Years For Whites Research Articles

Race, Mental Illness, and Premature Mortality: Double Jeopardy?

Back to table of contents Previous article Next article LettersFull AccessRace, Mental Illness, and Premature Mortality: Double Jeopardy?Elizabeth E. Piatt, Ph.D.Elizabeth E. PiattSearch for more papers by this author, Ph.D.Published Online:1 Feb 2011AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: Racial-ethnic disparities in mortality have been extensively noted in the literature (1). A number of studies have also established that a diagnosis of a mental disorder increases a person's risk of premature death (2). However, research has not focused on the issue of “double jeopardy,” as postulated by Dowd and Bengtson (3). If race-ethnicity and a mental illness diagnosis lead to a double disadvantage in regard to health, then racial-ethnic health disparities should be greater among persons with mental illness than among those who do not have mental illness.To address this issue, I compared racial-ethnic differences in premature mortality among decedents with severe mental illness and decedents in the general population without mental illness. Death records for the City of Akron, Ohio, were matched with clinical case management files from Community Support Services (CSS), a community mental health center in Akron. The sample consisted of 16,164 individuals who died between January 1998 and December 2004; 647 of these individuals also had CSS records and 15, 517 did not. The mean±SD age of decedents in the sample was 79.4±11.4 years. Fifty-six percent (N=9,052) of the decedents were female, 20% (N=3,233) were African American, and 80% (N=12,931) were white. The sample and methods have been described extensively elsewhere (2). Analysis was limited to African Americans and whites because reporting of race on death certificates for these groups has been shown to be accurate (4).I used multivariate ordinary least-squares regression to estimate premature mortality, adjusting for gender, marital status, education, mental illness diagnosis, race, and cause of death. After the analysis controlled for the other factors, race (b=2.5, p≤.001) and a mental illness diagnosis (b=4.5, p≤.001) were significantly related to premature mortality. The regression coefficients were used to calculate the predicted values of years of potential life lost (YPLL) for CSS and non-CSS decedents by race. The difference in YPLL between African Americans and whites was smaller among CSS decedents than among non-CSS decedents (2.1 years and 2.5 years, respectively). CSS decedents who were African American lost 15.8 years of life, compared with 13.7 years for white CSS decedents. Among non-CSS decedents, the YPLL for African Americans was 11.7 years, compared with 9.2 years for whites, for whom YPLL was lowest. [A table summarizing these results is available as an online supplement to this letter at ps.psychiatryonline.org.] As a final step, an interaction term was entered in the regression model to assess whether a mental illness diagnosis had a differential effect on YPLL by race. This interaction was not significant.Although both racial minority status and a mental illness diagnosis contributed independently to premature mortality, African-American decedents with severe mental illness in this study did not have a differential vulnerability to premature mortality compared with white decedents with severe mental illness. Although premature mortality was higher among CSS decedents overall (2), racial differences in YPLL among CSS decedents were smaller than racial differences in YPLL in the non-CSS sample. This appears to be because YPLL was so much higher among the white CSS decedents. These findings provide further support for the addition of primary health care services to mental health treatment.Dr. Piatt is affiliated with the Department of Sociology, Hiram College, Hiram, Ohio.Acknowledgments and disclosuresThe author thanks Christian Ritter, Ph.D., Robin Shura, Ph.D., and Erica Hill, M.A., for helpful comments on drafts of this letter.The author reports no competing interests.References1 Williams DR : The health of US racial and ethnic populations. Journals of Gerontology Series B 60:53–62, 2005 Crossref, Medline, Google Scholar2 Piatt E , Munetz M , Ritter C : An examination of premature mortality among decedents with serious mental illness and those in the general population. Psychiatric Services 61:663–668, 2010 Link, Google Scholar3 Dowd JJ , Bengtson VL : Aging in minority populations: an examination of the double jeopardy hypothesis. Journal of Gerontology 33:427–436, 1978 Crossref, Medline, Google Scholar4 Arias E , Schauman WS , Eschbach K , et al.: The validity of race and Hispanic origin reporting on death certificates in the United States. Vital Health Statistics 148:1–23, 2008 Google Scholar FiguresReferencesCited byDetailsCited ByThe physical health of Māori with bipolar disorder15 September 2020 | Australian & New Zealand Journal of Psychiatry, Vol. 54, No. 11Drug and Alcohol Dependence, Vol. 151 Volume 62Issue 2 February 2011Pages 223-224 Metrics Acknowledgments and disclosuresThe author thanks Christian Ritter, Ph.D., Robin Shura, Ph.D., and Erica Hill, M.A., for helpful comments on drafts of this letter.The author reports no competing interests.PDF download History Published online 1 February 2011 Published in print 1 February 2011

Survival outcomes based on race in gastric carcinoma: A SEER database analysis.

