Standardized Morbidity Ratio Research Articles

Classic Kaposi sarcoma in northern Sardinia: A prospective epidemiologic overview (1977-2003) correlated with malaria prevalence (1934)

Studies have demonstrated considerable variations in classic Kaposi sarcoma (CKS) incidence within Europe, with some of the highest incidences found in the Mediterranean area. As a Mediterranean area, northern Sardinia has a high CKS frequency. In order to determine CKS incidence in people born in and residing in northern Sardinia, a clinical prospective epidemiologic study was carried out between 1977 and 2003 by the Department of Dermatology, University of Sassari. We also evaluated a correlation between malaria prevalence in 1934, estimated on the eight historical sub-areas of the Sassari province, and the standardized morbidity ratio from 1977 to 2003. A total of 332 patients with CKS were identified. Incidence among the northern Sardinian population > or =40 years of age was 4.06/100,000 persons/year and it was almost stable through the years. The male to female ratio showed a significant decline from 3.6 to 2.5 (P = .03). Females had a statistically decreased risk of developing CKS compared to males (adjusted incidence rate ratio = 0.27; 95% CI: 0.21-0.34), and the risk of developing CKS increased exponentially with age. The prevalence of malaria in each sub-area ranged from 9% to 91%. The standardized morbidity ratio for CKS in the years between 1977 and 2003 ranged from 0.27 to 1.76; the regression coefficient was -0.85 (95% CI: -2.94-1.24), yielding a nonsignificant relationship between the two diseases. These results were obtained from patients with CKS in northern Sardinia and may not be applicable to other populations. The northern Sardinian population consistently has a very high incidence of CKS, while in our data, the correlation between malaria and CKS remains open to question.

Extracolonic Cancers Associated with Hereditary Nonpolyposis Colorectal Cancer in the Utah Population Database

The data describing the extracolonic cancers associated with hereditary nonpolyposis colorectal cancer (HNPCC) are variable. We ascertained all Amsterdam I criteria-positive pedigrees (N = 18) in the Utah Population Database (UPDB). We identified the extracolonic cancers in the colorectal cancer cases (N = 65) in these pedigrees, and in their first- (N = 509) and second-degree (N = 1,611) relatives. Standardized morbidity ratios were estimated by comparing the observed rates of extracolonic cancer in defined sets of relatives of probands with population expected rates estimated internally from the UPDB. The extracolonic cancers observed in significant excess in the 65 Amsterdam I criteria-positive colorectal cancer (CRC) cases in the UPDB were uterine (N = 3, p = 0.003), lip (N = 2, p = 0.007), stomach (N = 2, p = 0.009), female genitalia (N = 1, p = 0.004) and larynx (N = 1, p = 0.05). Extracolonic cancers observed in significant excess in the 509 first-degree relatives of the 65 colorectal cancer (CRC) cases in these Amsterdam I criteria pedigrees included: thyroid (N = 5, p = 0.0002) and prostate (N = 19, p = 0.002). Thyroid cancer (N = 6, p = 0.003) was found in significant excess in the second-degree relatives of the Amsterdam I criteria-positive CRC cases. In this population-based examination of the extracolonic cancers at excess in classic HNPCC pedigrees (selected by Amsterdam I criteria) we not only observed many of the same cancers previously reported to be associated with HNPCC in both CRC probands and their relatives, but also identified several previously unreported associations. Although our sample size is small, this study is population based, lacks ascertainment and recall bias, and benefits from uniform, consistent diagnoses of all cancers in a statewide registry.

