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CORK Bibliography: Mortality

81 citations. September 2011 to present

Prepared: March 2012

Amari E; Rehm J; Goldner E; Fischer B. Nonmedical prescription opioid use and mental health and pain comorbidities: A narrative review. (review). Canadian Journal of Psychiatry 56(8): 495-502, 2011. (77 refs.)

Objective: In North America, the prevalence of nonmedical prescription opioid use (NMPOU), and morbidity and mortality related to prescription opioid analgesics (POAs) has risen sharply. Epidemiologic studies have suggested a high prevalence of mental health and pain comorbidities in NMPOU samples. Given the potential importance for interventions, a narrative review was conducted on studies reporting data on the co-occurrence of NMPOU with mental health problems and pain symptoms in general, treatment, or special populations. Method: A search of MEDLINE, PubMed, PsycINFO, and Web of Science using defined search terms yielded 74 studies on NMPOU and mental health and (or) pain. Thirty-nine studies published between 1997 and 2009 were included in the review-based on the data they provided on NMPOU and mental health and pain comorbidities. Results: Our review found strong associations between NMPOU and the comorbidities of interest. Associations between NMPOU and mental health were strongest for depression (OR range 1.2 to 4.3) followed by anxiety disorders (OR range 1.2 to 3.0) in general and treatment populations. The prevalence of pain ranged from 14.5% to 61.5% in general, treatment, and street drug user samples reporting NMPOU. Conclusions: The extensive associations observed between NMPOU and mental health and pain comorbidities suggest that effective preventive or treatment interventions for NMPOU must consider and attend to these comorbidities. As POAs are widely available and used in North America, POAs may increasingly be used in nonmedical ways for pain or mental health problems not effectively diagnosed or treated.

Aune E; Roislien J; Mathisen M; Thelle DS; Otterstad JE. The "smoker's paradox" in patients with acute coronary syndrome: A systematic review. (review). BMC Medicine 9: AR 97, 2011. (39 refs.)

Background: Smokers have been shown to have lower mortality after acute coronary syndrome than nonsmokers. This has been attributed to the younger age, lower co-morbidity, more aggressive treatment and lower risk profile of the smoker. Some studies, however, have used multivariate analyses to show a residual survival benefit for smokers; that is, the "smoker's paradox". The aim of this study was, therefore, to perform a systematic review of the literature and evidence surrounding the existence of the "smoker's paradox". Methods: Relevant studies published by September 2010 were identified through literature searches using EMBASE (from 1980), MEDLINE (from 1963) and the Cochrane Central Register of Controlled Trials, with a combination of text words and subject headings used. English-language original articles were included if they presented data on hospitalised patients with defined acute coronary syndrome, reported at least in-hospital mortality, had a clear definition of smoking status (including ex-smokers), presented crude and adjusted mortality data with effect estimates, and had a study sample of > 100 smokers and > 100 non-smokers. Two investigators independently reviewed all titles and abstracts in order to identify potentially relevant articles, with any discrepancies resolved by repeated review and discussion. Results: A total of 978 citations were identified, with 18 citations from 17 studies included thereafter. Six studies (one observational study, three registries and two randomised controlled trials on thrombolytic treatment) observed a "smoker's paradox". Between the 1980s and 1990s these studies enrolled patients with acute myocardial infarction (AMI) according to criteria similar to the World Health Organisation criteria from 1979. Among the remaining 11 studies not supporting the existence of the paradox, five studies represented patients undergoing contemporary management. Conclusion: The "smoker's paradox" was observed in some studies of AMI patients in the pre-thrombolytic and thrombolytic era, whereas no studies of a contemporary population with acute coronary syndrome have found evidence for such a paradox.

Bolin K; Borgman B; Gip C; Wilson K. Current and future avoidable cost of smoking - Estimates for Sweden 2007. Health Policy 103(1): 83-91, 2011

To estimate current and future avoidable smoking-attributable costs in Sweden for the year 2007. Disease specific smoking-attributable proportions were calculated for Swedish smoking patterns and applied to estimate costs for smoking-related diseases based on data from public registers. Avoidable future effects of smoking were calculated employing a Markov simulation model. The estimated total cost in 2007 was USD 1.6 billion, or USD 181 per capita. Healthcare (direct) cost accounted for 30% of the total cost. The number of deaths was 97 per 100,000 inhabitants (79 in 2001); the number of years of potential life lost 1,227 per 100,000 inhabitants (1012 in 2001); and the number of years of potential productive life lost 226 (185 in 2001) per 100,000 inhabitants. Avoidable future lifetime costs, per 100,000 inhabitants, amounted to USD 19 million (healthcare), 14,000 years of potential life lost, corresponding to a present value of USD 158 million. Total avoidable cost of current smoking amounted to USD 16 billion. In spite of declining smoking-prevalence rates during the last 30 years, smoking-attributable deaths increased between 2001 and 2007. The number of life years lost per death decreased somewhat, indicating that the age distribution of those dying shifted further towards older age. Simulations indicate that smoking-cessation among young smokers yields considerable more benefits each year than smoking-cessation among older smokers. The health benefits that accrued in 2007, as a result of declining smoking prevalence since 1980, correspond to more than the total cost of smoking in that year.

Bolin K; Borgman B; Gip C; Wilson K. Current and future avoidable cost of smoking: Estimates for Sweden 2007. Health Policy 103(1): 83-91, 2011. (33 refs.)

Objective: To estimate current and future avoidable smoking-attributable costs in Sweden for the year 2007. Design: Disease specific smoking-attributable proportions were calculated for Swedish smoking patterns and applied to estimate costs for smoking-related diseases based on data from public registers. Avoidable future effects of smoking were calculated employing a Markov simulation model. Results: The estimated total cost in 2007 was USD 1.6 billion, or USD 181 per capita. Healthcare (direct) cost accounted for 30% of the total cost. The number of deaths was 97 per 100,000 inhabitants (79 in 2001); the number of years of potential life lost 1,227 per 100,000 inhabitants (1012 in 2001); and the number of years of potential productive life lost 226 (185 in 2001) per 100,000 inhabitants. Avoidable future lifetime costs, per 100,000 inhabitants, amounted to USD 19 million (healthcare), 14,000 years of potential life lost, corresponding to a present value of USD 158 million. Total avoidable cost of current smoking amounted to USD 16 billion. Conclusion: In spite of declining smoking-prevalence rates during the last 30 years, smoking-attributable deaths increased between 2001 and 2007. The number of life years lost per death decreased somewhat, indicating that the age distribution of those dying shifted further towards older age. Simulations indicate that smoking-cessation among young smokers yields considerable more benefits each year than smoking-cessation among older smokers. The health benefits that accrued in 2007, as a result of declining smoking prevalence since 1980, correspond to more than the total cost of smoking in that year.

Bozbas SS; Yilmaz EB; Dogrul I; Ergur FO; Savas N; Eyuboglu F et al. Preoperative pulmonary evaluation of liver transplant candidates: Results from 341 adult patients. Annals of Transplantation 16(3): 88-96, 2011. (22 refs.)

Background: Pulmonary disorders are among the commonly encountered and prognostically important problems in patients with chronic liver disease. To define the prevalence and types of respiratory disorders in patients with advanced liver disease evaluated for liver transplant (LT) candidacy, and to determine factors affecting postoperative outcome. Material/Methods: The records of 341 adult patients evaluated for LT candidacy were retrospectively examined. Demographic, clinical and laboratory data including chest X-ray, spirometry and echocardiography results were collected. Postoperative pulmonary complications and mortality rates were determined. Results: With a mean age of 45.1 years, 73 (21.4%) patients presented with respiratory symptoms or signs. The most common radiographic abnormality on chest X-ray was right diaphragm elevation (53.2%). Hypoxemia was detected in 38.1% of the patients. Pulmonary hypertension was detected in 100 of 327 (30.6%) patients on Doppler echocardiography. There were 141 patients who underwent surgery. Postoperative pulmonary complications developed in 60 patients, with pneumonia being the most prevalent complication (n=28). Smoking, emphysema, abnormal spirometry, pulmonary hypertension, hypoxia and orthodeoxia were found to be factors associated with increased postoperative pulmonary complications (P < 0.05 for all). Mortality rate was 24.1% (n=34) and found to be significantly higher in patients who developed a postoperative complication than in those who did not (38.7% vs. 13.8%, respectively; p=0.001). Conclusions: The authors' findings indicate that pulmonary disorders impact prognosis and are common in patients evaluated for LT candidacy. Postoperative pulmonary complication is one of the major factors affecting mortality. Therefore, in order to increase the success of the transplant operation, a thorough preoperative pulmonary evaluation is of paramount importance.

Breslow RA; Chen CM; Graubard BI; Mukamal KJ. Prospective study of alcohol consumption quantity and frequency and cancer-specific mortality in the US population. American Journal of Epidemiology 174(9): 1044-1053, 2011. (22 refs.)

Prospective associations between quantity and frequency of alcohol consumption and cancer-specific mortality were studied using a nationally representative sample with pooled data from the 1988, 1990, 1991, and 1997-2004 administrations of the National Health Interview Survey (n = 323,354). By 2006, 8,362 participants had died of cancer. Cox proportional hazards regression was used to estimate relative risks. Among current alcohol drinkers, for all-site cancer mortality, higher-quantity drinking (>drinks on drinking days vs. 1 drink on drinking days) was associated with increased risk among men (relative risk (RR) = 1.24, 95% confidence interval (CI): 1.09, 1.41; P for linear trend = 0.001); higher-frequency drinking (> days/week vs. <1 day/week) was associated with increased risk among women (RR = 1.32, 95% CI: 1.13, 1.55; P-trend < 0.001). Lung cancer mortality results were similar, but among never smokers, results were null. For colorectal cancer mortality, higher-quantity drinking was associated with increased risk among women (RR = 1.93, 95% CI: 1.17, 3.18; P-trend = 0.03). Higher-frequency drinking was associated with increased risk of prostate cancer (RR = 1.55, 95% CI: 1.01, 2.38; P for quadratic effect = 0.03) and tended to be associated with increased risk of breast cancer (RR = 1.44, 95% CI: 0.96, 2.17; P-trend = 0.06). Epidemiologic studies of alcohol and cancer mortality should consider the independent effects of quantity and frequency.

Brizer D. Death, drugs, and rock and roll. (Chapter 1). IN: Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. This is the introductory chapter to Part I which sets forth basic constructs of addiction medicine. This includes discusssion of the disease concept, abstinence as a treatment goal, medical sequelae of addiction, the relationship of substance use and suicide. psychotherapic paradigms, and drug therapies.

Bukowski R; Carpenter M; Conway D; Coustan D; Dudley DJ; Goldenberg RL et al. Association between stillbirth and risk factors known at pregnancy confirmation. Journal of the American Medical Association 306(22): 2469-2479, 2011. (32 refs.)

Context: Stillbirths account for almost half of US deaths from 20 weeks' gestation to 1 year of life. Most large studies of risk factors for stillbirth use vital statistics with limited data. Objective: To determine the relation between stillbirths and risk factors that could be ascertained at the start of pregnancy, particularly the contribution of these factors to racial disparities. Design, Setting, and Participants: Multisite population-based case-control study conducted between March 2006 and September 2008. Fifty-nine US tertiary care and community hospitals, with access to at least 90% of deliveries within 5 catchment areas defined by state and county lines, enrolled residents with deliveries of 1 or more stillborn fetuses and a representative sample of deliveries of only live-born infants, over-sampled for those at less than 32 weeks' gestation and those of African descent. Main Outcome Measure: Stillbirth. Results: Analysis included 614 case and 1816 control deliveries. In multivariate analyses, the following factors were independently associated with stillbirth: non-Hispanic black race/ethnicity (23.1% stillbirths, 11.2% live births) (vs non-Hispanic whites; adjusted odds ratio [AOR], 2.12 [95% CI, 1.41-3.20]); previous stillbirth (6.7% stillbirths, 1.4% live births); nulliparity with (10.5% stillbirths, 5.2% live births) and without (34.0% stillbirths, 29.7% live births) previous losses at fewer than 20 weeks' gestation (vs multiparity without stillbirth or previous losses; AOR, 5.91 [95% CI, 3.18-11.00]; AOR, 3.13 [95% CI, 2.06-4.75]; and AOR, 1.98 [95% CI, 1.51-2.60], respectively); diabetes (5.6% stillbirths, 1.6% live births) (vs no diabetes; AOR, 2.50 [95% CI, 1.39-4.48]); maternal age 40 years or older (4.5% stillbirths, 2.1% live births) (vs age 20-34 years; AOR, 2.41 [95% CI, 1.24-4.70]); maternal AB blood type (4.9% stillbirths, 3.0% live births) (vs type O; AOR, 1.96 [95% CI, 1.16-3.30]); history of drug addiction (4.5% stillbirths, 2.1% live births) (vs never use; AOR, 2.08 [95% CI, 1.12-3.88]); smoking during the 3 months prior to pregnancy (<10 cigarettes/d, 10.0% stillbirths, 6.5% live births) (vs none; AOR, 1.55 [95% CI, 1.02-2.35]); obesity/overweight (15.5% stillbirths, 12.4% live births) (vs normal weight; AOR, 1.72 [95% CI, 1.22-2.43]); not living with a partner (25.4% stillbirths, 15.3% live births) (vs married; AOR, 1.62 [95% CI, 1.15-2.27]); and plurality (6.4% stillbirths, 1.9% live births) (vs singleton; AOR, 4.59 [95% CI, 2.63-8.00]). The generalized R(2) was 0.19, explaining little of the variance. Conclusion: Multiple risk factors that would have been known at the time of pregnancy confirmation were associated with stillbirth but accounted for only a small amount of the variance in this outcome.

Cena H; Fonte ML; Turconi G. Relationship between smoking and metabolic syndrome. Nutrition Reviews. (review) 69(12): 745-753, 2011. (121 refs.)

