole. Long-term distributions of daily mean temperatures were analyzed for identification of heat waves and cold spells during the study period of 1999 to 2007. The authors investigated daily mortality from all non-accidental causes, coronary heart disease and cerebrovascular causes among the age groups 30-64 years and 65 years and over. Statistical analysis was in two steps. Step 1 involved Student's t-tests of samples, which consisted of cumulative mortalities during each heat wave. This provided a measure of the average health effect of all identified heat waves, and the same analysis was performed separately for cold spells. At Step 2, the authors compared the observed cumulative mortality during each individual temperature wave with expected seasonal mortality, using chi(2) tests. The analysis of the impacts of six heat waves and three cold spells provided sufficient evidence that cardiovascular and non-accidental mortalities increased in Yakutsk during both heat waves and cold spells. The magnitude of established health effects was approximately the same for heat and cold. No significant differences were found between the two analyzed age groups in terms of relative excess mortality. Coronary heart disease mortality increased more than two-fold during some of the identified temperature waves, while non-accidental mortality increased by approximately 50%. The time lags between the temperature wave and observed increase in mortality varied between 8 and 14 days, which indicated that the health effects of temperature extremes were delayed rather than immediate. The evidence obtained of the effects of temperature waves on cerebrovascular mortality was not conclusive. Addressing the methodological implications of dealing with small cities, the authors linked the sensitivity of the applied statistical tests to arithmetic means and relative standard deviations of daily death counts, and to the duration of temperature waves. The proposed methodology can be applied in other medium-sized towns (populations >200,000, approximately); however, only large relative increases in mortality will be statistically significant. For example, relative risks of less than 2.0 for coronary disease mortality and 1.4 for non-accidental mortality are likely to be non-significant.

Daily visibility and mortality: Assessment of health benefits from improved visibility in Hong Kong

Visibility in Hong Kong has deteriorated significantly over 40 years with visibility below 8 km in the absence of fog, mist, or precipitation, increasing from 6.6 days in 1968 to 54.1 days in 2007. We assessed the short-term mortality effects of daily loss of visibility. During 1996–2006, we obtained mortality data for non-accidental and cardiorespiratory causes, visibility recorded as visual range in kilometers, temperature, and relative humidity from an urban observatory, and concentrations of four criteria pollutants. A generalized additive Poisson regression model with penalized cubic regression splines was fitted to control for time variant covariates. For non-accidental mortality, an interquartile range (IQR) of 6.5 km decrease in visibility at lag 0–1 days was associated with an excess risk (ER%) [95% CI] of 1.13 [0.49, 1.76] for all ages and 1.37 [0.65, 2.09] for ages 65 years and over; for cardiovascular mortality of 1.31 [0.13, 2.49] for all ages, and 1.72 [0.44, 3.00] for ages 65 years and over; and for respiratory mortality of 1.92 [0.49, 3.35] for all ages and 1.76 [0.28, 3.25] for ages 65 years and over. The estimated ER% for daily mortality derived from both visibility and air pollutant data were comparable in terms of magnitude, lag pattern, and exposure–response relationships especially when using particulate matter with aerodynamic diameter ≤10 μm to predict the mortality associated with visibility. Visibility provides a useful proxy for the assessment of environmental health risks from ambient air pollutants and a valid approach for the assessment of the public health impacts of air pollution and the benefits of air quality improvement measures in developing countries where pollutant monitoring data are scarce.

Seasonal effect of PM10 concentrations on mortality and morbidity in Seoul, Korea: A temperature-matched case-crossover analysis

Explorations of interactions between air pollution and seasonal changes have represented one approach in examining the consequences of global warming. However, only a few studies have focused on evaluating the effects of seasonal air pollution using data on both morbidity and mortality in Asia. We examined the associations between PM(10) concentrations and mortality and hospital admissions in Seoul, Korea for the periods 2000-2006 and 2001-2006. We employed a temperature-matched case-crossover design, where reference periods matched case days in regard to temperature (same rounded to degrees celsius ( degrees C)), month, and year. A total of 238,826 deaths were identified, along with 98,570 and 93,553 inpatient admissions for cardiovascular and respiratory diseases, respectively. We found that the association with PM(10) and mortality/morbidity increased during the summer. During the study period, 10microg/m(3) increase in PM(10) was associated with the increase in mortality by 0.28% (95% confidence interval: 0.12, 0.44), 0.51% (0.19, 0.83), and 0.59% (-0.08, 1.26) for non-accidental, cardiovascular, and respiratory causes. 10microg/m(3) increase in PM(10) was also associated with increase in hospitalization from cardiovascular and respiratory causes by 0.77% (0.53, 1.01) and 1.19% (0.94, 1.44). In the summer, the increase in mortality and hospitalization was 0.57% (0.20, 0.93), 0.64% (-0.10, 1.38), 0.50% (-1.02, 2.05), 1.52% (0.89, 2.16), and 1.55% (0.87, 2.22). This study provides evidence that the effect of PM(10) on mortality and morbidity varies with season and increases during the summer season.