Ischemic stroke after heart failure: A community-based study

Although studies have examined the incidence of stroke in heart failure (HF), their findings are inconsistent and difficult to interpret because of heterogeneity in study design and population. Although HF remains a highly fatal disease, the excess mortality imparted from stroke is unknown. A random sample of cases of HF from 1979 to 1999 was identified and validated according to Framingham criteria. Strokes were identified by screening medical diagnoses and subsequent physician validation. Stroke risk in HF was compared with the risk in the general population with standardized morbidity ratios. Associations between selected characteristics and stroke were examined using proportional hazards regression. The study cohort included 630 persons with incident HF. During a median of 4.3 years of follow-up, 102 (16%) experienced an ischemic stroke. Heart failure was associated with a 17.4-fold increased risk for stroke compared with the general population in the first 30 days after HF diagnosis and remained elevated during 5 years of follow-up. Older persons with prior stroke or diabetes were more likely to experience stroke after HF diagnosis. Persons with stroke after HF were 2.31 times more likely to die compared with persons without stroke. In the community, persons with HF have a large increase in the risk for ischemic stroke compared with the general population. Stroke results in a >2-fold increase in mortality. Thus, prevention of stroke has the potential to improve survival among patients with HF, particularly among the elderly and those with diabetes or prior stroke.

INCIDENCE AND OUTCOMES OF KNEE AND HIP JOINT REPLACEMENT IN VETERANS AND CIVILIANS

This article describes the incidence of total knee and hip replacement, and compares post-surgery health status outcomes in veterans and civilians. The numbers of male veterans and civilians who had a knee and/or a hip replacement in South Australia (1994-2002) were obtained. Standardized morbidity ratios, and odds ratios for age group by veteran/civilian interactions, were calculated. Presurgery and 1-year post-surgery Medical Outcomes Short Form (36) Health Survey, Knee Society and Harris hip scores were completed. Independent samples t-tests were used to compare presurgery scores. ancova models were used to determine any differences between veterans and civilians post-surgery. For veterans, standardized morbidity ratios were 0.987 and 0.715 for knee and hip replacements, respectively (P < 0.0001). Veterans' odds ratios for knee and hip replacements were significantly lower in the 65- to 74-year age group (P < 0.001), similar in the 75- to 84-year and above 85-year age groups for hip replacement, but significantly higher in the above 85-year age group for knee replacement (P < 0.001). Presurgery, veterans reported significantly lower scores (P < 0.003) for knee function. After knee replacement, veterans reported significantly lower Medical Outcomes Short Form (36) Health Survey scores for bodily pain, physical functioning, role - physical, role--emotional, social functioning and physical component summary (P < 0.033). Significantly lower physical functioning, role--physical and physical component summary scores (P < 0.02) were reported by veterans post-surgery for hip replacement. Veterans are delaying joint replacement. Presurgical knee function is worse in veterans. Post-surgery, the veterans are worse off in a number of health status outcomes.

Declining incidence of peptic ulcer but not of its complications: a nation‐wide study in The Netherlands

Despite reports of decreasing hospitalizations and mortality due to peptic ulcer, it is unclear whether the incidence has truly declined over time. To investigate time trends in the incidence of and in hospital admission rates for peptic ulcer in the Netherlands. The nationwide registry of pathology reports (PALGA) and the national registry of hospital admissions (Landelijke Medische Registratie) were used. Standardized morbidity ratios were calculated to assess the magnitude of the changes. The age-adjusted incidence of gastric ulcer halved for both men (standardized morbidity ratio 0.48; CI 0.46-0.49) and women (standardized morbidity ratio 0.49; CI 0.47-0.51). Although the number of gastric biopsies obtained at endoscopy increased, the proportion with a diagnosis of peptic ulcer decreased by more than 50% (standardized morbidity ratio 0.47; CI 0.46-0.49). The admission rate for peptic ulcer more than halved between 1980 and 2003. In contrast, admission rates for complicated ulcers barely changed and slightly increased among women. The incidence of histopathologically confirmed gastric ulcer halved between 1992 and 2003 in the Netherlands. As the number of gastric biopsies increased in this period, a true decrease is likely. Hospital admissions for peptic ulcer declined dramatically between 1980 and 2003, but remained unchanged or slightly increased for complicated ulcers.