5 Background: Gastric cancer is one of the leading causes of cancer related deaths worldwide with the incidence declining in the United States. However the prognosis remains poor with variable survivals being reported among different races. We analyzed the effect of race on patterns of disease presentation and survival rates using the Surveillance, Epidemiology, and End Results (SEER) database. Methods: A total of 9,851 patients were diagnosed with gastric cancer from year 2004 to 2007 were identified from SEER database. Age, race, TNM staging, grade, treatment modalities utilized and cancer specific survival was collected. Results: Out of 9,851 patients, 64.63% were white, 12.17% were black, and 13.04% were Asian-Pacific islanders. Median age was 73 years for whites, 70 years in blacks, and 71 years in Asians. Sex distribution amongst races was more or less similar with 58.83% of whites, 59.47% of blacks, and 54.24% of Asians being men. 23.62% of whites had T1 lesions, 28.10% had T2, 19.58% were T3 and 28.70% had T4 lesions. 26.76% of blacks presented with T1 lesions, 26.63% with T2, 16.08% with T3 and 30.53% with T4. 18.69% of Asians had T1 lesions, 26.84% with T2, 23.44% had T3 and 31.03% had T4 lesions. 37.80% of whites, 36.70% of blacks, and 44.44% of Asians had lymph node involvement. Tumor grade was similar among all races. Surgery was performed in 31.49% of whites, 33.13% of blacks, and 40.48% of Asians. 14.68% of whites, 14.10% of blacks, and 19.43 % of all Asians underwent radiation therapy. Median overall survival in localized disease was 44 months, 43 months and 98 months (p < 0.0001) while in regional disease it was 16 months, 15 months and 23 months in whites, blacks and Asians respectively (p < 0.0001). Median survival in distant disease was 4 months in both whites and blacks; it was 5 months in Asians (p < 0.0001). Conclusions: Cancer-specific survival in gastric carcinoma is significantly better in localized, regional and metastatic disease in Asians when compared to whites and blacks independent of T stage, grade, nodal involvement and treatment modalities utilized. The reason for this observation is unclear, exposure and genetic factors are potential causes and this needs to be investigated. No significant financial relationships to disclose.

Freedom to Make Choices for Health

In 1969 inaugural issue of School Health Review, Douglass (1) examined four major issues he felt were central to question of choices one has about health: (1) problems with health care delivery methods; (2) persistent poverty in our population and its impact on health; (3) systemic problems inherent in social and institutional arrangements, what he referred to as network of health and health related pathologies; and (4) difficulty communicating or clarifying values in society, as evidenced by our failure to reconcile values we preach with health care that we practice. To begin his thesis, he argued that a person must be understood as a totality rather than as a sum of component parts. To address this perspective, he believed that health professionals must embrace a multidisciplinary approach to health care. W.E.B. Dubois had expressed same opinion in a study 70 years earlier, addressing a health system which compared health statistics of blacks with those of whites. Even then, he challenged us to focus on the absolute condition rather than their relative status. (2(p. 148)) To provide some historical context for time in which Douglass' paper was written, we gathered statistics on key health indicators such as poverty rate, life expectancy and infant mortality. Poverty rate is a key indicator that defines very notion of choice and freedom, In 1966, whereas poverty rate for blacks was 41.8% compared to just 11.3% for whites, in 2008, poverty rate for blacks was 24.7% and 8.6% for whites. (3) As one could assume, gaps remain for other health indicators. In 1960, life expectancy was 70.6 years for whites and just 63.6 years for blacks. (4) Nearly 40 years later, there was still inequity between two groups. In 2007, life expectancy was 78.3 years for whites and 73.7 years for blacks. (5) Infant mortality rate (IMR) followed a similar pattern. In 1960, IMR was 22.9 for whites and 44.3 for blacks; (6) IMR in 2005 was 5.76 for whites and 13.63 for blacks. (7) Although many of these overall statistics have improved remarkably over last few decades, persistent gaps remain between whites and blacks. With all of progress in field of health care over last three decades, why do these staggering statistical differences still exist? These gaps reveal intergroup differences as well as intra-group differences that are not commonly examined. Intra-group differences, as will be seen later, often correspond to systemic problems that remained unaddressed. Are we free to make choices for health? When Douglass asked this question in 1969, he proposed that inherent structure of system makes it impossible for individuals to select health. Therefore, understanding meaning of choice (i.e., right, power, or ability to decide among selections or alternatives) provides a potentially useful perspective in studying persistent gaps in health inequity from late 1960s, to today. Furthermore, question of having choices in health care evokes memories of 2009 town hall debates (or shouting matches, as it were), in which question of health care reform became a polarizing discourse. This national debate is at core of question regarding choices for health care in context of four issues raised by Douglass: a broken down and unsustainable health care system, persistent poverty and plight of uninsured, health-related pathologies exemplified in roles of tobacco and food industries in today's health problems, and conflicts between American values (e.g., out of many, one; versus looking out for number one). When these four basic factors are combined, issues of choice and freedom to choose boil down to a question of available options and comparative benefits that may arise from each. Secondly, there is also notion that health choices refer specifically to health care. Yet when we explore context of health conditions, it is clear that health choices made long before clinical encounters create varying levels of vulnerability to ill health. …

Racial disparities in incidence and survival among 37,977 blacks and whites with multiple myeloma.