Obesity and smoking are important causes of morbidity and mortality worldwide. The diseases and conditions associated with smoking make tobacco use one of the leading causes of death worldwide. In the World Health Organization European region, overweight and obesity are responsible for many chronic diseases, causing more than one million deaths each year. Smoking cessation is associated with a significantly reduced mortality risk in every body-mass-index group. Reductions in smoking and obesity would increase both the psychophysical well-being of the population and its economic productivity; it would also reduce the direct costs of pharmacological therapies and other forms of treatment. The aim of this review is to critically evaluate how tobacco smoking and obesity interact to reduce life expectancy, and to offer a comprehensive view of this issue that should be useful for clinical practice.

Chahine T; Schultz BD; Zartarian VG; Xue JP; Subramanian SV; Levy JI. Modeling joint exposures and health outcomes for cumulative risk assessment: The Case of radon and smoking. International Journal of Environmental Research and Public Health 8(9): 3688-3711, 2011. (51 refs.)

Community-based cumulative risk assessment requires characterization of exposures to multiple chemical and non-chemical stressors, with consideration of how the non-chemical stressors may influence risks from chemical stressors. Residential radon provides an interesting case example, given its large attributable risk, effect modification due to smoking, and significant variability in radon concentrations and smoking patterns. In spite of this fact, no study to date has estimated geographic and sociodemographic patterns of both radon and smoking in a manner that would allow for inclusion of radon in community-based cumulative risk assessment. In this study, we apply multi-level regression models to explain variability in radon based on housing characteristics and geological variables, and construct a regression model predicting housing characteristics using U.S. Census data. Multi-level regression models of smoking based on predictors common to the housing model allow us to link the exposures. We estimate county-average lifetime lung cancer risks from radon ranging from 0.15 to 1.8 in 100, with high-risk clusters in areas and for subpopulations with high predicted radon and smoking rates. Our findings demonstrate the viability of screening-level assessment to characterize patterns of lung cancer risk from radon, with an approach that can be generalized to multiple chemical and non-chemical stressors.

Choi M; Kim H; Qian H; Palepu A. Readmission rates of patients discharged against medical advice: A matched cohort study. PLoS ONE 6(9): article e24459, 2011. (28 refs.)

Objective: We compared the readmission rates and the pattern of readmission among patients discharged against medical advice (AMA) to control patients discharged with approval over a one-year follow-up period. Methods: A retrospective matched-cohort study of 656 patients(328 were discharged AMA) who were followed for one year after their initial hospitalization at an urban university-affiliated teaching hospital in Vancouver, Canada that serves a population with high prevalence of addiction and psychiatric disorders. Multivariate conditional logistic regression was used to examine the independent association of discharge AMA on 14-day related diagnosis hospital readmission. We fit a multivariate conditional negative binomial regression model to examine the readmission frequency ratio between the AMA and non-AMA group. Principal Findings: AMA patients were more likely to be homeless (32.3% vs. 11%) and have co-morbid conditions such as psychiatric illnesses, injection drug use, HIV, hepatitis C and previous gastrointestinal bleeding. Patients discharged AMA were more likely to be readmitted: 25.6% vs. 3.4%, p<0.001 by day 14. The AMA group were more likely to be readmitted within 14 days with a related diagnosis than the non-AMA group (Adjusted Odds Ratio 12.0; 95% Confidence Interval [CI]: 3.7-38.9). Patients who left AMA were more likely to be readmitted multiple times at one year compared to the non-AMA group (adjusted frequency ratio 1.6; 95% CI: 1.3-2.0). There was also higher all-cause in-hospital mortality during the 12-month follow-up in the AMA group compared to non-AMA group (6.7% vs. 2.4%, p = 0.01). Conclusions: Patients discharged AMA were more likely to be homeless and have multiple co-morbid conditions. At one year follow-up, the AMA group had higher readmission rates, were predisposed to multiple readmissions and had a higher in-hospital mortality. Interventions to reduce discharges AMA in high-risk groups need to be developed and tested.

Corkery JM; Schifano F; Oyefeso A; Ghodse AH; Tonia T; Naidoo V et al. 'Bundle of fun' or 'bunch of problems'? Case series of khat-related deaths in the UK. Drugs: Education, Prevention and Policy 18(6, special issue): 408-425, 2011. (94 refs.)

Twenty million people worldwide use khat (Catha edulis). Previously confined to Eastern Africa and Arabia, consumption is spreading to other regions. Chewing khat leaves releases the stimulants cathinone and cathine. Khat consumption has adverse health consequences including myocardial infarction, liver failure, depression, psychoses and dependence. Literature regarding khat-related mortality is scant: only one death (in 1945) due to physiological complications, and a small number of fatalities due to psychological problems associated with long-term khat use have been reported. However, deaths associated with khat do occur. Thirteen deaths in the UK occurring in 2004-2009 associated with khat consumption are described. All decedents were males (mean age 35). Four deaths resulted from the physiopathological consequences of long-term khat use; liver failure (3), left ventricular failure and pulmonary oedema (1). In a further case, the deceased died of a cardiovascular event precipitated by khat use causing either an infarction or electrical instability (arrhythmia) leading to death. Three confirmed and one possible suicide occurred of individuals with psychoses caused and/or exacerbated by long-term khat consumption. An accidental overdose of an anti-psychotic occurred where schizophrenia was exacerbated by khat use. Impaired judgment due to khat and alcohol led to two fatalities in road accidents. One fatality resulted from heroin intoxication, but khat was also present. Khat-consuming communities and health professionals need to be aware of the physiological and psychological effects of khat, together with the risks for mortality associated with its use.

Cousins G; Teljeur C; Motterlini N; McCowan C; Dimitrov BD; Fahey T. Risk of drug-related mortality during periods of transition in methadone maintenance treatment: A cohort study. Journal of Substance Abuse Treatment 41(3): 252-260, 2011. (38 refs.)

This study aims to identify periods of elevated risk of drug-related mortality during methadone maintenance treatment (MMT) in primary care using a cohort of 3,162 Scottish drug users between January 1993 and February 2004. Deaths occurring during treatment or within 3 days after last methadone prescription expired were considered as cases "on treatment." Fatalities occurring 4 days or more after leaving treatment were cases "off treatment." Sixty-four drug-related deaths were identified. The greatest risk of drug-related death was in the first 2 weeks of treatment (adjusted hazard ratio 2.60, 95% confidence interval 1.03-6.56). Risk of drug-related death was lower after the first 30 days following treatment cessation, relative to the first 30 days off treatment. History of psychiatric admission was associated with increased risk of drug-related death in treatment. Increasing numbers of treatment episodes and urine testing were protective. History of psychiatric admission, increasing numbers of urine tests, and coprescriptions of benzodiazepines increased the risk of mortality out of treatment. The risk of drug-related mortality in MMT is elevated during periods of treatment transition, specifically treatment initiation and the first 30 days following treatment dropout or discharge.

Cox S; Kuo C; Jamieson DJ; Kourtis AP; McPheeters ML; Meikle SF et al. Poisoning hospitalisations among reproductive-aged women in the USA, 1998-2006. Injury Prevention 17(5): 332-337, 2011. (36 refs.)

Objective: To describe poisoning hospitalisations among reproductive-aged women from 1998 to 2006. Methods 1998-2006 data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilisation Project were used to identify hospitalisations for poisonings among US women aged 15-44 years. Differences in hospitalisation characteristics were compared by intent using chi(2) statistics. Trends in poisoning hospitalisation rates were calculated overall and by subgroup. Results: There were approximately 636,000 poisoning hospitalisations in women aged 15-44 years during 1998-2006. Hospitalisations for intentionally self-inflicted poisonings had a higher proportion of women aged 15-24 years and privately insured women than did unintentional poisonings (p<0.001). Poisoning hospitalisations in rural areas and those that resulted in death were more likely to be of undetermined intent than those for which intent was specified (p<0.001). Co-diagnoses of substance abuse (34.5%) or mental disorders (66.5%) were high. The rate of poisoning hospitalisations overall and unintentional poisoning hospitalisations increased 6% and 22%, respectively, during this period (p<0.001). The most frequently diagnosed poisoning agent was acetaminophen. Poisonings attributable to acetaminophen, opioids, central nervous system stimulants and benzodiazepines increased, while poisonings attributable to antidepressants decreased (p<0.05). Conclusions: The increase in unintentional poisoning hospitalisations among women aged 15-44 years and the changing profile of poisoning agents should inform the healthcare community's poisoning prevention strategies. Poisoning prevention strategies should include a component to address substance abuse and mental health disorders among reproductive-age women.

Dahlgren A; Wargelius HL; Berglund KJ; Fahlke C; Blennow K; Zetterberg H et al. Do alcohol-dependent individuals with DRD2 A1 allele have an increased risk of relapse? A pilot study. Alcohol and Alcoholism 46(5): 509-513, 2011. (39 refs.)

Aims: The TaqIA polymorphism of the dopamine D2 receptor (DRD2) gene has been extensively studied in relation to alcoholism, and the TaqI A1 allele appears to be over-represented in alcohol-dependent individuals. In a recent study, this allele has also been associated with a highly increased mortality rate in alcohol-dependent individuals. In the present study, we investigated whether the TaqI A1 allele of the DRD2 gene region was associated with a higher relapse rate in alcohol-dependent individuals. Methods: Adult women (n = 10) and men (n = 40) with a diagnosis of alcohol-dependence were recruited from two Swedish 12-step treatment units for alcoholism. Subjects were genotyped for the TaqIA polymorphism. On average, 1.5 years after the end of the treatment program, subjects were re-interviewed by using the alcohol-related items from the Addiction Severity Index follow-up version. Results: Thirty-three (66%) subjects self-reported relapse and 17 (34%) abstinence during the follow-up period. Thirty-sex percent (18/50) were carriers of the A1 allele of the DRD2 gene region, and 64% (32/50) were non-carriers. Among the carriers of the A1 allele, 89% (16/18) reported relapse in contrast to 53% (17/32) in the non-carriers (P = 0.01; odds ratio = 7.1). Conclusion: The present study is, to our knowledge, the first report of an association between the TaqI A1 allele and a substantially increased relapse rate. It should be emphasized that the number of subjects is relatively small, and this investigation should therefore be considered as a pilot study.

Dargan PI; Sedefov R; Gallegos A; Wood DM. The pharmacology and toxicology of the synthetic cathinone mephedrone (4-methylmethcathinone). Drug Testing and Analysis 3(7-8, special issue): 434-463, 2011. (58 refs.)

Mephedrone (4-methylmethcathinone) is a synthetic cathinone that is used as a recreational drug. It has been available since 2007 but its availability and use increased significantly during 2009 and 2010. In this review article we will summarize the available literature on the sources, availability, and prevalence of the use ofmephedrone. We will also discuss the pharmacology of mephedrone, the patterns of acute toxicity associated with its use, the reports of fatalities associated with its use, and the potential for mephedrone dependence.

Davstad I; Allebeck P; Leifman A; Stenbacka M; Romelsjo A. Self-reported drug use and mortality among a nationwide sample of Swedish conscripts: A 35-year follow-up. Drug and Alcohol Dependence 118(2-3): 383-390, 2011. (59 refs.)

Background: Drug users in clinical samples have elevated mortality compared with the general population, but little is known about mortality among users of drugs within the general population. Aim: To determine whether self-reported use of illicit drugs and non-prescribed sedatives/hypnotics among young men in the general population is related to mortality. Methods: A 35-year follow-up of 48 024 Swedish men, born 1949-1951 and conscripted in 1969/1970, among whom drug use was reported by 8767 subjects. Cross-record linkage was effected between individual data from the Swedish conscription and other national registers. Deaths and causes of death/1000 person-years were calculated. Cox PH regression was used to estimate hazard ratios (HRs) for death with 95% confidence intervals (95% CIs). An HR was calculated for users of different dominant drugs at conscription compared with non-users by age interval, after adjusting for confounders and hospitalisation with a drug-related diagnosis. Results: Drug users showed elevated mortality (HR 1.61, p < 0.05) compared with non-users. After adjusting for risk factors, users of stimulants (HR 4.41, p < 0.05), cannabis (HR 4.27, p < 0.05), opioids (HR 2.83, p > 0.05), hallucinogens (HR 3.88, p < 0.05) and unspecified drugs (HR 4.62, p < 0.05) at conscription with a drug-related diagnosis during follow-up showed an HR approaching the standard mortality ratios in clinical samples. Among other drug users (95.5%), only stimulant users showed statistically significantly increased mortality (HR 1.96, p < 0.05). Conclusions: In a life-time perspective, drug use among young men in the general population was a marker of premature death, even a long time after exposure.

Dermengiu D; Radu D; Aciu F; Broscauceanu A; Sereteanu L; Gorun G et al. Drugs of abuse identified in the National Institute of Legal Medicine Mina Minovici Bucharest 2010. Romanian Journal of Legal Medicine 19(3): 229-232, 2011. (10 refs.)

In the last few years in Romania a modern system of drug detection has been developed in the legal medicine system, increasing the detection rate and the sensitivity of DRD detection. In this short report we will present a general profile of drug abuse in Bucharest in 2010. The study was conducted in 2010 when a total number of 208 toxicology tests were conducted in the National Institute of Legal Medicine, 105 on cadavers and 103 on living persons. As main results, in living the most frequently identified drugs of abuse were THC and opiates whilst in cadavers opiates were the most frequent, followed by benzodiazepines. Conclusions. Opiate consumption has a tendency to decrease compared with 2009. Legal highs seems to shift the pattern of drug consumption in Bucharest and surrounding areas, but a definite results can only be obtained using test results from 2011.

Dias AC; Araujo MR; Dunn J; Sesso RC; de Castro V; Laranjeira R. Mortality rate among crack/cocaine-dependent patients: A 12-year prospective cohort study conducted in Brazil. Journal of Substance Abuse Treatment 41(3): 273-278, 2011. (39 refs.)