Melanoma risk in congenital melanocytic naevi: a systematic review

The risk of malignant melanoma in congenital melanocytic naevi (CMN) is a matter of controversial and ongoing debate. The purpose of this systematic review is to provide a careful and detailed summary of the published data, including several recently published studies. Articles on CMN (n=1424) were retrieved from Medline, 1966-October 2005. Case reports and studies lacking relevant clinical information were excluded. Only systematic collections of cases were taken into consideration. Series with fewer than 20 patients or studies with a mean follow-up of <3 years were regarded as epidemiologically less significant. Fourteen articles were finally chosen for further analysis. The studies varied significantly with respect to study design (source of cases; retrospective vs. prospective analysis), age of patients, follow-up time, and naevus characteristics. The frequency of melanomas ranged between 0.05% and 10.7% and was significantly higher in smaller studies (P<0.0001). In a total of 6571 patients with CMN who were followed for a mean of 3.4-23.7 years, 46 patients (0.7%) developed 49 melanomas. The mean age at diagnosis of melanoma was 15.5 years (median 7). By comparison with age-adjusted data from the Surveillance, Epidemiology and End Results database, we calculated that patients with CMN carry an approximately 465-fold increased relative risk of developing melanoma during childhood and adolescence. Primary melanomas arose inside the naevi in 33 of 49 cases (67%). In seven cases (14%), metastatic melanoma with unknown primary was encountered; in four cases (8%) the melanoma developed at an extracutaneous site. The risk of developing melanoma and the rate of fatal courses were by far highest in CMN>or=40 cm in diameter. The overall risk of melanoma of 0.7% in all 14 studies was lower than expected. The higher incidence of melanomas in smaller studies indicates selection bias. The melanoma risk strongly depends on the size of CMN and is highest in those naevi traditionally designated as garment naevi. The median age of 7 years at diagnosis of melanoma points to a risk maximum in childhood and adolescence. Future studies on CMN should report: (i) diameter, percentage of body surface, and localization of the CMN; (ii) percentage of naevus area removed by excision or subject to dermabrasion or other superficial treatments; (iii) mean and median age at entry into the study; (iv) mean and median follow-up time; (v) details on each melanoma case; (vi) standardized morbidity ratio of melanoma; and (vii) percentage of neurocutaneous melanosis.

Short-Term Chloral Hydrate Administration and Cancer in Humans

Chloral hydrate, used as a hypnosedative in adults and children, has been shown to be genotoxic and carcinogenic in animal studies. We investigated the potential causal association between chloral hydrate exposure and cancer risk in humans. Cancer incidence was previously determined via biennial screening analyses of the 215 most commonly used drugs between 1976 and 1998 for a cohort of 143,574 outpatients at Kaiser Permanente who had prescriptions filled between 1969 and 1973. Among users of chloral hydrate, statistically significant elevations in standardised morbidity ratios were observed during various years for cancer at five anatomical sites, including the lung, stomach, prostate, skin melanoma and mouth floor. In this analysis, these associations were investigated using: (i) a dose-response analysis among exposed subjects; and (ii) a two-stage design with exposed and non-exposed persons. There was evidence of an increasing risk of prostate cancer with increasing number of dispensings of chloral hydrate, which persisted after controlling for benign prostatic hypertrophy, vasectomy and obesity; however, the trend was not statistically significant. There was no evidence of a dose-response relationship between chloral hydrate and risk of any of the other four cancers. In the two-stage design, analyses comparing exposed and unexposed subjects showed no increased risk of cancer after controlling for confounding variables; however, the data were suggestive for prostate cancer, where the increased risk associated with chloral hydrate exposure after adjustment for confounding variables persisted. No dose-response relationship was seen for any of the other four cancer sites. To our knowledge, this is the first study to examine the relationship between chloral hydrate exposure and cancer risk in humans. There was no persuasive evidence to support a causal relationship between chloral hydrate exposure in humans and the development of cancer. However, statistical power was low for weak associations, particularly for some of the individual cancer sites. Although animal data using much higher doses of chloral hydrate have demonstrated its genotoxicity and carcinogenicity, the effects of chloral hydrate in humans are still uncertain.