Temperature-dependent association between mortality rate and carbon monoxide level in a subtropical city: Kaohsiung, Taiwan

The objective of this study was to explore the combined effect of temperature and air pollutant levels on daily non-accidental deaths and cardiovascular causes of mortality. In this study, associations were assessed by means of time-series analyses over the period 1995–1999 for Kaohsiung, Taiwan's largest industrial city, which has a subtropical climate. Ambient exposures to various air pollutants, including carbon monoxide (CO), sulfur dioxide (SO2), ozone (O3), nitrogen dioxide (NO2), and particulate matter (PM10), were estimated from the arithmetic means of all daily measurements taken by an air quality monitoring station nearest to the residential district. Generalized additive models with non-parametric spline were used to identify associations between daily mortality and air pollutants as well as the air pollutant–temperature interaction correlation. Our findings indicate that CO is associated with increased risks of non-accidental and cardiovascular mortality. For a 0.2 ppm increase in CO, the increased relative daily risk of non-accidental death is at least 4% on the same day, when the mean temperature is above 24.8°C, while the increased relative risk of mortality due to cardiovascular diseases is 7% two days later at 19.7°C. The study also suggests a statistically significant interaction between CO concentration and daily mean temperature, with non-accidental mortality increasing with a warm outdoor temperature and the effect of CO on cardiovascular mortality being modified by a cold climate. Further reduction of CO pollution is thus deemed crucial for the benefit of public health.

Predicting adult health and mortality from adolescent facial characteristics in yearbook photographs

Several important longitudinal studies in the social sciences have omitted biomarkers that are routinely recorded today, including height and weight. To account for this shortcoming in the Wisconsin Longitudinal Study (WLS), an 11-point scale was developed to code high school senior class yearbook photographs of WLS participants for relative body mass (RBM). Our analyses show that although imperfect, the RBM scale is reliable (alpha = .91) and meets several criteria of validity as a measure of body mass. Measured at ages 17-18, the standardized relative body mass index (SRBMI) was moderately correlated (r = .31) with body mass index (BMI) at ages 53-54 and with maximum BMI reported between ages 16 and 30 (r = .48). Overweight adolescents (> or = 90th percentile of SRBMI) were about three times more likely than healthy-weight adolescents (10th-80th percentile of SRBMI) to be obese in adulthood and, as a likely consequence, significantly more likely to report health problems such as chest pain and diabetes. Overweight adolescents also suffered a twofold risk of premature death from all nonaccidental causes as well as a fourfold risk of heart disease mortality. The RBM scale has removed a serious obstacle to obesity research and lifelong analyses of health in the WLS. We suggest that other longitudinal studies may also be able to obtain photos of participants at younger ages and thus gain a prospectively useful substitute for direct measures of body mass.

Arsenic in Drinking Water and Adult Mortality

Arsenic is a potent human carcinogen and toxicant. Elevated concentration of arsenic in drinking water is a major public-health problem worldwide. We evaluated risks of adult mortality (due to cancer and cardiovascular and infectious diseases) in relation to arsenic exposure through drinking water. A cohort analysis was applied to survival data prospectively collected during 1991-2000 in a health and demographic surveillance system in Matlab, Bangladesh, where tubewells were installed beginning in the early 1970s. A total of 115,903 persons aged 15 or more years on 1 January 1991 were available for analysis. In this period, 9015 people died and 22,488 were lost to follow-up. Arsenic exposure data were derived from a survey in 2002-2003 of past and current water use and arsenic concentrations in all tubewells. We estimated risk of excess mortality in relation to arsenic exposure, using proportional hazards models. Even at low levels (10-49 mug/L) of arsenic in drinking water, we observed increased risk of death due to all nonaccidental causes (hazard ratio = 1.16 [95% confidence interval = 1.06-1.26]). Increased risks at exposure of 50-149 microg/L were observed for death due to cancers (1.44 [1.06-1.95]), cardiovascular disease (1.16 [0.96-1.40]), and infectious diseases (1.30 [1.13-1.49]). We observed clear dose-response relationships for each of these causes. Arsenic exposure through drinking water has generated excess adult mortality after 20-30 years of exposure.

Excess mortality during heat waves and cold spells in Moscow, Russia

Objectives: To estimate excess mortality during heat waves and cold spells, and to identify vulnerable population groups by age and cause of death. Methods: Daily mortality in Moscow, Russia from...