Mortality is a significant outcome among Brazilian crack/cocaine-dependent patients yet not well understood and is under investigated. This study examined a range of mortality indicators within a cohort of 131 crack/cocaine-dependent patients admitted into treatment and meeting criteria for dependence of crack (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). After 12 years of treatment discharge, 107 individuals were reassessed and 27 death cases were confirmed by official records, wherein in its majority were caused by homicide (n = 16). In this group, survival rate was 0.77 (95% confidence interval [CI] = 0.74-0.81) and previous history of IV cocaine use was' identified as a predictor of mortality (2.5, 95% CI = 1.08-5.79). High mortality rates among Brazilian crack/cocaine-dependent patients, exposure to violence, and HIV/AIDS were topics discussed in this study. This research highlights the importance of ongoing programs to manage crack/cocaine use along with other treatment features within this population.

Fass JA; Hardigan PC. Attitudes of Florida pharmacists toward implementing a state prescription drug monitoring program for controlled substances. Journal of Managed Care Pharmacy 17(6): 430-438, 2011. (38 refs.)

BACKGROUND: As of May 23, 2011, 35 states had an operational prescription drug monitoring program (POMP), and 13 additional states, including Florida in 2009, had passed legislation to implement a POMP. PDMPs, electronic databases that collect and track designated data on controlled substances and other commonly abused medications, are intended to serve as a tool for health care practitioners when prescribing and dispensing controlled substances to reduce drug abuse and diversion. In an analysis of 1,268 drug-caused deaths from January through June 2010 in Florida, the top 3 prescription drugs included the controlled substances oxycodone (56%), alprazolam (35%), and methadone (26%), all of which would be subject to reporting in Florida's POMP when implemented. Because pharmacists are the health care professionals most affected by POMP reporting requirements, evaluating their attitudes about POMP implementation is important. OBJECTIVES: To assess Florida pharmacists' attitudes toward implementing a POMP in the state. METHODS: This was a cross-sectional study conducted in Florida between February 2010 and June 2010 prior to the implementation of the proposed POMP. A random sample of 5,000 of approximately 26,000 pharmacists licensed in Florida was invited to participate in a voluntary and anonymous 10-question self-administered mail survey of which 4 survey items assessed pharmacists' attitudes towards implementing a POMP in the state. RESULTS: Of the 5,000 pharmacists contacted by mail, 911 (18.2%) completed the survey, of whom 836 responded to the items assessing opinions about PDMPs and provided practice site information. A majority of pharmacists across all practice settings agreed or strongly agreed with the statements that a POMP "should be implemented in Florida" (chain 84.0%, hospital 74.2%, independent 77.9%, and other 71.1%) and that a POMP would decrease "the incidence of doctor shopping" if implemented (chain 80.8%, hospital 67.2%, independent 71.7%, and other 63.3%). A majority of pharmacists across all practice settings disagreed or strongly disagreed with the statements that they would be "discouraged to dispense controlled substances" by the POMP (chain 61.4%, hospital 50.0%, independent 60.2%, and other 63.8%) and that POMP implementation would be "an invasion of patients' privacy" (chain 80.3%, hospital 67.7%, independent 67.3%, and other 69.3%). CONCLUSION: In a small-sample survey, a majority of Florida pharmacists across all practice settings were in favor of implementing a POMP in Florida. This is the first study to examine Florida pharmacists' attitudes toward POMP implementation, and the results should prompt future analyses of relevant outcomes, such as drug abuse, drug-related mortality, and doctor shopping.

Feigelman W; Jordan JR; Gorman BS. Parental grief after a child's drug death compared to other death causes: Investigating a greatly neglected bereavement population. Omega. Journal of Death and Dying 63(4): 291-316, 2011. (35 refs.)

This comparative survey contrasted 571 parents who lost children to various death causes: 48 to drug-related deaths and overdoses, 462 to suicide, 24 to natural death cases, and 37 to mostly accidental death cases. Groups were compared in terms of grief difficulties, mental health problems, post-traumatic stress, and stigmatization. Results did not show any appreciable differences in these respects between the suicide bereaved parents and those losing children to drug-related deaths. However, when the suicide and drug-related death survivors were specifically contrasted against accidental and natural death loss cases, a consistent pattern emerged showing the former group was consistently more troubled by grief and mental health problems than the latter two sub-groups. These differences remained when controls of time since the loss and gender differences were employed as covariates. These findings suggest that the powerful and intense stigma against drug use and mental illness, shared among the public-at-large, imposes challenges in healing of immense proportion for these parents as they find less compassionate responses from their significant others, following their losses.

Ford ES; Zhao GX; Tsai J; Li CY. Low-risk lifestyle behaviors and all-cause mortality: Findings from the National Health and Nutrition Examination Survey III Mortality Study. American Journal of Public Health 101(10): 1922-1929, 2011. (58 refs.)

Objectives. We examined the relationship between 4 low-risk behaviors never smoked, healthy diet, adequate physical activity, and moderate alcohol consumption and mortality in a representative sample of people in the United States. Methods. We used data from 16958 participants aged 17 years and older in the National Health and Nutrition Examination Survey III Mortality Study from 1988 to 2006. Results. The number of low-risk behaviors was inversely related to the risk for mortality. Compared with participants who had no low-risk behaviors, those who had all 4 experienced reduced all-cause mortality (adjusted hazard ratio [AHR]=0.37; 95% confidence interval [CI]=0.28, 0.49), mortality from malignant neoplasms (AHR =0.34; 95% CI=0.20, 0.56), major cardiovascular disease (AHR =0.35; 95% CI=0.24, 0.50), and other causes (AHR =0.43; 95% CI=0.25, 0.74). The rate advancement periods, representing the equivalent risk from a certain number of years of chronological age, for participants who had all 4 high-risk behaviors compared with those who had none were 11.1 years for all-cause mortality, 14.4 years for malignant neoplasms, 9.9 years for major cardiovascular disease, and 10.6 years for other causes. Conclusions. Low-risk lifestyle factors exert a powerful and beneficial effect on mortality.

Foy M; Spitz MR; Kimmel M; Gorlova OY. A smoking-based carcinogenesis model for lung cancer risk prediction. International Journal of Cancer 129(8): 1907-1913, 2011. (23 refs.)

Lung cancer is the leading cancer killer for both men and women worldwide. Over 80% of lung cancers are attributed to smoking. In this analysis, the authors propose to use a two-stage clonal expansion (TSCE) model to predict an individual's lung cancer risk based on gender and smoking history. The TSCE model is traditionally fitted to prospective cohort data. Here, the authors describe a new method that allows for the reconstruction of cohort data from the combination of risk factor data obtained from a case-control study, and tabled incidence/mortality rate data, and discuss alternative approaches. The method is applied to fit a TSCE model based on smoking. The fitted model is validated against independent data from the control arm of a lung cancer chemoprevention trial, CARET, where it accurately predicted the number of lung cancer deaths observed.

Fulceri F; Ferrucci M; Lenzi P; Soldani P; Paparelli ABA; Gesi M. MDMA (Ecstasy) enhances loud noise-induced morphofunctional alterations in heart and adrenal gland. (review). Microscopy Research and Technique 74(9): 874-887, 2011. (169 refs.)

Noise is an environmental stressor increasingly more present in modern life and, in particular, in a variety of recreational contexts. The aim of this work is to show the effects of noise on the myocardium and adrenal gland, through a careful review of the literature dealing with the peripheral effects of noise exposure in experimental and clinical studies. Noise induces adverse effects in human health, principally involving the cardiovascular and autonomic nervous systems, and the endocrine apparatus. Several factors in recreational environments potentially worsen the effects induced by loud noise. Among these, the intake of 3,4-methylenedioxymethamphetamine (MDMA) is frequently associated with noise exposure in recreational situations, because of its high compliance within social and relaxation settings. For this reason, MDMA is defined as a club drug-as its intake by young people often occurs in association with other factors, such as aggregation, high temperatures, and noise. It is known that self-administration of MDMA by humans causes severe toxicity. In particular, the myocardium is affected early after MDMA intake-resulting in tachycardia, hypertension, and arrhythmia. Furthermore, MDMA alters the activity of the adrenal glands by elevating catecholamines and corticosterone levels. This review shows that combining MDMA and loud noise exposure potentiates the effects that are produced by each single stimulant alone as seen in experimental animal models. The convergence of the effects of prolonged loud noise exposure and the consumption of MDMA on the same system might explain the sudden fatal events that happen in recreational situations.

Gillum RF; Kwagyan J; Obisesan TO. Smoking, cognitive function and mortality in a US national cohort study. International Journal of Environmental Research and Public Health 8(9): 3628-3636, 2011. (12 refs.)

Previous studies report that low levels cognitive function and history of smoking are associated with increased mortality risk. Elderly smokers may have increased risk of dementia, but risk in former smokers is unclear. We tested the hypotheses that the harmful effect of impaired cognitive function as related to mortality is greater in persons smoking at baseline than in others. Further, we used serum cotinine levels to assess recall bias of smoking history by cognitive function level. Data were analyzed from a longitudinal mortality follow-up study of 4,916 American men and women aged 60 years and over, examined in 1988-1994 with complete data followed an average 8.5 years. Measurements at baseline included smoking history, a short index of cognitive function (SICF), serum cotinine and socio-demographics. Death during follow-up occurred in 1,919 persons. In proportional hazards regression analysis, a significant interaction of current smoking with cognitive function was not found; but there was a significant age-smoking interaction. After adjusting for confounding by age or multiple variables, current smoking associated with over 2-fold increased mortality (hazards ratio and 95% confidence limits current versus never smoking 2.13, 1.75-2.59) and SICF with 32% reduction in mortality; top versus bottom SICF stratum 0.68, 0.53-0.88). Serum cotinine data revealed substantial recall bias of smoking history in persons with cognitive impairment. However analyses correcting for this bias did not alter the main conclusions: In a nationwide cohort of older Americans, analyses demonstrated a lower risk of death independent of confounders among those with high SICF scores and never smokers, without a significant interaction of the two.

Goldstein BD; Liu Y; Wu F; Lioy P. Comparison of the effects of the US Clean Air Act and of smoking prevention and cessation efforts on the risk of acute myelogenous leukemia. American Journal of Public Health 101(12): 2357-2361, 2011. (28 refs.)

Objectives. We used 2 approaches based on published information to compare the impacts on leukemia incidence and benzene exposure of the 1990 US Clean Air Act (CAA) amendments and smoking prevention and cessation efforts. Methods. We extrapolated leukemia mortality related to community air pollution levels and to cigarette smoking from data from the US Environmental Protection Agency and the US Surgeon General. We also estimated relative decline in total exposures to benzene (a known human leukemogen) owing to the CAA amendments and to smoking prevention and cessation efforts. Results. We estimated that because of the CAA, there will be approximately 300 fewer leukemia deaths in the United States during the period 2000 through 2020. During the closest comparable period (1987-2007), we estimated that decline in cigarette smoking led to 7120 fewer leukemia deaths, of which 1282 to 3702 were attributable to benzene. Similarly, the decline in smoking led to about a tenfold greater decrease in total-population benzene exposure than did the 1990 CAA amendments. Conclusions. Both the CAA and smoking cessation activities contribute to a decrease in leukemia incidence. Smoking cessation activities have had a greater effect in the past.

Grady B; van den Berg C; van der Helm J; Schinkel J; Coutinho R; Krol A et al. No impact of hepatitis C virus infection on mortality among drug users during the first decade after seroconversion. Clinical Gastroenterology and Hepatology 9(9): 786-U107, 2011. (31 refs.)

Background & Aims: Most studies of progression of chronic hepatitis C virus (cHCV) infection were conducted in hospital settings and were therefore biased for patients with severe disease. We evaluated the long-term outcomes of hepatitis C virus (HCV) infection among injecting drug users, recruited from outside the hospital setting, and examined the effect of cHCV on mortality after seroconversion. Methods: We studied data from 106 seroconverters with a documented or estimated date of HCV seroconversion. Cox proportional hazards analysis was used to determine the effect of HCV persistence, compared with HCV clearance, on survival after HCV seroconversion. The median follow-up time was 14.8 years (interquartile range, 7.8 -19.6). Results: cHCV infection developed in 71 of the subjects (67%; 95% confidence interval [CI], 57%-76%); 33 subjects died. One HCV-related death was observed 23 years after HCV seroconversion. Most causes of death were non-natural (n = 12) or acquired immune deficiency syndrome-related (n = 8). The effect of cHCV on mortality was nonproportional over time. When survival time was analyzed separately for 0-5 years, >5-10 years, and >10 years after HCV seroconversion, the age-adjusted hazard ratios for cHCV were 0.59 (95% CI, 0.16-2.20), 1.76 (95% CI, 0.36-8.53), and 8.28 (95% CI, 1.10-64.55), respectively, compared with resolved HCV infection. Conclusions: cHCV infection does not affect overall mortality in the first decade after seroconversion, compared with individuals who resolve HCV infection; however, during the second decade after infection, individuals with cHCV have an increased risk for all-cause mortality. Mortality from liver-related causes was low but might have been masked by competing mortality.

Graham K; Livingston M. The relationship between alcohol and violence: Population, contextual and individual research approaches. (editorial). Drug and Alcohol Review 30(5, special issue): 453-457, 2011. (48 refs.)

Hauck FR; Tanabe KO; Moon RY. Racial and ethnic disparities in infant mortality. (review). Seminars in Perinatology 35(4): 209-220, 2011. (96 refs.)

Racial and ethnic disparities in infant mortality in the United States seem to defy all attempts at elimination. Despite national priorities to eliminate these disparities, black infants are 2.5 times more likely to die in infancy compared with non-Hispanic white infants. This disparity is largely related to the greater incidence among black infants of prematurity and low birth weight, congenital malformations, sudden infant death syndrome, and unintentional injuries. This greater incidence, in turn, is related to a complex interaction of behavioral, social, political, genetic, medical, and health care access factors. Thus, to influence the persistent racial disparity in infant mortality, a highly integrated approach is needed, with interventions adapted along a continuum from childhood through the periods of young adulthood, pregnancy, postpartum and beyond. The content and methodologies of these interventions need to be adapted to the underlying behaviors, social influences, and technology and access issues they are meant to address. [Note: The association of both alcohol and drug use with increased risks for infant mortality is referenced.]