Increasing incidence of club foot with higher population density: Incidence and geographical variation in Denmark over a 16–year period—an epidemiological study of 936,525 births

Background The occurrence of club foot (CF) varies between countries and populations, and may be related to endogenous and exogenous factors. We analyzed the occurrence of CF in a whole country over a long period of time (16 years).Methods Patients born in Denmark with a foot deformity 1978–93 were identified from the National Patient Register and the Register of Inborn Malformations. The records for each patient were studied in the hospital departments to establish the diagnoses and to obtain additional information. Demographic data were obtained from the Danish National Demographical Institute and from the Danish Population Register.Results The incidence of isolated CF was 1.2/1,000 live births. It increased significantly during the study period, and the incidence of CF and the standardized morbidity ratio for CF were significantly positively correlated to population densities in the counties and the districts. There was no significant increase in the relative proportion of children with CF born to non-Scandina-vian parents during the period.Interpretation The increasing incidence of isolated CF with higher population density indicates that there may be exogenous factors that are pathogenic.

A Community-Based Study of Stroke Incidence after Myocardial Infarction

The rate of stroke after myocardial infarction (MI) remains unclear. To examine the rate of stroke after incident MI; compare it with that observed in the population of Rochester, Minnesota; determine how the rate of stroke after MI has changed over time; and examine the impact of stroke on survival after incident MI. Community-based cohort. Olmsted County, Minnesota. Persons with incident (first-ever) MI between 1979 and 1998. Ischemic or hemorrhagic stroke in hospitalized and nonhospitalized patients that was identified by screening of the medical record for stroke diagnostic codes and subsequent stroke confirmation by physician review of the recorded event. Medical record review was used to ascertain baseline characteristics and death. A total of 2160 persons with incident MI were hospitalized between 1979 and 1998 and followed for a median of 5.6 years (range, 0 to 22.2 years). The rate of stroke was 22.6 per 1000 person-months (95% CI, 16.3 to 30.6 per 1000 person-months) during the first 30 days after MI, corresponding to a 44-fold increase (standardized morbidity ratio, 44 [95% CI, 32 to 59]) risk for stroke in the population of Rochester, Minnesota. The risk for stroke remained 2 to 3 times higher than expected during the first 3 years after MI. Older age, previous stroke, and diabetes increased the risk for stroke, which did not decline over the study period. Strokes were associated with a large increase in the risk for death after MI (hazard ratio, 2.89 [CI, 2.44 to 3.43]). Findings may not be generalizable to different populations. The authors measured outcomes by reviewing medical records. In the community, the risk for stroke is markedly increased after MI, particularly early after MI, compared with the expected risk in population without MI. Stroke is associated with a large increase in the risk for death after MI.

Data on diabetes from the French cohort study in schizophrenia

To establish the impact of antipsychotic medication on the incidence of diabetes, we have analysed data from the prospective French Cohort study of mortality in schizophrenia. This generated a large database of 3470 patients with schizophrenia initially enrolled in 1993 for which data collection on comorbidity has been collected systematically every three years since. The primary objective of the study was to evaluate the mortality rate in the study cohort. From this database, the prevalence and incidence of diabetes can be studied. In 1993, nine patients in 10 were prescribed conventional antipsychotics and the remainder amisulpride and clozapine. Since the introduction of risperidone and olanzapine, atypical antipsychotics are now used in one-third of patients. Multiple antipsychotic medications are used in many patients, with the exception of those receiving clozapine. At inclusion, 2.2% of patients in the study cohort had a diagnosis of diabetes. Morbidity rates were higher in females than in males (3.4% and 1.6%, respectively) and it was only in females that the standard morbidity ratio with respect to the general population was significantly elevated (2.2; 95% confidence intervals: 1.6 and 2.9). The prevalence of diabetes in the study cohort rose over the course of the study. Multivariate regression analysis was performed in order to identify potential determinants of diabetes. For pre-existing diabetes, four factors were identified: age at first hospitalisation, age, obesity and duration of schizophrenia. The same factors with the exception of length of illness were identified for the incident cases. There was no evidence for an interaction between the class and type of antipsychotic medication and risk of treatment emergent diabetes. However, the use of multiple antipsychotic treatments makes the individualisation of specific risks associated with any other antipsychotic drug impossible.