8115 Background: Multiple myeloma (MM) is the most common hematologic malignancy in blacks. Prior studies suggest poorer survival among blacks than whites; however, some smaller hospital-based studies suggest similar survival in equal access health systems. We conducted a large-scale, population-based study to evaluate racial disparities in MM incidence and MM-specific survival. Methods: Data were obtained from the National Cancer Institute's Surveillance, Epidemiology and End Results-9 Registry, covering new diagnoses of MM from 1973-2005 with follow-up through 2006. Age at diagnosis was grouped into three strata (<50, 50-69, and 70+ years). Incidence rates were calculated using SEER*Stat. Cumulative MM-specific survival was assessed by the Kaplan-Meier method and the log-rank test. Results: 37,977 MM patients (5,798 blacks; 28,939 whites) were identified. Mean age at diagnosis was 65.7 years for blacks and 70.0 years for whites (p<0.001). Incidence was 2-fold higher in blacks than whites (10.9 and 4.9 per 100,000 person-years, respectively). This disparity was significantly greater among younger patients (3-fold higher incidence among patients <50 years old). MM-specific survival was better in blacks than whites at 5 and 10 years of follow-up (p<0.001). After the introduction of novel therapies, 5-year MM-specific survival for whites improved (38% in 1973-1979 vs 56% in 2000-2005; p<0.001); significant improvement was not seen in blacks over this period. Conclusions: Our study shows for the first time that, despite a 4-5 year younger average age at MM diagnosis and greater incidence rates, MM-specific survival was greater for blacks than whites. Previously reported excess mortality in blacks is only seen clinically because MM is more common in blacks than whites. These somewhat paradoxical results suggest disease heterogeneity by race. Whites demonstrate a more pronounced survival benefit following recent treatment advances, likely reflecting access disparities; regardless, blacks continue to show superior survival in the era of novel therapies. Further studies are needed to improve our understanding of the molecular basis of these patterns to appreciate disease subtype-specific features. No significant financial relationships to disclose.

Race and Intensity of Post-Remission Therapy in Acute Myeloid Leukemia (AML).

Abstract 1012Poster Board I-34 Background:Disparities in survival between black and white patients (pts) exist for many malignancies, including AML. Potential causes include differential access to care; variable aggressiveness of therapy; and biological heterogeneity. Black men with AML have lower complete remission (CR) and overall survival (OS) rates than black women and whites, as shown in a previous Cancer and Leukemia Group B (CALGB) study in which induction therapies were defined, but subsequent treatment compliance and intensity was unknown. We investigated whether differences in post-remission therapy (PRT) might explain disparity in outcome. Methods:All pts with newly diagnosed AML treated with cytarabine-based induction therapy between 1997 and 2008 were included. PRT was defined as either cytarabine-based chemotherapy or bone marrow transplant (autologous or allogeneic) administered to pts achieving a CR and prior to relapse or in the setting of no relapse. PRT was coded according to intensity, in cumulative mg/m2 of cytarabine or mitoxantrone received, with BMT assigned the highest intensity of cytarabine. Data on known prognostic factors (age, white blood cell count (WBC) at diagnosis, pathologic subtype, AML etiology, cytogenetic risk groups (as defined by CALGB 8461)) were collected and controlled for in multivariable analyses. Time to PRT was measured in days from date of discharge after induction chemotherapy to date of PRT initiation, excluding patients with time to PRT >150 days, considered too long to be true consolidation. Comparisons between black and white pts were performed using linear, logistic, and proportional hazard regressions, exploring intensity of and time to PRT, and number of PRT cycles, along with potential interaction terms, controlling for known prognostic factors for outcome. Results:Of 460 pts, 421 had adequate data on PRT. Of these, 379 (90%) were white, 32 (8%) black, 10 (2%) other, and 46% were female. Similar to CALGB data, and compared to whites, blacks were younger (mean age 53.5 vs. 57.5 years, p=.11), had a higher proportion of favorable (18.8% vs. 12.7%) and poor risk (34.4% vs. 24.5%) cytogenetics (p=.28), and were less likely to attain a complete remission (CR, 66% vs. 73%, p=.39), though differences did not reach significance due to sample size. Other baseline characteristics, including reinduction rates, were similar. The 236 pts who received PRT included 18 blacks (56%) and 218 whites (58%, p=.89). In univariate analyses, for blacks vs. whites, median time to PRT initiation was 31 vs. 23 days (p=.33); cytarabine intensity was 66,654 mg/m2 vs. 50,630 mg/m2 (p=.26); and number of cycles was 2.4 vs. 2.1 (p=.41), respectively. Median time to PRT among all men was 24 days, compared to 21 days for all women (p=.09), and for pts <60 years was 22 days, vs. 24 days for >=60 years (p=.43). Median survival was 0.72 years in both black and white patients (p=.57). Among those receiving PRT, median survival was 3 years in blacks and 1.4 years in whites (p =.22); for pts not receiving PRT, median survival was.22 years in blacks and.32 years in whites (p =.25). In multivariate analyses, time to PRT was shorter for whites (HR=.25, p=.016), particularly when white men were compared to black men (HR=.12, p=.012), whereas no differences were found for women. Survival differences did not reach significance; nor was there an interaction for male and black race. Conclusions:Time to PRT is shorter for whites compared to blacks with AML, though cycle dose intensity and number are similar. Despite this, overall survival was not different between blacks and whites receiving PRT. In the post-remission setting, blacks and whites appear to receive similar chemotherapy management, and thus differential treatment aggressiveness and compliance are not explanations for varying outcome between races. Disclosures:No relevant conflicts of interest to declare.