Hickman M; Vickerman P; Robertson R; Macleod J; Strang J. Promoting recovery and preventing drug-related mortality: Competing risks? (editorial). Journal of Public Health 33(3): 332-334, 2011. (27 refs.)

Hollowell J; Kurinczuk JJ; Brocklehurst P; Gray R. Social and ethnic inequalities in infant mortality: A perspective from the United Kingdom. (review). Seminars in Perinatology 35(4): 240-244, 2011. (21 refs.)

Social inequalities in infant mortality can be clearly demonstrated in the countries of the United Kingdom with a social gradient between different groups. Marked variations in infant mortality between ethnic groups are also evident in England and Wales, with the highest rates seen in Pakistani and Caribbean infants and the lowest rates in the white and Bangladeshi groups. Although individual risk factors for infant mortality are well understood, the reasons why certain social and ethnic groups have higher rates remain to be fully elucidated. Policies and interventions to tackle these inequalities are likely to be most effective if they have both universal and targeted components to �level-up� rates to the rate of the most advantaged in society. [Note: The association of both alcohol and drug use with increased risks for infant mortality is briefly discussed.]

Janssen E. Drug-related deaths in France in 2007: Estimates and implications. Substance Use & Misuse 46(12): 1495-1501, 2011. (38 refs.)

Compared with other European countries, France's low number of drug use-related deaths may appear enviable. Previous studies have suggested significant underreporting. The three official records listing drug-related deaths in France in 2007 were cross-checked. Different capture-recapture techniques were applied. The estimated numbers of drug-related deaths differ from the official figures. Different explanations and proposals to improve the recordings are consequently discussed. However, there are doubts as to the reliability of at least one of the records and the consequent accuracy of the proportion of overlapping cases. Estimates should be handled with caution and interpreted as upper bounds.

Jansson C; Alderling M; Hogstedt C; Gustavsson P. Mortality among Swedish chimney sweeps (1952-2006): An extended cohort study. Occupational and Environmental Medicine 69(1): 41-47, 2012. (31 refs.)

Objectives We extended a cohort study of Swedish chimney sweeps and prolonged follow-up in order to increase power and study those first employed after 1950 when oil began to replace wood as a main fuel for heating in Sweden. Methods Male Swedish chimney sweeps who were members of the national trade union in 1981-2006 were identified (n=1087) and included to a previous cohort of those employed in 1918-1980 (n=5287). All employment histories were updated, and the total extended cohort (n=6374) was linked to the registers of Causes of Death and Total Population and followed for mortality from 1952 through 2006. Standardised mortality ratios (SMRs) were estimated using the Swedish male population as reference. Results 1841 observed deaths resulted in an SMR for all causes of deaths of 1.29 (95% CI 1.24 to 1.36). Mortality was significantly increased for all malignant tumours, oesophageal cancer, bowel cancer, liver cancer, lung cancer, alcoholism, ischaemic heart disease, non-malignant respiratory diseases, liver cirrhosis, external causes and suicides. The lung cancer SMR remained increased, although attenuated, after adjustment for group-level smoking data, SMR of 1.52 (95% CI 1.26 to 1.89). Duration of employment showed no consistent evidence of dose-response associations. Alcohol-related deaths (liver cirrhosis and alcoholism) were not increased among those employed >30 years. Mortality among those employed after 1950 was similar to that of the entire cohort. Conclusions Chimney sweeps are exposed to high levels of toxic substances in the occupation, but excess alcohol and smoking habits were also observed, and the results must be interpreted cautiously. However, group-level data on tobacco smoking indicated that the lung cancer excess only to some extent could be explained by smoking habits, and the increased mortality from oesophageal cancer and ischaemic heart disease among chimney sweeps employed >30 years is less likely to be caused by excess alcohol habits.

Jimenez-Trevino L; Saiz PA; Garcia-Portilla MP; Diaz-Mesa EM; Sanchez-Lasheras F; Buron P et al. A 25-year follow-up of patients admitted to methadone treatment for the first time: Mortality and gender differences. Addictive Behaviors 36(12): 1184-1190, 2011. (50 refs.)

Introduction: We conducted a follow-up study to evaluate the outcome of a heroin-dependent population 25 years after their first enrollment in methadone maintenance treatment (MMT). We assessed mortality in the sample plus actual drug use, treatment, and medical factors associated with drug dependence, focusing on possible gender differences. Methods: Prospective follow-up study of 214 heroin-dependent patients consecutively admitted for MMT between 1980 and 1984 in the Asturias Public Health Service. The standardized mortality ratio (SMR) and 95% confidence interval (Cl) were calculated. An ad-hoc protocol on drug misuse and treatment, drug-related morbidity and Clinical Global Impression (CGI) scores were assessed in the survivors' sample. Results: Information was received on 159 subjects, 106 of whom were deceased. Men accounted for 76.2% of the study cohort. Over the 25-year follow-up period, the SMR was 22.51 (95% CI = 22.37-22.64). In the survivors sample, 39.6% were still enrolled in MMT; human immunodeficiency virus (HIV) was diagnosed in 47.2% and hepatitis B/C in 81.1%; current heroin use was reported by 22.6%. There were no gender differences in mortality or HIV and hepatitis B/C status. None of the female survivors were using heroin at the 25-year follow-up compared with 31.1% of males. Conclusions: This study confirms the high mortality of heroin addicts even after enrollment in MMT. Severity of the addiction in terms of mortality was similar in both genders. Women who survived the 25-year follow-up were more likely to have stopped using heroin than men.

Jones SN; Lachman VD. Continuing the dialogue: Reducing minimum legal drinking age laws from 21 to 18. Journal of Addictions Nursing 22(3): 138-143, 2011. (37 refs.)

The purpose of this paper is to examine both sides of the debate revolving around the issue of reducing the minimum legal drinking age law from age 21 to 18 years of age. Ethical considerations surrounding the issue are offered. The current 1984 National Minimum Drinking Age Act (MLDA 21) has been shown to save lives. However, in 2008 the major supporters of reducing the minimum legal drinking age laws from 21 to 18 issued a call to dialogue. The Amethyst Initiative and Choose Responsibility have spearheaded opposition to MDLA 21. They call for a public dialogue about the ineffectiveness of MLDA 21 laws; whereas proponents of MLDA 21 laws provide evidence-based data that the MLDA 21, laws save lives. The authors provide arguments in opposition to reducing the age requirements of the MLDA 21 laws and present ethical considerations that represent both sides of the issues. The authors conclude that in view of the adverse consequences of alcohol-related traffic injuries/fatalities among youth ages 15-20, continuation of the dialogue is warranted.

Kerr WC; Greenfield TK; Bond J; Ye Y; Rehm J. Racial and ethnic differences in all-cause mortality risk according to alcohol consumption patterns in the National Alcohol Surveys. American Journal of Epidemiology 174(7): 769-778, 2011. (32 refs.)

Previous studies have found J-shaped relations between volume of alcohol consumed and mortality risk in white Americans but not in African Americans, suggesting the need for studies in which race/ethnicity-defined subgroups are analyzed in separate comparable models. In the present study, the authors utilized mortality follow-up data (through 2006) on respondents from the 1984 and 1995 National Alcohol Surveys, including similar numbers of black, white, and Hispanic respondents by oversampling the minority groups. Cox proportional hazards models controlling for demographic, socioeconomic, mental health, and drug- and tobacco-use measures were used to estimate mortality risk from all causes. Findings indicated a protective effect of moderate alcohol drinking (2-30 drinks/month for women and 2-60 drinks/month for men) with no monthly >= 5-drink days) relative to lifetime abstention for whites only. Elevated mortality risk relative to moderate drinking was found in former drinkers with lifetime alcohol problems. Moderate drinkers who consumed >= 5 drinks in 1 day at least monthly were also found to have increased risk, suggesting the importance of identifying heavy-occasion drinking for mortality analyses. These differential results regarding lifetime abstainers may suggest bias from differential unmeasured confounding or unmeasured aspects of alcohol consumption pattern or may be due to genetic differences in the health impact of alcohol metabolism.

Kuo CJ; Liao YT; Chen WJ; Tsai SY; Lin SK; Chen CC. Causes of death of patients with methamphetamine dependence: A record-linkage study. Drug and Alcohol Review 30(6): 621-628, 2011. (36 refs.)

Introduction and Aims. Methamphetamine use leads to increased likelihood of premature death. The authors investigated the causes of death and risk of mortality in a large cohort of patients with methamphetamine dependence. Design and Methods. A cohort of 1254 subjects with methamphetamine dependence, admitted to a psychiatric centre in Taiwan from January 1990 to December 2007, was retrospectively studied. Diagnostic and sociodemographic data for each subject were extracted from the medical records based on a chart review process. Mortality data were obtained by linking to the National Death Certification System and standardised mortality ratios (SMRs) were estimated. The risk and protective factors for all-cause deaths were explored by means of survival analyses. Results. During the study period, 130 patients died. Of them, 63.1% died unnatural deaths, while the remaining 36.9% died natural deaths. The 1 year cumulative rates for unnatural and natural deaths were 0.018 and 0.006, respectively, and the 5 year rates were 0.046 and 0.023, respectively. The cohort had excessive mortality (SMR = 6.02), and women had a higher SMR for unnatural deaths than men (26.19 vs. 9.82, P = 0.001). For all-cause deaths, comorbidity with other substance use disorders was associated with increased risk of death, despite that being married was associated with a reduced risk. Discussion and Conclusions. A substantial proportion of the deceased died natural deaths, but most died unnatural deaths. The findings show significant evidence to provide valuable insight into premature deaths among methamphetamine-dependent users. This information is valuable for development of prevention and intervention programs.

Lagas JS; Wagenaar JFP; Huitema ADR; Hillebrand MJX; Koks CHW; Gerdes VEA et al. Lethal morphine intoxication in a patient with a sickle cell crisis and renal impairment: Case report and a review of the literature. (review). Human & Experimental Toxicology 30(9): 1399-1403, 2011. (29 refs.)

Morphine-6-glucuronide, the active metabolite of morphine, and to a lesser extent morphine itself are known to accumulate in patients with renal failure. A number of cases on non-lethal morphine toxicity in patients with renal impairment report high plasma concentrations of morphine-6-glucuronide, suggesting that this metabolite achieves sufficiently high brain concentrations to cause long-lasting respiratory depression, despite its poor central nervous system penetration. We report a lethal morphine intoxication in a 61-year-old man with sickle cell disease and renal impairment, and we measured concentrations of morphine and morphine-6-glucuronide in blood, brain and cerebrospinal fluid. There were no measurable concentrations of morphine-6-glucuronide in cerebrospinal fluid or brain tissue, despite high blood concentrations. In contrast, the relatively high morphine concentration in the brain suggests that morphine itself was responsible for the cardiorespiratory arrest in this patient. Given the fatal outcome, we recommend to avoid repeated or continuous morphine administration in renal failure.

Launiainen T; Broms U; Keskitalo-Vuokko K; Pitkaniemi J; Pelander A; Kaprio J et al. Nicotine, alcohol, and drug findings in young adults in a population-based postmortem database. Nicotine & Tobacco Research 13(9): 763-771, 2011. (42 refs.)

Introduction: To obtain reliable information on nicotine and drug use through a population-based study, the prevalence of nicotine use in deceased young adults was studied in the Finnish postmortem toxicology database for a 3-year period. The nicotine user and non-nicotine user groups were compared by alcohol, drug, and drug-of-abuse findings and by the manner of death. Methods: Nicotine users were identified based on detection of nicotine, cotinine, and/or trans-3'-hydroxycotinine in urine from a population-based sample of deceased young adults aged 15-34 years at the time of death (n = 1,623, similar to 60% of all fatalities). Background: information from case referrals was used to distinguish the abuse of medicines from their therapeutic use. The manner of death was taken from death certificates. Results: Nicotine use was more common in young adults (75%) than among all cases in the database (55%). There were twice as many ethanol-positive cases in nicotine users (60%) than in non-nicotine users (30%). Nicotine use was common (70%-79%) among individuals on antipsychotics, antidepressants, anxiolytics, and/or hypnotics and sedatives. The proportion of nicotine users was also high among the drugs-of-abuse positive cases (85%). There were fewer deaths that were classified as natural in the nicotine users group. Conclusions: Among deceased young adults, nicotine use was two to three times as common as has been estimated for the corresponding living population (20%-30%). Nicotine use was also strongly associated with substance abuse and mental illnesses requiring pharmacotherapy. This group of young adults usually cannot be reached by traditional health surveys.

Lee CD; Sui XM; Hooker SP; Hebert JR; Blair SN. Combined impact of llfestyle factors on cancer mortality in men. Annals of Epidemiology 21(10): 749-754, 2011. (28 refs.)

PURPOSE: The impact of lifestyle factors on cancer mortality in the U.S. population has not been thoroughly explored. We examined the combined effects of cardiorespiratory fitness, never smoking, and normal waist girth on total cancer mortality in men. METHODS: We followed a total of 24,731 men ages 20-82 years who participated in the Aerobics Center Longitudinal Study. A low-risk profile was defined as never smoking, moderate or high fitness, and normal waist girth, and they were further categorized as having 0, 1, 2, or 3 combined low-risk factors. RESULTS: Over an average of 14.5 years of follow-up, there were a total of 384 cancer deaths. After adjustment for age, examination year, and multiple risk factors, men who were physically fit, never smoked, and had a normal waist girth had a 62% lower risk of total cancer mortality (95% confidence interval [CI], 45%-73%) compared with men with no low-risk factors. Men with all 3 low-risk factors had a 12-year (95% CI, 8.6-14.6) longer life expectancy compared with men with no low-risk factors. Approximately 37% (95% CI, 17%-52%) of total cancer deaths might have been avoided if the men had maintained all 3 low-risk factors. CONCLUSIONS: Being physically fit, never smoking, and maintaining a normal waist girth is associated with lower risk of total cancer mortality in men.