High risk of venous thrombosis in patients with pancreatic cancer: A cohort study of 202 patients

To estimate the risk of venous thrombosis associated with pancreatic malignancies we followed a cohort of patients with pancreatic cancer (n = 202). We calculated incidence rates of venous thrombosis and compared this with population rates using a Standardised Morbidity Ratio (SMR). The effects of location, histology and treatment were assessed by Cox-modelling. The incidence of venous thrombosis was 108.3/1000 patient-years (95% confidence interval (CI) 64.4-163.8), 58.6-fold increased (SMR 58.6, 95% CI 36.9-92.9). Patients with a tumour of the corpus/cauda had a 2-fold increased risk compared with those with a tumour of the caput. Patients treated with chemotherapy had a 4.8-fold increased risk (HR(adj) 4.8, 95% CI 1.1-20.8), whereas radiotherapy did not increase the risk. In a postoperative period of 30 d, patients had a 4.5-fold increased risk of venous thrombosis (HR(adj) 4.5, 95% CI 0.5-40.9). The risk was 1.9-fold increased in the presence of distant metastases (HR(adj) 1.9, 95% CI 0.7-5.1). Anti-thrombotic prophylaxis seems warranted in the first month after surgery, during and after treatment with chemotherapy, and when distant metastases have been diagnosed.

Incidence of TB in Inmates with Latent TB Infection: 5-Year Follow-up

Inmates are a high-risk population for tuberculosis (TB) control efforts, including treatment for latent tuberculosis infection (LTBI). Completion of therapy after release has been poor. The goal of this study was to evaluate therapy completion and active disease over 5 years in a cohort of inmates. The sample was from a completed randomized trial in 1998-1999 of education or incentive versus usual care to improve therapy completion after release from the San Francisco County Jail. Records from the jail, the County Tuberculosis Clinic, and the California TB Registry were used to measure therapy completion and development of active TB. Analyses were conducted in 2005. Of a total 527 inmates, 31.6% (n=176) completed therapy, of whom 59.7% (n=105) completed it in jail. Compared with the U.S.-born, foreign-born inmates residing in the United States for < or =5 years were less likely to complete the therapy (adjusted odds ratio [AOR]=0.49, 95% confidence interval [CI]=0.28-0.85), and those with more education were more likely to complete the therapy (AOR=1.06, 95% CI=1.01-1.12). Three subjects developed active TB in the 5 years of follow-up, resulting in an annual rate of 108 per 100,000. Compared with California rates, subjects were 59 times as likely to develop active TB (standardized morbidity ratio of 59.2, 95% CI=11.2-145.1). None had completed therapy, none were new immigrants, and two were known to be HIV-positive at diagnosis. Completion of therapy for LTBI is a challenge, but the active TB seen in this jail cohort emphasizes the importance of continued efforts to address TB risk in this population.

Statistical Challenges in Evaluating Dose-Response Using Epidemiological Data

Statistical Challenges in Evaluating Dose-Response Using Epidemiological Data

A Graphical Method to Evaluate Exposure-Response Relationships in Epidemiologic Studies Using Standardized Mortality or Morbidity Ratios

In occupational epidemiology, exposure-response analyses play an important role in the evaluation of the etiologic relevance of chemical and physical exposures. The standardized mortality or morbidity ratio (SMR) has been commonly used in occupational cohort studies. Statistical approaches to evaluate exposure-response patterns using SMRs have mostly been limited to analyses in which the exposure under investigation is categorized. Here, a graphical method for evaluating exposure-response patterns is presented based on SMR estimates across moving exposure windows. This method is demonstrated using the results of two hypothetical cohort studies. The proposed approach may be useful for graphical exploration of exposure-response trends in situations where the number of observed cases is small.

The Risk of Cancer Among Patients Previously Hospitalized for Atopic Dermatitis

In treatment of severe atopic dermatitis, drugs with carcinogenic potentials are used to manage the disease. We therefore analyzed whether patients having severe atopic eczema had an increased cancer risk. The study population included all individuals hospitalized in Denmark with a primary diagnosis of atopic dermatitis during 1977-1996. Follow-up was conducted in 1996 in the Danish Cancer Register. A total of 6275 persons were included. Among 2030 adult patients, an increased risk of cancer was observed, standard morbidity ratio (SMR)=1.5 (95% CI: 1.2-1.9). Half the excess cases of cancer was keratinocyte carcinomas of the skin diagnosed within the first 9 y of follow-up, SMR=2.4 (95% CI: 1.4-3.9). For men, SMR=2.7 (95%CI: 1.2-5.4). In conclusion, earlier hospitalized adult atopic dermatitis patients had an increased risk of cancer. Half the excess cases of cancer were keratinocyte carcinomas. This may be a result of a detection bias or due to the carcinogenic potentials of some of the therapies of severe atopic dermatitis.