Donor–Recipient Race Mismatch and Graft Survival After Pediatric Heart Transplantation

Black recipient race has been shown to predict poorer graft survival after pediatric heart transplantation. We analyzed our single-center experience comparing graft survival by race and the impact of donor-recipient race mismatch. One hundred sixty-nine consecutive primary pediatric heart transplant patients were analyzed by donor and recipient race (white recipient, 99; black recipient, 60; other, 10). The groups were similar in preoperative characteristics. There were fewer donor-recipient race matches in blacks compared with whites (10 versus 71; p < 0.0001). Although 30-day and 6-month graft survival was similar for black and white recipients (93.9% and 85.8% versus 93.3% and 83.3%, respectively), overall actuarial graft survival was significantly lower in blacks (p < 0.019). Blacks tended to have a higher incidence of positive retrospective crossmatch (n = 26, 43%) than whites (n = 29, 29%), but this was not statistically significant (p = 0.053). The median graft survival for black recipients was 5.5 years compared with 11.6 years for whites. Donor-recipient race mismatch predicted poorer graft survival (5-year graft survival 48.9% versus 72.3%; p = 0.0032). The median graft survival for donor-recipient race-matched patients was more than twice that for mismatched patients (11.6 years versus 4.4 years). Cox proportional hazard analysis showed that donor-recipient race mismatch neutralized the effect of race on graft survival. Graft survival after pediatric heart transplantation is inferior for black recipients compared with white recipients. These differences may be explained by a high incidence of donor-recipient race mismatch, which also predicts poorer outcome for all racial groups with pediatric heart transplantation. These data may have implications for future donor allocation schemes.

Longitudinal Trends in Use of Bone Mass Measurement Among Older Americans, 1999–2005

Bone mass measurement (BMM) is useful to identify persons with low bone mass who are at increased risk for fracture. Given the increased emphasis that is being placed on preventive services such as screening for osteoporosis, we evaluated trends in BMM among Medicare beneficiaries. We studied a 5% sample of Medicare beneficiaries >or=65 yr of age in 1999-2005. We identified claims for BMM tests performed in both facility and nonfacility settings, evaluated temporal trends in use of these tests, and described the proportion of tests attributable to each specialty of physicians submitting claims. We also assessed patterns of serial testing among individuals who were tested more than once. Claims data from all years were pooled to describe the proportion of persons in the population ever tested. From 1999 to 2005, use of central DXA increased by approximately 50%, and use of peripheral DXA declined. The greatest increases in central DXA occurred among internists, family practitioners, and gynecologists. In 1999, the proportion of 65-yr-old women tested was 8.4%; this increased to 12.9% in 2005. Corresponding proportions for men were 0.6% and 1.7%, respectively. Between 40% and 73% of persons receiving central DXA were retested, most at approximately 2-yr intervals. Aggregating data across all years for whites and blacks, 30.0% of women and 4.4% of men underwent central DXA at least once. We conclude that, although use of DXA steadily increased from 1999 to 2005, only approximately 30% of women and 4% of men at least 65 yr old had a central DXA study. Given the importance of central DXA to assess the risk of osteoporotic fractures, strategies to increase central DXA use to test at-risk persons are warranted.

Abstract 2307: Seattle Heart Failure Model Overestimates Time to Mortality in Patients Referred for Heart Transplantation

Background : Accurate determination of time to death in advanced heart failure (HF) patients is critical for appropriate transplant candidate selection. Recently, Seattle Heart Failure Model (SHFM) was introduced to assess HF prognosis, however it was developed from a general HF population and its accuracy in advanced HF patients has not been reported. Methods : We collected data on 51 advanced HF patients referred for transplant evaluation who died during follow-up (mean age 57.4±17.5 years, 70.1% male, and 56.9% white). Time to death prediction by the SHFM was assessed by plotting actuarial survival time vs. model error (=predicted-actual). Gender and race based stratified analysis were also performed. Results : Median ejection fraction was 0.15 (25%–75%: 0.10 – 0.25), heart rate was 87±19 bpm, and systolic blood pressure was 117±22 mmHg. Overall 90.2% patients were on ACE inhibitor or angiotensin receptor blockers, 82.4% on beta-blockers, and 74.6% had a defibrillator implanted. Median expected survival by the SHFM was 6.4 (3.8 –9.7) years. Median actual survival was 2.0 (1.1–3.9) years. Residual analysis showed that the SHFM overestimated survival by 3.8 (1.5– 6.5) years, p&lt;0.001, Fig 1 . Overall 86.3% patients lived shorter than projected survival. The SHFM overestimated survival more in black vs. white patients (4.5 years, 25%–75%: 2.3–7.9 years in blacks vs. 2.8 years, 25%–75%: 0.7– 6.0 years in whites, p=0.07). No significant gender differences were noted. Conclusion : The SHFM significantly overestimates survival in advanced HF patients referred for transplantation, especially in blacks. Further studies are needed to modify and validate the SHFM in these patients.