Levin J. Alcoholism. (Chapter 12). IN: Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. This chapter is part of Part II, a section with the title "The Real World." The chapters in this section focus on particular drugs. This chapter deals with alcohol/alcoholism. Other chapters in this section deal with alcohol's presentation and treatment in primary care; nicotine addiction and smoking cessation; clinical approaches in working with cocaine and methadone dependence; methadone maintenance for opiate dependence; and prescription drug abuse.

Liangpunsakul S. Clinical characteristics and mortality of hospitalized alcoholic hepatitis patients in the United States. Journal of Clinical Gastroenterology 45(8): 714-719, 2011. (13 refs.)

Background and Aims: Alcoholic hepatitis (AH) is the most florid manifestation of alcoholic liver disease. In this study, we examined the clinical characteristics and risk factors associated with mortality in hospitalized AH patients in the United States using the 2007 Nationwide inpatient sample of the Healthcare Cost and Utilization Project. Methods: Patients who were hospitalized with the primary diagnosis of AH in the United States in 2007 were identified using International Classification of Diseases-9 code. We further characterized these subjects based on associated symptoms (such as ascites, hepatic encephalopathy, and coagulopathy), complications during hospitalization (such as sepsis, pneumonia, spontaneous bacterial peritonitis, and acute renal failure), and categories pertaining to hospital characteristics, such as teaching status. The predictors of mortality were calculated using logistic regression analyses. Results: There were 8,043,415 in-patient admissions, of which 56,809 (0.71%) were hospitalized with the primary diagnosis of AH. The mean age was 53.2 years, and 27% were female. The average length of stay was 6.5 +/- 7.7 days and 3,881 subjects (6.8%) died during hospitalization. Medicare and Medicaid were the main primary expected payer sources (51.8%) with the average total charges during hospital stay of $37,769. In the multivariate analyses, older age, presence of sepsis, spontaneous bacterial peritonitis, pneumonia, urinary tract infection, acute renal failure, hepatic encephalopathy, and coagulopathy were independently associated with in-patient mortality. Conclusions: In-hospital mortality rate for AH remains high, especially in those with infectious complications, hepatic encephalopathy, coagulopathy, and acute renal failure. Our analysis documented significant healthcare cost and utilization among hospitalized AH patients.

Liew HP. Trajectories of alcohol consumption among the elderly widowed population: A semi-parametric, group-based modeling approach. Advances In Life Course Research 16(3): 124-131, 2011. (41 refs.)

Even though research on the use, misuse, and abuse of alcohol among the elderly has burgeoned in recent decades (see reviews by Johnson, 2000; Kirchner et al., 2007; Patterson & Jeste, 1999), only a few empirical studies have explored the post-bereavement alcohol consumption trajectories among the elderly widowed population. To fill this research gap, this study aims to examine the temporal processes underlying the relationship between widowhood and subsequent drinking behaviors among the elderly widowed population and to examine the potential predictors of these trajectories. The empirical work of this study is based on longitudinal data from the 1992 to 2008 Health and Retirement Study (HRS). A semi-parametric mixture model (SPMM) is used to estimate the distinctive trajectories of post-bereavement alcohol consumption. Results reveal that the type of drinking trajectory that characterize the post-bereavement drinking behavior of an individual is largely dependent upon the characteristics of the individuals (e.g. gender), the health conditions and health behavior of deceased spouse, pre-bereavement alcohol consumption, and depression. Another important finding is that bereaved men seem to have greater difficulty overcoming the transitional burden associated with widowhood.

Lipkin M; Lee J. Alcoholism in primary care. (Chapter 13). IN: Brizer D; Castandea R, eds. Clinical Addiction Psychiatry. New York: Cambridge University Press, 2011

This book is described as an anthology of essays setting forth the most current and authoritative information on addiction theory, practice and research. Each chapter is authored by a recognized authority in the field. The volume covers diverse material, from the environment, to genetics, culture and spirituality, treatment and pharmacology. The book, with 24 essays, is organized in three parts. This chapter is part of Part II, a section with the title "The Real World." The chapters in this section focus on particular drugs. This chapter deals with alcohol/alcoholism and its presentation and clinical care in primary care.. Other chapters in this section deal with twelve step approaches; nicotine addiction and smoking cessation; clinical approaches in working with cocaine and methadone dependence; methadone maintenance for opiate dependence; and prescription drug abuse.

Lovrecic B; Semerl JS; Tavcar R; Maremmani I. Sociodemographic and clinical differences among deceased and surviving cohort members of opioid maintenance therapy. Heroin Addiction and Related Clinical Problems 13(3): 39-47, 2011. (27 refs.)

This study aimed to analyse the differences found among surviving and deceased heroin addicts in opioid maintenance treatment in the years 2004-2006 in Slovenia in terms of their sociodemographic and clinical characteristics. 3,950 heroin addicts entered our retrospective cohort study; of these, 69 had died by the end of the study. Mean age as recorded at entry into treatment was significantly higher among those who had died by the end of the study than among survivors. Men and those who had undergone more than one treatment died significantly more frequently than women and those in their first treatment. In addition, those who were unemployed or had had fewer years of education proved to be more likely to die. Heroin was the main drug in both groups; among its users death rates were significantly higher than among those taking other widely used addictive drugs. This is the first cohort study that has taken the step of recording indirect deaths. Further studies are now needed to acquire a better understanding of the phenomenon.

MacVane CZ; Doty CI. Clinical pathology conference: A deadly cause of seizures in a 67-year-old alcoholic. Academic Emergency Medicine 18(9): e77-e83, 2011. (21 refs.)

A 67-year-old male presented via emergency medical services (EMS) to the emergency department (ED) of an urban academic medical center with a chief complaint of seizure. The patient�s wife called EMS after finding him on the floor that morning with generalized, shaking movements. He was incontinent of urine and stool. She last saw the patient the previous evening and reports that he had been in his usual state of health. He drank several bottles of wine the day before, which was not unusual for the patient. She stated that he had never had a previous seizure. who presented with a new-onset seizure, had findings of fever, bilateral foot ulcers, evidence of ischemia by ECG and cardiac enzymes, and an abnormal head CT. The diagnostic test that was performed was a transthoracic echocardiogram. This revealed an aortic valve vegetation, leading to a final diagnosis of infective endocarditis.

Maskell PD; De Paoli G; Seneviratne C; Pounder DJ. Mephedrone (4-methylmethcathinone)-related deaths. Journal of Analytical Toxicology 35(3): 188-191, 2011. (14 refs.)

Mattisson C; Bogren M; Ojehagen A; Nordstrom G; Horstmann V. Mortality in alcohol use disorder in the Lundby Community Cohort: A 50 year follow-up. Drug and Alcohol Dependence 118(2-3): 141-147, 2011. (45 refs.)

Aims: To describe the mortality and causes of death among subjects with alcohol use disorder in comparison with those without alcohol disorder and to study whether mental disorders increase mortality in alcoholics. Design and setting: Data were analysed from the database of the Lundby Study, comprising 3563 subjects followed from 1947 to 1997. Method: A community-based sample was investigated in 1947 with follow-ups in 1957, 1972 and 1997. Best-estimate consensus diagnoses of mental disorders, including alcohol use disorder, were assessed. In the total cohort, 427 cases of alcohol use disorders were identified. Differences in mortality between subjects with alcohol use disorders and non-alcoholics were studied using Cox regression models and causes of death were compared between alcoholic subjects and other participants. Risk factors for mortality among the 348 individuals with alcohol use disorders and known age-of-onset were analysed by means of Cox regression analyses. Results: The hazard ratio for mortality was higher for alcoholics compared to other subjects in the cohort. A substantial proportion of the causes of death among the alcoholics was suicide N = 27(6.3%) (26 males, 1 female). In the multivariate models of risk factors in alcohol use disorders, anxiety disorders, psychotic disorders, alcohol induced psychotic disorders and dementia were risk factors for premature death. Conclusion: The mortality risk for subjects with alcohol use disorder was increased, females were especially vulnerable. The risk for suicide was high among males with alcohol problems. Anxiety disorders and severity of alcohol use disorder turned out as risk factors for premature death.

Medalia C; Chang VW. Gender equality, development, and cross-national sex gaps in life expectancy. International Journal of Comparative Sociology 52(5): 371-389, 2011. (58 refs.)

Female life expectancy exceeds male life expectancy in almost every country throughout the world. Nevertheless, cross-national variation in the sex gap suggests that social factors, such as gender equality, may directly affect or mediate an underlying biological component. In this article, we examine the association between gender equality and the sex gap in mortality. Previous research has not addressed this question from an international perspective with countries at different levels of development. We examine 131 countries using a broad measure of national gender equality that is applicable in both Less Developed Countries (LDCs) and Highly Developed Countries (HDCs). We find that the influence of gender equality is conditional on level of development. While gender equality is associated with divergence between female and male life expectancies in LDCs, it is associated with convergence in HDCs. The relationship between gender equality and the sex gap in mortality in HDCs strongly relates to, but is not explained by, sex differences in lung cancer mortality. Finally, we find that divergence in LDCs is primarily driven by a strong positive association between gender equality and female life expectancy. In HDCs, convergence is potentially related to a weak negative association between gender equality and female life expectancy, though findings are not statistically significant.

Millet JP; Orcau A; Rius C; Casals M; de Olalla PG; Moreno A et al. Predictors of death among patients who completed tuberculosis treatment: A population-based cohort study. PLoS ONE 6(9): e25315, 2011. (44 refs.)

Background: Mortality among patients who complete tuberculosis (TB) treatment is still high among vulnerable populations. The objective of the study was to identify the probability of death and its predictive factors in a cohort of successfully treated TB patients. Methods: A population-based retrospective longitudinal study was performed in Barcelona, Spain. All patients who successfully completed TB treatment with culture-confirmation and available drug susceptibility testing between 1995-1997 were retrospectively followed-up until December 31, 2005 by the Barcelona TB Control Program. Socio-demographic, clinical, microbiological and treatment variables were examined. Mortality, TB Program and AIDS registries were reviewed. Kaplan-Meier and a Cox regression methods with time-dependent covariates were used for the survival analysis, calculating the hazard ratio (HR) with 95% confidence intervals (CI). Results: Among the 762 included patients, the median age was 36 years, 520 (68.2%) were male, 178 (23.4%) HIV-infected, and 208 (27.3%) were alcohol abusers. Of the 134 (17.6%) injecting drug users (IDU), 123 (91.8%) were HIV-infected. A total of 30 (3.9%) recurrences and 173 deaths (22.7%) occurred (mortality rate: 3.4/100 person-years of follow-up). The predictors of death were: age between 41-60 years old (HR: 3.5; CI: 2.1-5.7), age greater than 60 years (HR: 14.6; CI: 8.9-24), alcohol abuse (HR: 1.7; CI: 1.2-2.4) and HIV-infected IDU (HR: 7.9; CI: 4.7-13.3). Conclusions: The mortality rate among TB patients who completed treatment is associated with vulnerable populations such as the elderly, alcohol abusers, and HIV-infected IDU. We therefore need to fight against poverty, and promote and develop interventions and social policies directed towards these populations to improve their survival.

Molina DK; Hargrove VM. Fatal cocaine interactions: A review of cocaine-related deaths in Bexar County, Texas. American Journal of Forensic Medicine and Pathology 32(1): 71-77, 2011. (40 refs.)

Although cocaine is a widely abused illicit substance that is known to cause death, deaths due to its use appear to occur in a minority of those who use it. This report was designed to review drug-related deaths due to cocaine, and the concomitant use of other drugs/medications. A retrospective review of drug deaths at the Bexar County Medical Examiner's Office in San Antonio, Texas, was undertaken for cases where cocaine was one of the drugs implicated in causing death. Analysis was performed comparing the concentrations of cocaine and benzoylecgonine present and the absence or presence of other drugs. The data obtained showed that cocaine was toxic over a large range with deaths occurring at concentrations ranging from 0.01 to 78 mg/L. Analyses also indicated an increased lethality when cocaine is used in combination with ethanol, heroin, opiates, and antidepressant/antipsychotic medications, which is consistent with previous reports and research. Antihistamine data showed that there may be relationship between increased toxicity and coingestion, although more research is necessary.

Molina DK; Hargrove VM. What is the lethal concentration of hydrocodone? A comparison of postmortem hydrocodone concentrations in lethal and incidental intoxications. American Journal of Forensic Medicine and Pathology 32(2): 108-111, 2011. (9 refs.)

Hydrocodone is a semisynthetic opioid medication that is widely used as an analgesic and antitussive. Since 2004 it has been the most commonly prescribed drug in the United States and is often misused as a drug of abuse. Hydrocodone is frequently encountered in the postmortem setting, both as a cause of death and incidentally. Unfortunately, information regarding the concentrations of hydrocodone found with chronic high-dose use is lacking, and interpretation of postmortem concentrations can be difficult. A retrospective review of postmortem and "Driving under the Influence" (DUI) cases in Bexar County Texas in which hydrocodone was present was conducted. The cases were included in the study if they fit the criteria of belonging to 1 of 3 categories: the hydrocodone either caused or was the main contributor to death; the hydrocodone was incidental and definitively did not cause or contribute to death; and the DUI cases. The average hydrocodone concentration in the cases where the hydrocodone caused death was 0.47 mg/L (median, 0.38 mg/L). The average hydrocodone concentration in cases where it was incidental to death was 0.15 mg/L (median, 0.08 mg/L). The average hydrocodone concentration in the DUI cases was 0.09 mg/L (median, 0.08 mg/L). Analysis showed the possibility of postmortem redistribution as well as significant overlap of the concentrations noted in the different groups. Given that no definitive lethal concentration could be delineated, it is recommended that each hydrocodone case encountered be assessed individually to include a thorough medical record review to accurately interpret hydrocodone concentrations. It has also been shown that concentrations as high as 0.3 mg/L peripherally and 1.4 mg/L centrally can be present and not result in death. In addition, further research into hydrocodone concentrations with chronic use and hydrocodone metabolism is necessary.