Outcomes Among Valvular Heart Disease Patients Experiencing Ischemic Stroke or Transient Ischemic Attack in Olmsted County, Minnesota

To estimate the rates and predictors of survival and recurrence among residents of Olmsted County, Minnesota, who received an Initial diagnosis based on 2-dimensional color Doppler echocardiography of moderate or severe mitral or aortic stenosis or regurgitation and who experienced a first ischemic stroke, transient ischemic attack (TIA), or amaurosis fugax. At the Mayo Clinic in Rochester, Minn, we used the resources of the Rochester Epidemiology Project to identify Individuals who met the criteria for inclusion in the study and to verify exclusion criteria. The study included all residents of Olmsted County, Minnesota, who experienced a first Ischemic stroke, TIA, or amaurosis fugax within 30 days of or subsequent to receiving a first-time 2-dimensional color Doppler echocardlography-based diagnosis of moderate or severe mitral or aortic stenosis or regurgitation between January 1, 1985, and December 31, 1992. The Kaplan-Meier product-limit method was used to estimate the rates of subsequent stroke and death after the ischemic stroke, TIA, or amaurosis fugax. The Cox proportional hazards model was used to assess the effect of several potential risk factors on subsequent stroke occurrence and death. For the 125 patients in the study, the Kaplan-Meier estimates of the risk of death and the risk of stroke at 2-year follow-up were 38.6% (95% confidence interval [CI], 29.9%-47.5%) and 18.5% (95% CI, 10.0%-27.0%), respectively. Compared with the general population, death rates were significantly Increased (standardized mortality ratio = 1.75; 95% CI, 1.38-2.19; P < .001) but rates of subsequent stroke occurrence were not (standardized morbidity ratio = 1.20; 95% CI, 0.75-1.84; P = .40). After adjustment for age, sex, and cardiac comorbidity, neither the type nor severity of valvular heart disease was an independent determinant of survival or subsequent stroke occurrence. Patients with mitral or aortic valvular heart disease who experience Ischemic stroke, TIA, or amaurosis fugax have Increased rates of death, but not recurrent stroke, compared with expected rates. Other cardiovascular risk factors are more important determinants of survival In these patients than the type or echocardiographic severity of the valvular heart disease.

Assessment of cardiovascular disease risk factors and diabetes mellitus in Australian prisons: is the prisoner population unhealthier than the rest of the Australian population?

Introduction: This paper compares the prevalence estimates of diabetes and cardiovascular disease (CVD) risk factors in the Indigenous and non‐Indigenous New South Wales (NSW) prisoner population in 1996 and 2001, and also compares the 2001 prevalence estimates with Australian population data.Methods: In 1996 and 2001, 789 and 916 prisoners, respectively, in NSW underwent a face‐to‐face interview covering behavioural risks and physical and mental health. Weight, height and blood pressure were recorded and blood was taken for measurement of cholesterol and random blood sugar.Results: The prevalence of hypertension, hypercholesterolaemia and smoking were lower in the 2001 prison survey as compared with the 1996 survey but the prevalence of smoking was extremely high in both the prison surveys (88% in 1996 and 79% in 2001). There were no differences in the age and sex‐adjusted prevalence estimates for any condition except that the prison sample had a higher standardised morbidity ratio for angina than the AusDiab population.Conclusion: This study highlights the high prevalence of CVD risk factors, particularly in younger prisoners, when compared with the Australian non‐prison population.Implications: Programs should be put in place to routinely screen for chronic disease conditions and to educate Australian prisoners regarding CVD and diabetes risk factors and their long‐term management.