Genome-wide linkage analyses for age at diagnosis of hypertension and early-onset hypertension in the HyperGEN study

A genome-wide scan was performed to identify chromosomal regions related to age at diagnosis of hypertension and to early-onset hypertension in white and African American families from the Hypertension Genetic Epidemiology Network (HyperGEN). Age at diagnosis of hypertension was reported by participants at recruitment and standardized residuals adjusted for sex, study center, and body mass index were created. Participants were classified as having early-onset hypertension if their reported age at diagnosis was before 45 years in whites or before 35 years in African Americans. Variance component linkage analysis was performed for age at diagnosis and an affected sibpair linkage analysis was performed for early-onset hypertension, both implemented in GENEHUNTER. In whites, the heritability of diagnosis age was estimated to be 35% and the maximum LOD score was found on chromosome 1 at 123 cM (LOD = 1.48). The maximum LOD score for early-onset hypertension was located on chromosome 18 at 69 cM (LOD = 1.21). In African Americans, the heritability of age of diagnosis was estimated to be 42% and the maximum LOD scores were found on chromosome 4 at 120 cM (LOD = 2.44) and on chromosome 15 at 60 cM (LOD = 2.31). The maximum LOD for early-onset hypertension in African Americans was also on chromosome 4 at 153 cM (LOD = 2.05) and overlies the mineralocorticoid receptor. Although these results report modest LOD scores, several of these loci have been previously reported to be linked to hypertension and blood pressure, lending further support that genes related to the risk of hypertension may be at these loci.

Poster 17: Functional outcome for asian americans at a traumatic brain injury model systems center

Objective: To compare the demographics and functional outcome for Asian Americans and whites treated at a Traumatic Brain Injury Model Systems (TBIMS) center. Design: Prospective, single-center trial. Participants: 30 Asian Americans and 133 whites admitted to a TBIMS center between February 1989 and July 2000. Subjects had to meet all the criteria to be entered into the Traumatic Brain Injury National Database. Interventions: Not applicable. Main Outcome Measures: All information was collected at the time of acute admission as well as at rehabilitation admission and discharge. Demographic data (gender, age), preinjury characteristics (prior employment, level of education, drug use), Glasgow Coma Scale (GCS), and outcome scales (Disability Rating Scale [DRS], FIM™ instrument) were obtained. Results: Most Asians (67%) and whites (74%) were men. More Asians were either students (20% vs 7%) or homemakers (10% vs 1%) preinjury. The average age at the time of injury was 30.7 years for Asians and 39.3 years for whites. Average admission GCS score was 9.1 for Asians and 10.5 for whites. Prior traumatic brain injury (TBI) requiring hospitalization was 7% for Asians and 21% for whites. The mean DRS change score ± SD was 8.5±4.5 for Asians and 6.8±4.3 for whites. Conclusion: Preinjury employment status differed between Asians and whites, with more Asians being students or homemakers. The history of TBI was significantly lower for Asians than whites. Asians were generally younger at the time of injury. DRS change was slightly better for Asians. There were no other statistically significant differences between both groups in DRS or FIM scores.

Autopsy findings in a human immunodeficiency virus-infected population over 2 decades: influences of gender, ethnicity, risk factors, and time.

To examine autopsy pathology in an urban population infected with the human immunodeficiency virus (HIV) and to determine if age at death and disease frequencies are associated with gender, HIV risk factors, ethnicity, and therapeutic era. Retrospective analysis of autopsy data from 394 HIV-infected adults. The population was divided into 3 therapeutic eras for analysis: group A, 1979-1986; group B, 1987-1995; and group C, 1996-2000. Women died at significantly younger ages than men (mean +/- SEM age, 38.9 +/- 1.0 years vs 42.5 +/- 0.64 years), even after adjustment for risk factors, ethnicity, and therapeutic era. This age discrepancy occurred despite a lower prevalence of arteriosclerosis, cachexia, and hepatitis B in women and no significant differences in the frequencies of other infectious diseases. Whites had a longer survival than patients of other ethnicities (mean age at death, 44.7 +/- 1.2 years for whites, 39.9 +/- 0.80 years for blacks, and 41.3 +/- 0.87 years for Hispanic individuals). Renal, cardiac, and splenic pathologies, Mycobacterium avium-intracellulare (MAI) infection, and cachexia were more common in blacks than in whites and/or Hispanic individuals, and cytomegalovirus and systemic lymphoma were more common in whites and Hispanic individuals than in blacks. Diseases associated with intravenous drug use were hepatitis C, cirrhosis, and tuberculosis; those with all sexual risk factors, cytomegalovirus infection, herpes simplex virus infection, and Pneumocystis carinii pneumonia; and those with homosexual risk, Kaposi sarcoma and MAI infection. The prevalence of many disease entities changed over time: compared with the other groups, group C had lower prevalences of many viral and fungal illnesses, MAI infection, systemic lymphoma, cachexia, and Kaposi sarcoma and higher prevalences of hepatitis, cirrhosis, arteriosclerosis, staphylococcal and streptococcal infections, and traumatic lesions. When the data were adjusted for changing demographic and risk composition, the only significant changes in disease frequency for period C were decreased prevalences of PCP and Kaposi sarcoma and increased prevalences of cirrhosis and arteriosclerosis. Significant gender- and ethnicity-related differences in age of death occurred in this HIV-infected population, and these differences were not explained by the frequencies of diseases. The lower prevalences of PCP and Kaposi sarcoma in group C are likely a reflection of the impact of potent therapies on causes of mortality. The higher prevalences of cirrhosis and arteriosclerosis suggest that entities not targeted by antiretroviral reconstitution of immunity will play an increasingly important role in HIV-related mortality in the future.