Morland J; Steentoft A; Simonsen KW; Ojanpera I; Vuori E; Magnusdottir K et al. Drugs related to motor vehicle crashes in northern European countries: A study of fatally injured drivers. Accident Analysis and Prevention 43(6): 1920-1926, 2011. (32 refs.)

The aim of this study was to find which drugs and drug combinations were most common in drivers who died, in particular, in single vehicle crashes where the responsibility for the crash would be referred to the driver killed. The study included all available blood samples from drivers, who died within 24h of the accident, in the years 2001 and 2002 in the five Nordic countries (total population about 24 million inhabitants). The samples were analysed for more than 200 different drugs in addition to alcohol, using a similar analytical programme and cut-off limits in all countries. In three countries (Finland, Norway and Sweden) blood samples were available for more than 70% of the drivers, allowing representative prevalence data to be collected. 60% of the drivers in single vehicle crashes had alcohol and/or drug in their blood samples, compared with 30% of drivers killed in collisions with other vehicles. In single vehicle accidents, 66% of the drivers under 30 years of age had alcohol and/or drugs in their blood (alcohol only - 40%; drugs only - 12%; alcohol and drugs - 14%). The drugs found were mostly illicit drugs and psychoactive medicinal drugs with warning labels (in 57% and 58% respectively of the drivers under 30 with drugs present). Similar findings were obtained for drivers 30-49 years of age (63% with alcohol and/or drugs). In drivers aged 50 years and above, killed in single vehicle crashes (48% with alcohol and/or drugs) illicit drugs were found in only one case, and psychoactive medicinal drugs were detected less frequently than in younger age groups. In 75% of single vehicle crashes, the driver was under 50 years. Thus, the majority of accidents where the drivers must be considered responsible, occurred with drivers who had recently used alcohol, or drugs, alone or in combination. The drugs involved were often illicit and/or psychoactive drugs with warning labels. Therefore a large proportion of single vehicle accidents appear to be preventable, if more effective measures against driving after intake of alcohol and drugs can be implemented.

Morris CD; Waxmonsky JA; May MG; Tinkelman DG; Dickinson M; Giese AA. Smoking reduction for persons with mental illnesses: 6-month results from community-based interventions. Community Mental Health Journal 47(6): 694-702, 2011. (76 refs.)

Persons with mental illnesses use tobacco at significantly higher and heavier rates than the general population, and suffer greater tobacco- related morbidity and mortality. However, there are few existing tobacco cessation interventions for these individuals. This study examined two tobacco cessation interventions, a telephonic quitline intervention (counseling and nicotine replacement therapy) and a community-based group counseling intervention with adults currently receiving community mental health services. At 6-month follow-up, both groups demonstrated significantly reduced tobacco use, but participants who received both quitline services and the group counseling intervention were significantly more likely to have a 50% tobacco use reduction. Across groups, the overall intent-to-treat cessation rate was 7%. Tobacco dependence, depression symptoms, and psychotic symptoms decreased significantly for all treatment groups, while health and mental health functioning increased. Findings suggest that common community tobacco cessation services are effective for this population.

Morrison DS; Batty GD; Kivimaki M; Smith GD; Marmot M; Shipley M. Risk factors for colonic and rectal cancer mortality: Evidence from 40 years' follow-up in the Whitehall I study. Journal of Epidemiology and Community Health 65(11): 1053-1058, 2011. (35 refs.)

Background: Modifiable behavioural risk factors-including exercise, obesity and smoking-have been causally associated with colorectal cancer mortality. However, results have been inconsistent and undiagnosed cancers may affect baseline risk factors, distorting the temporal relationship that is observed between them. Objective: To determine whether risk factors for colorectal cancers available in the Whitehall I study were predictive of colonic or rectal cancer mortality. Methods Prospective cohort study over 40 years on Whitehall I men aged 40-69 on entry between 1967 and 1970. Associations between baseline risk factors and cause-specific mortality were tested with Cox proportional hazards models. Events within the first 10 years of follow-up were excluded to minimise 'reverse causality. Results: 329 colon and 121 rectal cancer deaths occurred among 17,949 men followed up for a total of 472,523 person-years. Age and smoking were associated with increased mortality from colorectal cancers. Compared with never-smokers, current smoking was associated with age-adjusted HRs for colon and rectal cancers of 1.45 (95% CI 1.03 to 2.03) and 1.97 (95% CI 1.02 to 3.80), respectively. A significant effect of current smoking on rectal cancer mortality was only apparent after events in the first 10 years of follow-up were excluded. No convincing evidence was found that body mass index, diabetes mellitus, blood pressure or physical activity were associated with colorectal cancer mortality. Conclusion: Smoking significantly increases mortality from colorectal cancer and its decreasing prevalence in the UK may partly explain falling mortality from the disease. Changes in health behaviours in response to early cancer symptoms may result in differential misclassification or 'reverse causality' unless early events are excluded. Although many individual cohort studies have not shown significant relationships between behavioural risk factors and colorectal cancer mortality, their contribution to meta-analyses remains important.

Nicoll R; Henein MY. Alcohol and the heart. (commentary). Alcoholism: Clinical and Experimental Research 35(10): 1737-1738, 2011. (17 refs.)

Alcohol consumption and disease or mortality display a J-shaped curve, with moderate amounts of alcohol being more protective than abstention, binge drinking, or heavy drinking. Red wine appears to be particularly protective for cardiovascular disease and associated conditions such as type 2 diabetes. There are, however, controversies concerning the effect of red wine on hypertension, in which there may be significant gender and ethnic differences. Overall, it seems that both ethanol and the polyphenols in red wine may contribute to the protective effect.

Nielsen K; Nielsen SL; Siersma V; Rasmussen LS. Treatment of opioid overdose in a physician-based prehospital EMS: Frequency and long-term prognosis. Resuscitation 82(11): 1410-1413, 2011. (14 refs.)

Background: Prehospital treatment of opioid overdose accounts for a significant proportion of the workload of the emergency system in most major cities. Treatment consists of basic life support and administering naloxone. In our physician-manned mobile emergency care unit (MECU), most patients are released and not admitted to hospital. In this study, we aimed to assess the pattern in the number of episodes with opioid overdose treated by MECU in Copenhagen during a 10-year period and to investigate risk factors for mortality of these patients beyond the initial contact. Methods: Data were collected prospectively in the MECU database covering all cases of opioid overdose in a 10-year period between 1994 and 2003. The pattern in the number of opioid overdose was analysed in Poisson regression models, and mortality was analysed in Kaplan-Meier plots and in Cox regression models. Results: A total of 4762 episodes of opioid overdose were recorded. Patients were identified in 3245 of these episodes. The annual number of episodes decreased significantly over the data-collection period: from 639 overdoses out of 4520 (14.1%) patients treated in 1994 to 311 out of 7263 patients treated (4.3%) in 2003. A total of 352 patients had cardiac arrest at the scene. The MECU released 2246 patients (69.3%) after treatment, while 675 (20.8%) were admitted to hospital and 322 (9.9%) died. Long-term prognosis was poor with 14% mortality at 1 year. Long-term mortality was significantly related to increasing age, time of the year and if the patient had previous episodes of opioid overdose. Conclusions: There has been a significant decrease in the number of opioid overdoses during this 10-year-period. Long-term mortality is high in these patients and highest in those with advanced age and numerous episodes of opioid overdose.

Nyhlen A; Fridell M; Backstrom M; Hesse M; Krantz P. Substance abuse and psychiatric co-morbidity as predictors of premature mortality in Swedish drug abusers a prospective longitudinal study 1970-2006. BMC Psychiatry 11: e-article 122, 2011. (42 refs.)

Background: Few longitudinal cohort studies have focused on the impact of substances abused and psychiatric disorders on premature mortality. The aim of the present study was to identify predictors of increased risk of drug related death and non drug related death in substance abusers of opiates, stimulants, cannabis, sedatives/hypnotics, hallucinogens and alcohol over several decades. Methods: Follow-up study of a consecutive cohort of 561 substance abusers, admitted to a detoxification unit January 1970 to February 1978 in southern Sweden, and followed up in 2006. Demographic and clinical data, substance diagnoses and three groups of psychiatric diagnoses were identified at first admission. Causes of death were coded according to ICD-10 and classified as drug related deaths or non drug related deaths. To identify the incidence of some probable risk factors of drug related premature death, the data were subjected to a competing risks Cox regression analysis. Results: Of 561 patients in the cohort, 11 individuals had either emigrated or could not be located, and 204/561 patients (36.4%) were deceased by 2006. The cumulative risk of drug related death increased more in the first 15 years and leveled out later on when non drug related causes of death had a similar incidence. In the final model, male gender, regular use of opiates or barbiturates at first admission, and neurosis were associated with an increased risk of drug related premature death, while cannabis use and psychosis were associated with a decreased risk. Neurosis, mainly depression and/or anxiety disorders, predicted drug related premature death while chronic psychosis and personality disorders did not. Chronic alcohol addiction was associated with increased risk of non drug related death. Conclusions: The cohort of drug abusers had an increased risk of premature death to the age of 69. Drug related premature death was predicted by male gender, the use of opiates or barbiturates and depression and anxiety disorders at first admission. The predicted cumulative incidence of drug related death was significantly higher in opiate and barbiturate abusers over the observed period of 37 years, while stimulant abuse did not have any impact. Alcohol contributed to non drug related death.

Ottaviani G. Sudden infant and perinatal unexplained death: are we moving forward yet? (review). Cardiovascular Pathology 20(5): 302-306, 2011. (41 refs.)

Autonomic nervous system and cardiac conducting system dysfunctions have been proposed to be implied in the pathogenesis of sudden infant death syndrome (SIDS). However, most clinicians and even pathologists lack experience with detailed examination of the brainstem and cardiac conducting system and may not recognize lesions within those systems that potentially could be crucial factors in the sudden unexpected perinatal and infant death. Recent anatomical, pathological, and bacteriological studies in SIDS confirm that the multidisciplinary approach provides the best approach to the challenging problems of SIDS and sudden unexplained perinatal death.

Parry CD; Patra J; Rehm J. Alcohol consumption and non-communicable diseases: Epidemiology and policy implications. Addiction 106(10): 1718-1724, 2011. (47 refs.)

Aims This paper summarizes the relationships between different patterns of alcohol consumption and various on non-communicable disease (NCD) outcomes and estimates the percentage of NCD burden that is attributable to alcohol. Methods A narrative review, based on published meta-analyses of alcohol consumption-disease relations, together with an examination of the Comparative Risk Assessment estimates applied to the latest available revision of Global Burden of Disease study. Results: Alcohol is causally linked (to varying degrees) to eight different cancers, with the risk increasing with the volume consumed. Similarly, alcohol use is related detrimentally to many cardiovascular outcomes, including hypertension, haemorrhagic stroke and atrial fibrillation. For other cardiovascular outcomes the relationship is more complex. Alcohol is furthermore linked to various forms of liver disease (particularly with fatty liver, alcoholic hepatitis and cirrhosis) and pancreatitis. For diabetes the relationship is also complex. Conservatively, of the global NCD-related burden of deaths, net years of life lost (YLL) and net disability adjusted life years (DALYs), 3.4%, 5.0% and 2.4%, respectively, can be attributed to alcohol consumption, with the burden being particularly high for cancer and liver cirrhosis. This burden is especially pronounced in countries of the former Soviet Union. Conclusions: There is a strong link between alcohol and non-communicable diseases, particularly cancer, cardiovascular disease, liver disease, pancreatitis and diabetes, and these findings support calls by the World Health Organization to implement evidence-based strategies to reduce harmful use of alcohol.

Pesis-Katz I; Williams GC; Niemiec CP; Fiscella K. Cost-effectiveness of intensive tobacco dependence intervention based on self-determination theory. American Journal of Managed Care 17(10): E393-E398, 2011. (27 refs.)

Objectives: To evaluate cost-effectiveness of a tobacco dependence intervention based on self-determination theory (SDT) and consistent with the Public Health Service (PHS)-sponsored Clinical Practice Guideline for Treating Tobacco Use and Dependence. Study Design: Adult smokers were recruited into a randomized cessation-induction trial of an intensive intervention versus community care. Seven-day point prevalence (7dPP) tobacco abstinence and cost-effectiveness of the intervention were examined using 737 participants with health insurance. Methods: Community care (CC) participants received smoking-cessation pamphlets and information on local treatment programs. Intervention participants received those materials and were asked to meet 4 times over 6 months with study counselors to discuss their health in a manner that supported autonomy and perceived competence. The third-party payer's perspective was used for this analysis, and the primary outcome was cost-effectiveness using self-reported 7dPP tobacco abstinence at 6 months. Sensitivity analyses were performed using costs of generic medications, biochemically validated tobacco abstinence, actual rates of tobacco abstinence, life-years saved (not adjusted for quality of life), and costs in 2011 US dollars. A subgroup analysis was conducted using smokers who did not want to stop within 30 days. Results: Smokers in the intervention, relative to CC, were more likely to attain 7dPP tobacco abstinence at 6 months. The overall incremental cost-effectiveness ratio was $1258 per quality-adjusted life-year saved, in US dollars. The sensitivity and subgroup analyses yielded similar results. Conclusions: An intervention based on SDT and consistent with the PHS Guideline facilitated tobacco abstinence among insured smokers and was cost-effective compared with other tobacco dependence and medical interventions.

Puddu PE; Menotti A; Tolonen H; Nedeljkovic S; Kafatos AG. Determinants of 40-year all-cause mortality in the European cohorts of the Seven Countries Study. European Journal of Epidemiology 26(8): 595-608, 2011. (30 refs.)