Spatial distribution of Escherichia coli O157-positive farms in Scotland

Using a sample of 949 Scottish farms with finishing cattle, the spatial distribution of Escherichia coli O157-positive farms was investigated using disease mapping models. The overall prevalence of E. coli O157-positive farms was estimated as 22%. The regions used in this study were the 16 postcode areas of Scotland. For each region, the posterior relative risk (RR) was estimated as a model-based alternative to the saturated standardized morbidity ratio (SMR), i.e., the ratio between observed and expected cases in a region. Three Bayesian hierarchical models with generalized linear modeling of the area-specific risks were used to estimate the posterior relative risk of E. coli O157-positive farms in the postcode areas: a random-effects model incorporating only spatially uncorrelated heterogeneity; a model incorporating both spatially correlated and uncorrelated heterogeneity; and a pseudo-mixture model with unstructured correlation and a weighted mix of two variance components representing the spatial correlation and a jump structure. None of the models identified any areas with a significant increase or decrease in risk. The deviance information criteria slightly favored the simplest model (RR range: 0.92–1.09). However, this model appeared to smooth out more of the variation in the RR compared to the pseudo-mixture model, which gave a more informative pattern of the posterior relative risks (range: 0.81–1.22).

Risk Factors for Cardiovascular Disease in Homeless Adults

Homeless people represent an extremely disadvantaged group in North America. Among older homeless men, cardiovascular disease (CVD) is the leading cause of death. The objective of this study was to examine cardiovascular risk factors in a representative sample of homeless adults and identify opportunities for improved risk factor modification. Homeless persons were randomly selected at shelters for single adults in Toronto. Response rate was 79%. Participants (n=202) underwent interviews, physical measurements, and blood sampling. The mean age of participants was 42 years, and 89% were men. The prevalence of smoking among homeless subjects (78%; 95% confidence interval [CI], 72% to 84%) was significantly higher than in the general population (standardized morbidity ratio [SMR], 254; 95% CI, 216 to 297). Hypertension, high cholesterol, and diabetes were not more prevalent than in the general population but were often poorly controlled. Homeless men were significantly less likely to be overweight or obese than men in the general population (SMR, 79; 95% CI, 63 to 98). Cocaine use in the last year was reported by 29% of subjects (95% CI, 23% to 36%). CVD was reported by 15% of subjects, fewer than one third of whom reported taking aspirin or cholesterol-lowering medication. According to multiple-risk-factor equations, the median estimated 10-year absolute risk of myocardial infarction or coronary death among homeless men aged 30 to 74 years was 5% (interquartile range, 3% to 9%). Cardiovascular risk factor modification is suboptimal among homeless adults in Toronto, despite universal health insurance. Multiple risk factor equations may underestimate true risk in this population because of inadequate accounting for factors such as cocaine use and heavy smoking.

High incidence of genetic human transmissible spongiform encephalopathies in Italy

To assess the incidence and mortality rates of genetic transmissible spongiform encephalopathy (TSE) diseases in Italy. The authors have sequenced the prion protein gene (PRNP) in 643 patients referred to the Italian Registry of Creutzfeldt-Jakob disease (CJD) and related disorders between 1993 and 2002. Crude age- and sex-specific incidence and mortality rates were calculated. Differences in morbidity from genetic TSE diseases in the 20 Italian regions were assessed by the standardized morbidity ratio (SMR). A total of 130 cases were classified as genetic TSE diseases with a mean yearly incidence rate of 0.28 cases per million people. Genetic TSE diseases represent 17.7% of all TSE diseases, including sporadic, iatrogenic, and variant CJD. The most frequent mutation was the V210I (n = 54), and the second most common the E200K (n = 42). Mortality rates for genetic TSE diseases did not increase in any of the age groups under examination over the 10 years of surveillance. The analysis of regional distribution of genetic cases by place of birth revealed that in Campania and Calabria regions the number of genetic TSE cases was higher than in other regions. In Italy the incidence of genetic transmissible spongiform encephalopathy (TSE) diseases is the second highest among European countries. Genetic analysis is important for a correct classification of patients with TSE.