Autopsy findings in a human immunodeficiency virus-infected population over 2 decades: Influences of gender, ethnicity, risk factors, and time

Objectives To examine autopsy pathology in an urban population infected with the human immunodeficiency virus (HIV) and to determine if age at death and disease frequencies are associated with gender, HIV risk factors, ethnicity, and therapeutic era. Design and methods Retrospective analysis of autopsy data from 394 HIV-infected adults. The population was divided into 3 therapeutic eras for analysis: group A, 1979-1986; group B, 1987-1995; and group C, 1996-2000. Results Women died at significantly younger ages than men (mean +/- SEM age, 38.9 +/- 1.0 years vs 42.5 +/- 0.64 years), even after adjustment for risk factors, ethnicity, and therapeutic era. This age discrepancy occurred despite a lower prevalence of arteriosclerosis, cachexia, and hepatitis B in women and no significant differences in the frequencies of other infectious diseases. Whites had a longer survival than patients of other ethnicities (mean age at death, 44.7 +/- 1.2 years for whites, 39.9 +/- 0.80 years for blacks, and 41.3 +/- 0.87 years for Hispanic individuals). Renal, cardiac, and splenic pathologies, Mycobacterium avium-intracellulare (MAI) infection, and cachexia were more common in blacks than in whites and/or Hispanic individuals, and cytomegalovirus and systemic lymphoma were more common in whites and Hispanic individuals than in blacks. Diseases associated with intravenous drug use were hepatitis C, cirrhosis, and tuberculosis; those with all sexual risk factors, cytomegalovirus infection, herpes simplex virus infection, and Pneumocystis carinii pneumonia; and those with homosexual risk, Kaposi sarcoma and MAI infection. The prevalence of many disease entities changed over time: compared with the other groups, group C had lower prevalences of many viral and fungal illnesses, MAI infection, systemic lymphoma, cachexia, and Kaposi sarcoma and higher prevalences of hepatitis, cirrhosis, arteriosclerosis, staphylococcal and streptococcal infections, and traumatic lesions. When the data were adjusted for changing demographic and risk composition, the only significant changes in disease frequency for period C were decreased prevalences of PCP and Kaposi sarcoma and increased prevalences of cirrhosis and arteriosclerosis. Conclusions Significant gender- and ethnicity-related differences in age of death occurred in this HIV-infected population, and these differences were not explained by the frequencies of diseases. The lower prevalences of PCP and Kaposi sarcoma in group C are likely a reflection of the impact of potent therapies on causes of mortality. The higher prevalences of cirrhosis and arteriosclerosis suggest that entities not targeted by antiretroviral reconstitution of immunity will play an increasingly important role in HIV-related mortality in the future.

Linkage of left ventricular contractility to chromosome 11 in humans: The HyperGEN Study.

Impaired left ventricular (LV) contractility is a major cause of cardiovascular death, especially congestive heart failure. The identification of susceptibility genes that contribute to impaired LV contractility may uncover mechanisms underlying LV contractile impairment and the development of congestive heart failure. The Hypertension Genetic Epidemiology Network (HyperGEN) collected echocardiographic measurements of myocardial contractility in a large biethnic sample of hypertensive siblings (390 blacks and 398 whites in 179 and 165 sibships, respectively). All participants expressed hypertension before age 60 years, and the mean age of siblings was 52 years in blacks and 61 years in whites. We adjusted myocardial contractility for gender, age, and age(2), and we calculated standardized residuals separately for men and women in both ethnic groups. We conducted multipoint variance components linkage analysis using GENEHUNTER2 and 387 anonymous markers (CHCL8 marker set). We found evidence for significant linkage to a microsatellite marker, D11S1993 (lod, 3.93 in blacks), approximately 54 cM from the tip of the short arm of chromosome 11, that accounted for 72% of the phenotypic variation in LV contractility. A chromosome 22 locus showed suggestive evidence for linkage (lod, 2.83 in whites and 1.15 in blacks). The chromosome 11 peak coincides with the region containing myosin-binding protein C. Mutations in this gene are linked to familial hypertrophic cardiomyopathy. Our results show strong evidence for linkage of a region of chromosome 11 with LV contractility in blacks and suggest that an important gene for impaired LV contractility is harbored in this region.

Racial differences in the outcome of left ventricular dysfunction.

Population-based studies have found that black patients with congestive heart failure have a higher mortality rate than whites with the same condition. This finding has been attributed to differences in the severity, causes, and management of heart failure, the prevalence of coexisting conditions, and socioeconomic factors. Although these factors probably account for some of the higher mortality due to congestive heart failure among blacks, we hypothesized that racial differences in the natural history of left ventricular dysfunction might also have a role. Using data from the Studies of Left Ventricular Dysfunction (SOLVD) prevention and treatment trials, in which all patients received standardized therapy and follow-up, we conducted a retrospective analysis of the outcomes of asymptomatic and symptomatic left ventricular systolic dysfunction among black and white participants. The mean (+/-SD) follow-up was 34.2+/-14.0 months in the prevention trial and 32.3+/-14.8 months in the treatment trial among the black and white participants. The overall mortality rates in the prevention trial were 8.1 per 100 person-years for blacks and 5.1 per 100 person years for whites. In the treatment trial, the rates were 16.7 per 100 person-years and 13.4 per 100 person-years, respectively. After adjustment for age, coexisting conditions, severity and causes of heart failure, and use of medications, blacks had a higher risk of death from all causes in both the SOLVD prevention trial (relative risk, 1.36; 95 percent confidence interval, 1.06 to 1.74; P=0.02) and the treatment trial (relative risk, 1.25; 95 percent confidence interval, 1.04 to 1.50; P=0.02). In both trials blacks were also at higher risk for death due to pump failure and for the combined end point of death from any cause or hospitalization for heart failure, our two predefined indicators of the progression of left ventricular systolic dysfunction. Blacks with mild-to-moderate left ventricular systolic dysfunction appear to be at higher risk for progression of heart failure and death from any cause than similarly treated whites. These results suggest that there may be racial differences in the outcome of asymptomatic and symptomatic left ventricular systolic dysfunction.