If a few risk factors had predictive power for all-cause mortality in different geographical-cultural areas, then preventive efforts might be concentrated on these. Thirteen potential risk factors were measured in 6,554 men aged 40-59 around 1960 in Northern, Southern and Eastern European areas of the Seven Countries Study. In 40 years 85.3% of men died in the pooled areas (87.9, 81.8 and 87.9% in Northern, Southern and Eastern Europe, respectively). Six risk factors were significant predictors of events in all three areas: directly for age, smoking habits, mean blood pressure, heart rate and ECG abnormalities; inversely for forced expiratory volume. In a pooled model also father and mother life status, socio-economic status, and arm circumference (the last one in an inverse way) had significant coefficients that were not heterogeneous across areas (except for socio-economic status). Serum cholesterol was around significance. ROC curves had values of 0.833, 0.806 and 0.819 respectively in Northern, Southern and Eastern Europe, and 0.827 in the pooled areas. Correlation coefficients between observed and expected cases in deciles of estimated risk were between 0.98 and 0.99. Survivors after 40 years in the lower half of the estimated risk were 10.7, 23.6 and 13.3% in Northern, Southern and Eastern Europe, respectively. Under- or over-estimate of cross-applying risk functions did not exceed 15%. All-cause mortality and survival in middle aged men during 40 years were strongly associated with a few, mainly cardiovascular, risk factors, whose predictive power was similar in different cultures across Europe.

Radisauskas R; Prochorskas R; Grabauskas V; Bernotiene G; Tamosiunas A; Veryga A. Recent heavy alcohol consumption at death certified as ischaemic heart disease: Correcting mortality data from Kaunas (Lithuania). Alcohol and Alcoholism 46(5): 614-619, 2011. (18 refs.)

Aims: To assess the proportion of deaths assigned to ischaemic heart disease (IHD) which in fact were caused by the toxic effects of alcohol, and how this may affect the official statistics of mortality from IHD in Lithuania. Methods: Using the IHD register in Kaunas, Lithuania, and verifying underlying causes of death using standard international methodology, 3061 cases were found in Kaunas city who had died from IHD at age 25-64 during 1993-2007. Out-of-hospital sudden deaths accounted for 2467 cases (81%), including 1498 where forensic autopsy was conducted and post-mortem concentration of alcohol in blood and urine was available. Results: In total, 78.4% of all initial IHD diagnoses were verified, while in 8.7% of deaths the underlying cause of death was corrected into an alcohol-related cause and in 12.9% to other diseases. Alcohol was found in about half (50.3%) of out-of-hospital death cases subjected to autopsy. In 18.0% of cases, the alcohol concentration was 3.5% or higher. Alcohol was more likely to be present in winter months and at weekends. Conclusion: A significant number of alcohol-attributable deaths in Lithuania were misclassified as coronary deaths, accounting for almost one-tenth of officially registered deaths from IHD in ages 25-64. A high prevalence of positive post-mortem blood or urine alcohol tests suggests that the proportion of alcohol-related deaths among out-of-hospital IHD deaths may be actually even higher. A similar situation may be present in some other countries where high levels of alcohol consumption and binge drinking patterns are observed.

Rhodes A; Moreno RP; Metnitz B; Hochrieser H; Bauer P; Metnitz P. Epidemiology and outcome following post-surgical admission to critical care. Intensive Care Medicine 37(9): 1466-1472, 2011. (10 refs.)

To describe the factors related to outcome in patients admitted to the intensive care unit (ICU) after major surgery at a national level (in Austria). Analysis of a prospectively collected database of ICU admissions over an 11-year period. Factors associated with mortality and how this changed with time were explored using logistic multilevel modelling. A total of 88,504 surgical patients had a mean ICU length of stay of 6.5 days and total hospital stay of 31.3 days. They had an ICU mortality of 7.6% and a hospital mortality of 11.8%. Factors associated with hospital mortality included age (odds ratio (OR) 1.42 per 10 years of age), urgency of operation (2.02 for emergency when compared to elective), SAPS II score (OR 1.09), reason for admission being a medical cause and the specific nature of the surgery itself: thoracic (OR 1.81), cardiovascular (OR 1.25), trauma (OR 1.22) or gastrointestinal surgery (OR 1.71). In addition patients who had pre-existing chronic renal (OR 1.40), respiratory (OR 1.20) or cardiac failure (OR 1.29), cirrhosis (OR 2.50), alcoholism (OR 1.42), acute kidney injury (OR 1.88) and/or non-metastatic cancer (OR 1.20) were associated with higher hospital mortality than patients without this co-morbidity. There was a reduction in the OR for death over the whole 11-year period. This improved outcome remained valid even after adjusting for the identified risk factors for mortality (OR per year 0.96). This study has shown the high level of demand for critical care for this patient group and an improving rate of survival.

Roerecke M; Greenfield TK; Kerr WC; Bondy S; Cohen J; Rehm J. Heavy drinking occasions in relation to ischaemic heart disease mortality: An 11-22 year follow-up of the 1984 and 1995 US National Alcohol Surveys. International Journal of Epidemiology 40(5): 1401-1410, 2011. (46 refs.)

Background: The relationship between alcohol consumption and ischaemic heart disease (IHD) risk is complex and several issues remain unresolved because many studies used rather crude exposure measures often based on one or two questions. The objective of this study was to investigate the association between heavy drinking occasions and IHD mortality while controlling for average daily alcohol intake and separating former drinkers from lifetime abstainers. Methods: Cox regression analyses were used with IHD mortality as the outcome in a sample of 9934 participants of the US National Alcohol Surveys conducted in 1984 and 1995. Results: To the end of 2006, 326 deaths from IHD were recorded in the 11- to 22-year follow-up period. Any past heavy drinking occasions in former drinkers [hazard ratio (HR) = 2.06; 95% confidence interval (95% CI): 1.10-3.85] compared with former drinkers without such drinking occasions, and any heavy drinking occasion in current drinkers at baseline (HR = 2.05; 95% CI: 1.03-3.98) compared with current drinkers with average daily intake of one to two drinks, were associated with higher IHD mortality in men and any heavy drinking occasions among drinkers of up to 1 drink average consumption in women with similar effect size. Confounding effects from age, race, education, employment, income, marital status, geographical region, depression score, survey period or other drug use were small. Conclusions: Among former and current drinkers, heavy drinking occasions should be taken into account when examining the complex association of alcohol consumption on IHD mortality risk.

Roxburgh A; Bruno R; Larance B; Burns L. Prescription of opioid analgesics and related harms in Australia. Medical Journal of Australia 195(5): 280-284, 2011. (24 refs.)

Objective: To document trends in: (i) prescribing of morphine and oxycodone; (ii) hospital separations for overdose; (iii) presentations for treatment of problems associated with these drugs; and (iv) oxycodone-related mortality data in Australia. Design and setting: Cross-sectional study analysing prescriptions for morphine and oxycodone based on figures adjusted using Australian Bureau of Statistics estimated resident population and prospectively collected data from: (i) the National Hospital Morbidity Database on hospital separations primarily attributed to poisoning with opioids other than heroin ("other opioids"); (ii) the Alcohol and Other Drug Treatment National Minimum Data Set for treatment episodes where morphine or oxycodone were the primary or other drugs of concern; (iii) the National Coronial Information System on deaths where oxycodone was the underlying cause of death or a contributory factor. Main outcome measures: Population-adjusted numbers of (i) prescriptions for morphine and oxycodone by 10-year age group, (ii) hospital separations for "other oploid" poisoning, and (Hi) treatment episodes related to morphine or oxycodone; and (iv) number of oxycodone-related deaths. Results: Prescriptions for morphine declined, white those for oxycodone increased. Prescriptions for both were highest among older Australians. Hospital separations for "other opioid" poisoning doubled between the financial years 2005-06 and 2006-07. Treatment episodes for morphine remained stable, white those for oxycodone increased. There were 465 oxycodone-related deaths recorded during 2001-2009. Conclusions: Oxycodone prescriptions in Australia have increased, particularly among older Australians. The increase may, in part, reflect appropriate prescribing for pain among an ageing population. However we are unable to differentiate non-medical use from appropriate prescribing from this data. In comparison to heroin, the morbidity and mortality associated with oxycodone is relatively low in Australia. There is a continued need for comprehensive training of general practitioners in assessing patients with chronic non-malignant pain and prescribing of opioids for these patients, to minimise the potential for harms,.associated with use of these medications.

Schneider B; Baumert J; Schneider A; Marten-Mittag B; Meisinger C; Erazo N et al. The effect of risky alcohol use and smoking on suicide risk: Findings from the German MONICA/KORA-Augsburg Cohort Study. Social Psychiatry and Psychiatric Epidemiology 46(11): 1127-1132, 2011. (36 refs.)

Smoking and heavy alcohol use predicts suicidal behaviour. Whether the simultaneous presentation of both conditions induces an amplified effect on risk prediction has not been investigated so far. In a community-based cohort study, a total of 12,888 subjects (6,456 men, 6,432 women; age range of 25-74 years at assessment) from three independent population-based cross-sectional MONICA surveys (conducted in 1984/85, 1989/90, and 1994/95), representative for the Southern German population, was followed up until 31 December 2002. Standardized mortality ratios (SMR) for deaths from suicide using German population rates were calculated for smoking and high alcohol consumption. After a mean follow-up time of 12.0 (SD 4.4) years and 154,275 person-years at risk, a total of 1,449 persons had died from all causes and 38 of them from suicide. Compared to the general population, mortality from suicide was increased for risky alcohol consumption (SMR = 2.37; 95% CI 1.14-4.37) and for smoking (SMR = 2.30; 95% CI 1.36-3.63). A substantial increase in suicide mortality (SMR = 4.80; 95% CI 2.07-9.46) was observed for smokers with risky alcohol consumption. The approximately fourfold increased relative risk for completed suicide in subjects with smoking and risky alcohol consumption indicates a synergistic effect which deserves an increased alertness.

Sepanlou SG; Poustchi H; Kamangar F; Malekzadeh R; Malekzadeh Reza. Effectiveness and feasibility of lifestyle and low-cost pharmacologic interventions in the prevention of chronic diseases: A review. (review). Archives of Iranian Medicine 14(1): 46-53, 2011. (115 refs.)

Chronic diseases are already major causes of morbidity and mortality in Iran, similar to what is seen in other countries. However, there doesn't yet exist a comprehensive plan to cope with the epidemic of chronic diseases in Iran. Several lifestyle and low-cost pharmacological interventions have been proposed to reduce the burden of chronic diseases. Lifestyle interventions require a comprehensive infrastructure that can be quite costly in this country, but several components of extensive lifestyle interventions, including self-help materials and brief advice by health workers, can be integrated into the existing system. Pharmacological interventions may have substantial contribution to the capacity and preparation of Iran's healthcare system to confront the epidemic of chronic diseases. Further research needs to be performed to determine the feasibility and efficacy of each of these methods in order for policy makers to take the appropriate measures on adopting each of these strategies to prevent and control chronic diseases.

Sidorenkov O; Nilssen O; Grjibovski AM. Determinants of cardiovascular and all-cause mortality in northwest Russia: A 10-year follow-up study. Annals of Epidemiology 22(1): 57-65, 2012. (32 refs.)

PURPOSE: To study conventional and novel risk factors associated with high cardiovascular disease (CVD) and all-cause mortality in Russia. METHODS: A prospective cohort study of 3704 adults was performed in Arkhangelsk. The baseline examination was conducted in 1999-2000. The average follow-up was 10.2 years. Information on lifestyle and marital, educational, and psychosocial status was self-reported in a questionnaire. Data on risk factors were collected in a medical examination that included the drawing of blood samples. RESULTS: By October 2010 a total of 147 male and 95 female deaths had occurred. In 59 male and 20 female deaths in which a diagnosis was made by a forensic pathologist, the autopsy data were studied to extract information on post-mortem blood alcohol concentration. A positive blood alcohol concentration was found in 21 (36%) male and 6 (30%) female forensic autopsies. Women reporting consumption of at least 80 g of alcohol monthly and consumption of 5 or more alcohol units during one drinking episode had a greater risk of cardiovascular death than abstainers; relative risk (RR) was 5.06 (95% confidence interval [95% CI], 1.54-16.7) and 3.21 (95% CI, 1.07-9.58), respectively. ApoB/ApoA1-ratio was the strongest predictor of CVD and all-cause death in men (RR, 7.62; 95% CI, 3.15-18.4; and RR, 4.39; 95% CI, 2.22-8.68, respectively) and CVD death in women (RR 3.12; 95% CI, 1.08-8.98). Men who were obese and had obtained a university education had a 40% lower risk of all-cause death. Low serum albumin was associated with high mortality in both genders. CONCLUSIONS: Hazardous alcohol consumption is an independent risk factor of CVD mortality in women. The mechanisms behind its damaging effect are not yet clear. Nutritional factors such as serum albumin are important predictors of all-cause mortality in both genders.

Simonsen KW; Hansen AC; Rollmann D; Kringsholm B; Muller IB; Johansen SS et al. Drug-related death in Denmark in 2007. Danish Medical Bulletin 58(8): a4307, 2011. (14 refs.)

Introduction: We investigated fatal poisonings among drug addicts in 2007. The cause of death, abuse pattern and geographic differences are presented. MATERIAL AND METHODS: All drug-related deaths examined at the three forensic medicine institutes in Denmark in 2007 were evaluated. RESULTS: The number of drug-related deaths in 2007 was 226. Methadone deaths had increased since 1997 while heroin/morphine deaths decreased. In earlier studies, very few deaths from central stimulants like cocaine and amphetamines occurred (1-1.5%), but in 2007 6% of the deaths were caused by these drugs. Multiple drug use was common. Heroin/morphine, cocaine, amphetamine, cannabis, methadone, benzodiazepines and alcohol were included in the poly-drug use. Conclusion: This investigation shows stabilization in the number of fatal poisonings in drug addicts. Geographic differences were observed. Methadone was the most frequent cause of fatal poisoning and there was a continuous decrease in heroin/morphine deaths. Fatal deaths from cocaine and amphetamine have increased considerably. Multiple drug use was common.