The Continuing Significance of Race Revisited: A Study of Race, Class, and Quality of Life in America, 1972 to 1996

More than a decade ago, we (Thomas and Hughes 1986) demonstrated that the subjective well-being of African Americans in the United States was significantly and consistently lower than that for whites over the 14-year period from 1972 to 1985. Since then, evidence has accumulated on several important dimensions of well-being that African Americans fare as well as or better than whites, suggesting a change in the pattern observed for nearly 40 years. Using data from the General Social Survey (GSS) for the period 1972 to 1996, we show that quality of life continues to be worse for African Americans than it is for whites, although anomia and mistrust have increased a little more rapidly in recent years for whites than for blacks. Racial disparities in quality of life do not vary by and are not explained by socioeconomic status. Although racial inequality appears to be the primary cause of these differences, the exact processes producing them are as yet unknown.

Time trend of female breast carcinoma in situ by race and histology in Connecticut, USA.

A rapid increase of female breast cancer has been reported in many areas of the world and the reasons are not fully understood. While some have attributed the increase to the increasing detection of early stage breast cancer through mammography screening, few studies have directly examined the time trend of in situ breast cancer specifically. This study included all incident cases of female breast carcinoma in situ reported to the Connecticut Tumor Registry between 1973 and 1992. The age-adjusted incidence rates and age-specific incidence rates were calculated by histology and by race. The age-adjusted incidence rates were standardised to the 1970 United States standard million population. The study found that the overall age-adjusted incidence rate of in situ breast cancer has increased dramatically, from 3.53/100000 in 1973-1975 to 17.51/100000 in 1991-1992. The increase was not uniform during the past two decades of cancer registration. In fact, most of the observed rise has occurred since the early 1980s. This increase was found in both Caucasians and Blacks. The results by histology indicate that the dramatic increase in carcinoma in situ is mostly attributable to an increase in ductal carcinoma in situ. The increase was also observed in all age groups 40 years and over. These results are consistent with the use pattern and the reported effect of mammography screening. Therefore, these results are qualitatively consistent with the idea that mammography screening is largely responsible for the recent upsurge in female breast cancer incidence in this population. The study also found that the age group 40-49 years in whites experienced a rapid increase in incidence that began in the same time period as the older age groups, but it has since levelled off. The potential impact of the highly publicized debate regarding the efficacy of mammography in this age group in recent years is discussed.

THE INCIDENCE OF CYSTIC FIBROSIS

We develop a statistical model for estimating cystic fibrosis (CF) incidence among infants born in the U.S.A. that accounts for under-diagnosis due to death prior to diagnosis and we apply it to the Cystic Fibrosis Foundation Patient Registry data for the years 1989 to 1991. The resulting estimate of incidence relative to live births among whites is 1:3419 while that among non-whites is 1:12,163. As a by-product of the modelling approach, estimates of the underlying average diagnosis age given survival to diagnosis are 4.09 years for whites and 4.55 years for non-whites, but this difference was not statistically significant and appears to demonstrate that diagnosis efforts may be approximately the same for whites and non-whites. Also, as another by-product of the modelling approach, CF mortality was estimated as more severe for females than males and marginally more severe for non-whites than whites. A variety of statistical methods underlie achievement of these results, including semi-parametric maximum likelihood, survival analysis, multiple imputation and bootstrap techniques.