Skov-Ettrup LS; Eliasen M; Ekholm O; Gronbaek M; Tolstrup JS. Binge drinking, drinking frequency, and risk of ischaemic heart disease: A population-based cohort study. Scandinavian Journal of Public Health 39(8): 880-887, 2011. (26 refs.)

Introduction: Light-to-moderate alcohol drinking is associated with a decreased risk of ischaemic heart disease (IHD). However, drinking heavily and in binges has been suggested to increase IHD risk. This complexity makes the issue of binge drinking within the light-to-moderate alcohol range an important area for further investigation. Methods: This population-based cohort study included 26,786 men and women who participated in the Danish National Cohort Study in 1994, 2000, and 2005. Binge drinking (defined >5 drinks/day) and risk of IHD and all-cause mortality was investigated among light-to-moderate drinkers (defined <= 21 and <= 14 drinks/week for men and women, respectively). In the entire study population, we investigated the association between drinking frequency, separately and combined with total weekly alcohol intake, and risk of IHD and all-cause mortality. Results: 1136 individuals developed IHD during a mean follow up of 6.9 years. Among male light-to-moderate drinkers reporting occasional binge drinking, the hazard ratio (HR) of IHD was 0.81 (95% CI 0.61-1.08) compared to male light-to-moderate drinkers reporting no binge drinking. Corresponding HR for women was 0.97 (95% CI 0.54-1.76). For women drinking 5-6 days/week, the risk of IHD was lower than for women drinking 1-2 days/week (HR 0.54, 95% CI 0.32-0.90). We did not observe any patterns when looking at combinations of total weekly alcohol intake and drinking frequency. Conclusions: Among light-to-moderate alcohol drinkers, binge drinking was not associated with risk of IHD and all-cause mortality. Overall, drinking frequency did not appear to be an important determinant of the risk of IHD and all-cause mortality.

Sokka T; Pincus T. Poor physical function, pain and limited exercise: Risk factors for premature mortality in the range of smoking or hypertension, identified on a simple patient self-report questionnaire for usual care. BMJ Open 1: e-000070, 2011. (38 refs.)

Objective: To analyse poor physical function, pain, limited exercise and smoking, assessed in a patient-friendly self-report questionnaire format that has been completed by every patient at every visit over 20-30+/-14years in the authors' and other usual care settings, to predict 5-year mortality in a general older population. Methods: An extended version of a Multidimensional Health Assessment Questionnaire was mailed to 2000 subjects in Finland, identified as a randomly selected control cohort for a rheumatoid arthritis cohort. The questionnaire included queries concerning baseline physical function, pain, exercise and smoking status, identical to the clinic version, as well as age and 25 medical conditions. Five-year survival was analysed according to descriptive statistics, Kaplan-Meier curves and Cox regressions. Results: The questionnaire was returned by 1523 subjects (76%). Five-year survival was 94% in all subjects, 98% in subjects with no disease or no acutely life-threatening disease, and 17% in subjects with an acutely life-threatening disease. Hazard ratios (HRs) for 5-year mortality were 3.5 for poor physical function, 2.2 for pain, 5.2 for limited exercise and 4.6 for smoking (p<0.01); 5-year survivals were 93%, 97%, 93% and 95%, respectively, compared with 91% for hypertension. Each of the four patient history variables predicted mortality at higher levels in subjects who reported no versus one or more acutely life-threatening conditions. Conclusions: Poor physical function, pain, limited exercise and smoking can be assessed systematically on a simple standard Multidimensional Health Assessment Questionnaire, to identify potentially modifiable risk factors for premature mortality in the infrastructure of usual medical care and health maintenance.

Susnjara IM; Gojanovic MD; Vodopija D; Capkun V; Smoljanovic A. Influence of war on quantitative and qualitative changes in drug-induced mortality in Split-Dalmatia County, Croatia. Croatian Medical Journal 52(5): 629-636, 2011. (54 refs.)

Aim: To study drug-induced mortality and characteristics of overdose deaths in the war (1991-1995), pre-war (1986-1990), and post-war period (1996-2000) in Split-Dalmatia County. Methods: We retrospectively searched through Databases of the Department of Forensic Medicine, University Hospital Split, the national register of death records, the archives of the Split-Dalmatia County Police, and the Register of Treated Drug Addicts of the Croatian National Institute of Public Health, covering the period from 1986 to 2000, according to drug poisoning codes IX and X of the International Classification of Diseases. The indicators were statistically analyzed. Results There were 146 registered drug-induced deaths, with 136 (93%) deceased being men. The median age of all cases was 27 years (interquartile range 8). Most of them were single (70.6%), unemployed (44.6%), and secondary school graduates (69.2%). In the war period, there were 4.8 times more deaths than in the pre-war period (P = 0.014), and in the post-war period there were 5.2 times more deaths than in the pre-war period (P = 0.008). The most common site of death was the deceased person's home. The toxicological analyses showed that 59 (61%) deaths were heroin related, alcohol use was found in 62 cases (42.5%), and multi-substance use was found in more than a half of the cases. In 133 (91.1%) cases, deaths were classified as unintentional, whereas 13 (8.9%) were classified as suicides. Conclusion: The war, along with other risk factors, contributed to unfavorable developments related to drug abuse in Split-Dalmatia County, including the increase in the drug-induced mortality rate.

Susnjara IM; Smoljanovic A; Gojanovic MD. Drug related deaths in the Split-Dalmatia County 1997-2007. Collegium Antropologicum 35(3): 823-828, 2011. (40 refs.)

Drug overdoses are a major cause of mortality for drug users and, in many countries, are the leading cause of death in this group. The aim of the present study is to explore the frequency of all drug related deaths in the Split-Dalmatia County in the period between 1997 and 2007 and to analyze some of the characteristics of these deaths to help target preventive policies. The data on drug related deaths were collected using records from the Department of Forensic Medicine, Clinical Hospital Centre Split, University of Split, School of Medicine. There were 190 drug related deaths in the observed period of 11 years. Statistically significant difference (p=0.004, chi(2)-test for trend) was found in the number of deaths in 1997 in comparison with the number of deaths in 2007. The majority of 105 (55%) the decedents were 25-34 years old, and 92.1% (175) of them were male. There was a 94% higher probability of mortality in the 25-34 years group (chi(2)=5.55, p=0.064). Average age of all dead people was 31.01 +/- 7.59 years (median 31.0 years; range 18-49). Almost three quarters of the decedents were single and more than three fifths hadn't been employed. The most common location of death was at home. Approximately, 80% were autopsied followed by full histological and toxicological analyses. Out of all examined cases, the majority of drug related deaths (93 or 60.8%) were attributed to heroin. Heroin was the sole cause of death in 35(22.9%) cases. Methadone was cause of death in 24 (15.7%) cases. 3.4-methylenedioxy-methamphetamine (MDMA) deaths were rare (3.3%). Cocaine deaths were also rare (1.3%). Three fifths (55.6%) of the cases involved includes multi-substance use. During the investigation there was an evident trend towards multi-substance abuse patterns. These data suggest that interventions to prevent drug related mortality should address the use of drugs such as heroin and alcohol in combination.

Tian XB; Tang Z; Jiang JM; Fang XH; Wu XG; Han W et al. Effects of smoking and smoking cessation on life expectancy in an elderly population in Beijing, China, 1992-2000: An 8-year follow-up study. Journal of Epidemiology 21(5): 376-384, 2011. (29 refs.)

Background: We assessed the effects of smoking and smoking cessation on life expectancy and active life expectancy among persons aged 55 years or older in Beijing. Methods: This study included 1593 men and 1664 women who participated in the Beijing Longitudinal Study of Aging, which commenced in 1992 and had 4 survey waves up to year 2000. An abridged life table was used to estimate life expectancy, in which age-specific mortality and age-specific disability rates were adjusted by using a discrete-time hazard model to control confounders. Results: The mean ages (SD) for men and women were 70.1 (9.25) and 70.2 (8.72) years, respectively; mortality and disability rates during follow-up were 34.7% and 8.0%, respectively. In both sexes, never smokers had the highest life expectancy and active life expectancy across ages, as compared with current and former smokers. Current heavy smokers had a shorter life expectancy and a shorter active life expectancy than light smokers. Among former smokers, male long-term quitters had a longer life expectancy and longer active life expectancy than short-term quitters, but this was not the case in women. Conclusions: Older adults remain at higher risk of mortality and morbidity from smoking and can expect to live a longer and healthier life after smoking cessation.

Tidey J. Smoking is associated with an increased risk of death in people aged 35-54 with schizophrenia. (commentary). Evidence-Based Mental Health 14(4): e99, 2011. (0 refs.)

This is a commentary on an article by Kelly DL, et al. Cigarette smoking and mortality risk in people with schizoprhrenia. Schizoprhenia Bulletin 37: 832-838, 2011.

Todorovic MS; Mitrovic S; Aleksandric B; Mladjenovic N; Matejic S. Association of pulmonary histopathological findings with toxicological findings in forensic autopsies of illicit drug users. Vojnosanitetski Pregled 68(8): 639-642, 2011. (11 refs.)

Background/Aim. Drug abuse remains a significant social problem in many countries. The aim of the study was to estimate association between pulmonary histopathological changes and results of toxicological analyses in forensic autopsies of illicit drug users. Methods. This investigation was performed in the Institute of Forensic Medicine, Belgrade, and in the Clinical Center, Department of Forensic Medicine, Kragujevac, from 2000 to 2004, and included 63 medicolegal autopsies of heroin or other drug consumers who suddenly died. Autopsies, postmortem toxicological examination of drugs and serological analyses of anti-HIV/HBV/HCV antibodies were performed. Results. The deceased persons were mostly male, 46/63 (73.01%), ranged in age from 19 to 49 years (mean 31 years) and all were whites. Postmortem toxicological examination was performed on all of the deceased persons and drugs in the fatal range were identified in only eight of them (12.7%), in the toxic range in ten (15.87%), and in minimal concentrations in 35 (55.56%) of the deceased persons. Drugs identified in the fatal, toxic or minimal range included heroin-morphine (38/53), cocaine (4/53), tramadol (3/53), and lorazepam (1/53). In the 7 remaining subjects, ethanol in combination with heroin was found in 4 cases, and diazepam in combination with heroin in 3 cases. Dominant pathomorphological changes were findings in the lung tissue. Most common histological changes observed in drug users were pulmonary edema - 55/63 (87.3%), acute alveolar hemorrhages - 49/63 (77.78%), hemosiderin-laden macrophages (siderophages) - 52/63 (82,54%), and emphysematous changes - 51/63 (80,95%). Conclusion. Pulmonary edema is the frequent non-specific autopsy finding which is associated with virtually all routes of drug administration. The histopathological study is necessary to determinate a cause of death when a deceased person has the history of dependence or abouse of psychoactive drugs with negative toxicological results.

Valento M; Feinzimer B; Bryant SM. Drowning in bath salts: A case of abuse with fatal outcome. (meeting abstract). Clinical Toxicology 49(6): 528-529, 2011. (0 refs.)

Wood S; Mcinnes MM; Norton DA. The bad thing about good games: The relationship between close sporting events and game-day traffic fatalities. Journal of Consumer Research 38(4): 611-621, 2011. (51 refs.)

For sports fans, great games are the close ones-those between evenly matched opponents, where the game remains undecided until the very end. However, the dark side to sporting events is the incidence of traffic fatalities due to game-related drinking. Here, we ask whether the closeness of the game affects the number of fatalities that occur. Two opposing predictions can be made. Games that are not close ("blowouts") may be less engaging, thus increasing drinking. Alternatively, close games may be more dangerous, increasing competition-associated testosterone that spills over into aggressive driving. An analysis of major sporting events (2001-8) shows that closer games are significantly correlated with more fatalities. Importantly, increased fatalities are observed only in locations with winning fans (game site and/or winners' hometown), congruent with a testosterone-based account. Ultimately, this finding has material consequences for public welfare on game days and suggests that one silver lining for losing fans may be a safer drive home.

Zabransky T; Csemy L; Grohmannova K; Janikova B; Brenza J. Mortality of cohort of very young injecting drug users in Prague, 1996-2010. Central European Journal of Public Health 19(3): 152-157, 2011. (27 refs.)

Aim: To determine the mortality in a cohort of very young injecting drug users (IDUs), and the factors associated with it. Design: A database linkage prospective (follow-up) cohort study. Setting: A convenience sample of clients of 2 low-threshold facilities, 1 drug treatment clinic, and one special facility for children with severe behavioural disorders, who were all younger than 19 and older than 15, was interviewed one or more times in 1996-8 and asked to agree with their being interviewed again after 10 or more years. Participants: 151 (65 male, 86 female) IDUs recruited in October 1996 December 1998. Measurement: Database linkage study compared unique identifiers (IDs) of the recruited subjects with the general register of deaths to determine the life status, and the causes of death of those deceased. Where necessary, we examined the death protocols directly. Findings: Altogether, 8 deaths were registered between recruitment and 31st December 2008 (1,660 person-years). All the deceased were male, and all their deaths were "unnatural" - that is, caused by drug overdose or accident. This translates into the crude mortality rates for the whole cohort being 4.8 deaths per 1,000 person-years (PY), and into a specific mortality ratio in the males SMR=14.4 with the peak at the age of 15-20 (SMR=60.1), declining to SMR=8.2 at the age of 25-30. Except gender, we found no "predictors of death" in this high-risk cohort. Conclusion: The overall mortality in the cohort was substantially higher than in the general population; in the male part of the cohort of young injecting drug users it was excessively high in the first three years after recruitment, and caused by external causes exclusively; the mortality in the female sub-cohort was zero, i.e. lower than in the general population of the same age range. Our findings suggest a need to develop targeted prevention of overdoses and other unnatural deaths in young male drug injectors.

Zamparutti G; Schifano F; Corkery JM; Oyefeso A; Ghodse AH. Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007. British Journal of Clinical Pharmacology 72(2): 330-337, 2011. (58 refs.)

AIMS: Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction. METHODS: Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database. RESULTS: Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases. CONCLUSIONS: Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e. g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.