Black Adolescent Females: A Comparison of Early versus Late Coital Initiators

Practitioners, researchers, educators, and policymakers continue to express concern about the increasing number of adolescents who are becoming sexually active. This issue is important because of the established association between early coital experiences and increased pregnancy risk, early childbearing, and increased contraction of sexually transmitted diseases, especially human immunodeficiency virus (HIV) (Hayes, 1987; Jessor, Costa, Jessor, & Donovan, 1983). Much attention has been given to the relatively young age at sexual initiation among black youth compared to those of other races. In fact, data show that urban black females become sexually active at a mean age of 14.4 years; the comparable age is 16.2 years for whites (Moore & Erickson, 1985; Zabin, Smith, Hirsch, & Hardy, 1986; Zelnik & Shah, 1983). Other researchers report that black females are more likely to become pregnant during adolescence (Henshaw & VanVort, 1989), are 2.5 times as likely to carry the pregnancy to term, and 5.5 times as likely to be single mothers as are their white counterparts (Bumpass & McLanahan, 1987). Some studies, however, are based on information obtained from convenient, clinical nonprobability samples representing low-income blacks and middle-income whites. Given this constraint, some researchers have expressed concern about the generalizability of studies on adolescent sexuality (Bell-Scott & McKenry, 1986; Murry, 1992; Weddle, McKenry, 8L Leigh, 1988). Further, it is not uncommon for researchers to exclude information about internal family processes and to fail to consider within-group differences in attempting to understand issues of sexuality among blacks. In view of these concerns, the main goal of the present study is to identify factors that contribute to the timing of first sexual intercourse among a nationally representative sample of black adolescent females. Toward this end, (a) socioeconomic indicators (e.g., family income, mothers' educational status, and mothers' employment status), (b) parental control (e.g., degree of strictness), (c) family structure, (d) family sexuality socialization, (e) pubertal timing, (f) adolescent's sexual knowledge about reproduction and contraception, (g) social autonomy (e.g., adolescent's employment patterns), and (h) religiosity (e.g., frequency of church attendance) were examined for their usefulness in discriminating adolescents who will become sexually active at age 15 years or younger from those who wait until age 18 years and beyond. REVIEW OF RELATED RESEARCH SOCIOECONOMIC STATUS Social and economic status of families seem to be fundamentally related to adolescent sexual behavior patterns. Most studies, however, do not consider variation in family socioeconomic status in attempting to understand and explain black adolescent sexuality. In recent years, a few studies have revealed a lower incidence of early coital behavior among black adolescent females from middle-income families and among those whose mothers had high educational attainment (Hogan & Kitagawa, 1985; Leigh, Weddle, & Loewen, 1988). On the other hand, daughters of low-income families are at greater risk because early sexual experimentation appears to be more socially acceptable in their neighborhoods (Hogan & Kitagawa, 1985). In addition, lack of perceived or real opportunities, in terms of marriage, education, and employment, may precipitate early coital behavior among low-income youth as a pathway to adult status (Abrahamse, Morrison, & Waite, 1988; Hogan & Kitagawa, 1985). However, to test the generalizability of this relationship, there is a need to examine this phenomenon in nationally representative samples. PARENTAL CONTROL Empirical data supporting the association between parental control and adolescent sexual behavior indicate that daughters are less likely to initiate sexual intercourse at a young age when their parents define limits and supervise dating activities (Abrahamse et al. …

South Africa: The sustainable development challenge

inequalities of any country in the world,' there is serious overcrowding in the townships, squatter camps and environmentally degraded homelands, the economy remains heavily dependent on the export of non-renewable minerals with little beneficiation and a country with a rich racial and cultural mix has been bitterly divided by institutionalised racial segregation. Raising the challenge of sustainable development can help the South African policy debate go forward in new directions. At the heart of the problem is how best to move from separate development to sustainable development. The most pressing sustainable development challenge facing the country is improving the livelihoods of the poorest. As a result of the apartheid system the black population was uniquely disadvantaged. Per capita income of the black population in 1990 was only 12% of that of the whites and for coloureds and Indians it remained appalling low, 25% and 35% respectively.2 Two-thirds of the African population and half of the total population live below the poverty datum line according to the Foundation for Research Development, while in the rural areas the number of the African population living below the poverty datum line rises to four-fifths.3 Although the ten homelands account for only 14% of the total land area, 44% of the total population live here and population density is 101 per square kilometre compared with the country average of 32 per square kilometre. Life expectancy at birth is 58 years for blacks and 70 years for whites. Inequality was built into the system through unequal expenditure on health, education and all social services; expropriation of black rights to use and benefit from the natural resource base of the country and discrimination against any free and full black participation in the modernising economy, either as entrepreneurs with access to credit and services, or as skilled workers competing on a par with white colleagues. Segregation was institutionalised and was reinforced by negative discrimination across the board against the non-white population. Improving the livelihoods of the poorest means finding ways for people to Barry Munslow is a Reader in the School of Politics and Communication Studies, University of Liverpool. Patrick Fitzgerald is the Director of the Graduate School of Public and Development Management, University of the Witwatersrand.

KIDNEY TRANSPLANTS IN BLACK RECIPIENTS

Primary kidney transplants from living related and cadaveric donors to black recipients failed twice as rapidly as those to white recipients in data reported to the United Network for Organ Sharing Scientific Renal Transplant Registry between 1987 and 1991. The projected half-life for 132 HLA-identical sibling donor transplants in blacks was 15 years versus 29 years for 1,033 whites (P<0.001). For recipients of cadaveric grafts, the half-lives were 5 years for blacks (n=5,282) and 10 years for whites (n=14,917). The 1-year graft survival rates and half-lives improved with HLA matching in both blacks and whites, but the 2-fold difference in long-term survival rates persisted even among recipients of well-matched grafts. With a zero HLA-A,B-mismatched donor, blacks had an 8-year half-life, compared with 17 years for whites (P<0.001). The racial difference was most marked in young adults, with a 15–20% disparity at 3 years between blacks and whites aged 16–30. Pediatric and older black patients had 3-year graft survival rates similar to those of whites. Antilymphocyte globulin or OKT3 prophylaxis improved graft survival by 2% at 1 year and 5% at 2 years among blacks, but the half-life remained 5.6 years. In contrast to these findings in the United States, 63 blacks transplanted in Canada had the same short- and long-term graft survival as whites, suggesting an important long-term influence of the health care system and socioeconomic factors. In addition to improved access to health care and improved HLA typing of blacks, more black donors are needed to provide better matched transplants for blacks awaiting transplants.